Complications Of Endoscopic Sphincterotomy Research Articles

Risk factors for delayed hemorrhage after endoscopic sphincterotomy

BackgroundHemorrhage is one of the most serious complications of endoscopic sphincterotomy (EST). The risk factors for delayed hemorrhage are not clear. This study aimed to explore the risk factors for post-EST delayed hemorrhage and suggest some precautionary measures. MethodsThis study analyzed 8477 patients who successfully underwent endoscopic retrograde cholangiopancreatography (ERCP) and EST between January 2007 and June 2015 in the First Affiliated Hospital of Nanchang University. Univariate and multivariate analyses were performed to find the risk factors for delayed hemorrhage after EST. ResultsOf the 8477 patients screened, 137 (1.62%) experienced delayed hemorrhage. Univariate analysis showed that male, the severity of jaundice, duodenal papillary adenoma and carcinoma, diabetes, intraoperative bleeding, moderate and large incisions, and directional deviation of incision were risk factors for post-EST delayed hemorrhage (P < 0.05). Multivariate analysis showed that intraoperative bleeding [odds ratio (OR) = 3.326; 95% CI: 1.785–6.196; P < 0.001] and directional deviation of incision (OR = 2.184; 95% CI: 1.266–3.767; P = 0.005) were independent risk factors for post-EST delayed hemorrhage. ConclusionsDelayed hemorrhage is the most common and dangerous complication of EST. Intraoperative bleeding and directional deviation of incision are independent risk factors for post-EST delayed hemorrhage.

Sump Syndrome as a Complication of Endoscopic Sphincterotomy

Sump Syndrome as a Complication of Endoscopic Sphincterotomy

Su1620 Long-Term Complications of Endoscopic Sphincterotomy, Mainly Influenced by Biliary Infection and High Risk Factors of Bile Duct, Not Determined by Loss of Sphincter of Oddi Function

Su1620 Long-Term Complications of Endoscopic Sphincterotomy, Mainly Influenced by Biliary Infection and High Risk Factors of Bile Duct, Not Determined by Loss of Sphincter of Oddi Function

A Prospective Randomized Controlled Study of Endoscopic Sphincterotomy With the Endocut Mode or Conventional Blended Cut Mode

Background:Although the potential advantages of the Endocut mode (E-mode) of endoscopic sphincterotomy (EST) over the conventional blended cut mode (C-mode) have been reported, the problems, including the small sample size and retrospective analysis, that occurred in previous studies make it difficult to conclude the advantage of the E-mode regarding the safety and efficacy. We performed a prospective randomized controlled study to compare these modes.Methods:A total of 360 patients with choledocholithiasis or stenosis of the bile duct were randomly assigned to one of the modes. To avoid the technical bias due to multiple operators or institutions, the main operator and the institution were restricted to only one experienced doctor and 3 institutions at his place of employment, respectively. We defined pancreatitis, bleeding, and perforation as complications of EST. Besides, bleeding includes endoscopically evident bleeding that was defined as visible during the procedure of sphincterotomy and temporary slight oozing.Results:The complications occurred in 20 (11.2%) patients from the E-mode group: pancreatitis in 6 (3.4%) and endoscopically evident bleeding in 14 (7.8%). In contrast, the complications occurred in 25 (13.8%) patients from the C-mode group: pancreatitis in 7 (3.9%) and endoscopically evident bleeding in 18 (9.9%), although these findings were not statistically significant. Overall, there were no severe complications. There were no significant differences in completion ratio of EST and the time taken for the sphincterotomy between both groups.Conclusions:The E-mode could not surpass the C-mode in safety and efficacy under the operation by a single endoscopist.

Biliary type Sphincter of Oddi dysfunction: Symptomatic outcomes and complications after ERCP AND endoscopic sphincterotomy

Introduction: The diagnosis and therapy of functional biliary disorders remains a challenge. Sphincter of Oddi (SO) dysfunction (SOD) can be defined such as a motility disorder of the SO. Endoscopic sphincterotomy (EST) is a standard treatment of choice in those patients with organic SO stenosis or abnormal SO manometry. The aims of our current study were to analyze the outcome and complications of EST in our SOD patients.

Pay attention on complications of endoscopic sphincterotomy

Endoscopic Sphincterotomy (EST) is more popular because of slight trauma and early recovery,therefore,its complications are always neglected,and the abuse of EST occur now and then.This paper summarized the applications of EST and analyzed its complications in recent 10 years in our country,It demonstrates that EST should been correctly treated and appropriately used. Key words: Sphincterotomy; Complication; Endoscopy

Squential treatment of extrahepatic bile duct calculus using the technique of three-endoscope-combination in one anesthetic session

Objective A retrospective study to evaluate the feasibility of the sequential treatment of extrahepatic bile duct calculus and acute gallstone pancreatitis using the technique of combination of duodenoscope, laparoscope and choledochoscope in one anesthetic session. Methods 112 patients with extrahepatic bile duct calculus (including 23 patients associated with acute gallstone pancreatitis) were treated using this technique. The data were analyzed. Results The technique was successfully carried out in 102 patients but 10 patients had to be treated by conventional open operation.For the patients treated by this technique, 16 patients were treated by endoscopic sphincterotomy (EST) plus choledochotomy. The stones were removed through a choledochoscope, and the bile duct was drained by a T-tube (LCTD). 18 patients were treated by endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (LC). The choledocholiths were removed by a choledochoscope through the cystic duct. 22 patients were treated by choledochotomy, and the calculus was removed through a choledochoscope and the bile duct was primarily sutured. 46 patients were treated by endoscopic nasobiliary drainage (ENBD) plus LC, choledochotomy. The calculi were through a choledochoscope and followed by primary suture of the bile duct. The mean time of endoscopic treatment, LC and postoperative hospital day were 35 min, 110 min and 6.5 d respectively. None of the 102 patients died after operation. 9 patients developed complications of ERCP or EST including acute pancreatitis (n=6), hemorrhage of papilla duodeni (n=2) and duodenal perforation (n= 1). 11 patients developed biliary fistula after primary suturing of the choledochus and they recovered with drainage; 2 patients developed residual or recurrent biliary fistula after the T tube was removed and they recovered after drainage via a [aparoscope. During follow-up for 1 to 3 years using ultrasonic or MRCP examinations, 3 cases of stones were found and they were removed by EST. There was no stenosis of common bile duct. Conclusions Our results suggested that the three-endoscope-combination in one anesthetic session for the treatment of extrahepatic bile duct calculi and acute gallstone pancreatitis was safe and efficacious. Moreover, this technique reduced the complications of EST. This technique increased the success rate using minimal invasive surgery. Key words: Cholelithasis; Gallstone pancreatitis; Laproscope; Choledochoscop; Duodenoscope

Large Balloon Dilation vs. Mechanical Lithotripsy for the Management of Large Bile Duct Stones: A Prospective Randomized Study

The removal of large bile duct stones (>12 mm) after endoscopic sphincterotomy (EST) remains a challenging issue in therapeutic endoscopy. The aim of this prospective, randomized, controlled trial was to compare the effectiveness and complications of EST followed by large balloon dilation (LBD) with that of EST followed by mechanical lithotripsy (ML) for the management of large bile duct stones. A total of 90 patients with large bile duct stones (12-20 mm) were randomized to EST followed by LBD (n=45) or EST followed by ML (n=45). Success rate was determined with a final cholangiogram, whereas type and rate of post-procedure complications were assessed prospectively. Complete bile duct stone removal was accomplished in 97.7% of patients subjected to EST-LBD as compared with 91.1% of those subjected to EST-ML (P=0.36). Post-procedure complications were observed in two (4.4%) patients subjected to EST-LBD and in nine (20%) patients subjected to EST-ML (P=0.049). Rates of pancreatitis were similar between the two groups (one case in each), as was post-endoscopic retrograde cholangio pancreatography (ERCP) hemorrhage (one case in each group). None of the patients subjected to EST-LBD developed cholangitis, while this was seen in six patients subjected to EST-ML (0.0 vs. 13.3%, P=0.026). One patient subjected to EST-ML developed perforation, which was successfully managed conservatively. None of our patients with complications died. EST followed by LBD is equally effective as EST followed by ML for the removal of large bile duct stones, although it is associated with fewer complications.

Availability of endoscopic microwave tissue coagulation therapy for endoscopic sphincterotomy-induced bleeding

Endoscopic sphincterotomy (ES) is a popular technique for the management of common bile duct stones. However, bleeding is one of the most common and potentially serious complications of ES. In the present article we described 2 patients with ES-induced bleeding, in whom our endoscopic hemostatic technique of microwave tissue coagulation (MTC) arrested the bleeding. MTC is tissue coagulation leveraging auto-induction heat. Therefore, duodenal tissue is coagulated homogenously without carbonization and the coagulation area is limited within an area of 5 mm in width and 2 mm in depth at a coagulation under our operational conditions (50 watts times 3-5 seconds at one go) using coaxial cable of 2.4 mm in diameter. It means that by applying MTC hemostatic therapy for ES-induced bleeding, there is little risk of acute pancreatitis and duodenal perforation. Moreover, MTC therapy is able to approach from tangential adjusting easily with the straight-view scope. As a result, MTC therapy has an important advantage in terms of both facility and safety as an endoscopic hemostatic method for the treatment of ES-induced bleeding.

MANAGEMENT OF ENDOSCOPIC SPHINCTEROTOMY‐INDUCED BLEEDING

Bleeding is one of the most common and potentially serious complications of endoscopic sphincterotomy (ES) and the overall frequency ranges from 2% to 5%. Patients with coagulopathy and anticoagulant therapy should be excluded from ES. ES using microprocessor‐controlled electrosurgical generator setting for Endocut mode, and a step‐wise manner of controlled incision may reduce the frequency of bleeding. Once ES‐induced bleeding occurs, diluted epinephrine irrigation, coagulation using papillotome, and balloon tamponade may be effective. If the bleeding continues, vessel ligation with a hemoclip should be performed to achieve a permanent hemostasis. Diluted epinephrine injection is an alternative technique when the point of bleeding is not identified. All endoscopists who perform ES should have suitable knowledge of management of bleeding and be experts in hemostasis.

Common bile duct diameter and complications of endoscopic sphincterotomy.

To assess the relationship between distal common bile duct (CBD) diameter and the incidence of an immediate complication following endoscopic sphincterotomy (ES), all patients undergoing ES between January 1986 and October 1990 were studied. The overall risk of an immediate complication following ES in 655 patients was 5.6 per cent (37 patients). Patients with calculi were at greater risk if the distal CBD was dilated (P < 0.001); the complication in those with stones was most likely to be haemorrhage (81 per cent). The relative risk of a complication increased ten times if the distal bile duct diameter was > 0.8 cm. Patients with stricture of the distal CBD did not have a significantly greater risk of complication than those with stones (9.7 versus 4.9 per cent). There was no significant difference between the mean distal CBD diameter of those with stricture and controls (0.61 versus 0.44 cm).

Endoscopic sphincterotomy: The whole truth

An 8 year experience of 602 patients (median age 76 years) referred for endoscopic management of common bile stones is reported. No patient referred for treatment has been excluded. A diagnostic cholangiogram was achieved in 94 per cent and sphincterotomy was accomplished in 91.5 per cent. The bile ducts were demonstrated to be completely cleared of stones in 491 (81.6 per cent) of 602 patients. A mean number of 1.9 endoscopic retrograde cholangiopancreatography examinations per patient were necessary to achieve this result. Complications of endoscopic sphincterotomy, which were strictly defined, occurred in 10.5 per cent of patients although five patients had two complications (total complication rate 11.3 per cent). The 30-day mortality rate was 2.2 per cent, seven of 13 deaths (1.2 per cent) occurring as a direct result of sphincterotomy. There have been statistically significant improvements in bile duct clearance and complication rates with increasing experience of endoscopists.

Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference?

Bleeding as a complication of endoscopic sphincterotomy is influenced by several factors. The objective of this study was to compare rates of bleeding after sphincterotomy performed with two different electrosurgical current generators (Valleylab SSE2L and ERBE ICC200). A total of 6179 consecutive reports of ERCP were analyzed to compare the frequency of endoscopically and clinically evident bleeding after sphincterotomy when using the Valleylab SSE2L generator (from February 1994 to November 1997) and the ERBE ICC200 generator (from December 1997 to September 2000). Relevant risk factors were assessed by univariate analysis and significant predictors were included in a multiple logistic regression model. A total of 2711 sphincterotomies were performed in 2309 patients (1749 biliary, 962 pancreatic). Endoscopically observed bleeding occurred in 68 patients (5.5%) in the ValleyLab group and 13 (1.2%) in the ERBE group. The ValleyLab generator was independently associated with an increase in endoscopically observed bleeding (OR 4.02: 95% CI[2.13, 7.61], p <0.001). There was no significant difference in clinically evident bleeding between the two groups. Use of the microprocessor-controlled ERBE electrosurgical generator for endoscopic sphincterotomy was associated with a significantly lower frequency of endoscopically observed bleeding but not clinically evident bleeding.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A 85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session. There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later. Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent

Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent

Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent

Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent

Complications of endoscopic sphincterotomy: results from a single tertiary referral center.

Complications of endoscopic sphincterotomy (ES) have been assessed in recent multicenter studies. The aim of this series was to report and identify risk factors for complications of ES at a single tertiary referral center. Between 1996 and 2000, 1159 consecutive endoscopic retrograde cholangiopancreatographies (ERCP) procedures were performed and their related complications were assessed. A total of 658 patients (57 %) underwent ES. All the clinical, radiological and biological data were carefully recorded within the 30 days following the procedure. Multivariate analysis was performed using a stepwise logistic model. The morbidity rate for ES was 7.7 %, being moderate to severe in 5 %. Morbidity included acute pancreatitis (3.5 %), perforations (1.8 %), sepsis (1.2 %) and bleeding (1.2 %). The 30-day mortality was 0.9 %. In the 1159 ERCP procedures, 231 patients underwent precut papillotomy (20 %) followed by sphincterotomy in 174 cases. Using logistic regression analysis, the risk factors for ES were precut papillotomy (relative risk, RR 2.76), confidence interval, (CI 1.39 - 5.49) and the presence of sphincter of Oddi dysfunction (RR, 7.72, CI 3.2 - 18.4). In this single-center series, we found a complication rate of ES in about 7 %, comparable to that in multicenter series. Precut papillotomy and sphincter of Oddi dysfunction were the main independent risk factors for ES.

Complications of endoscopic sphincterotomy: Can heparin prevent acute pancreatitis after ERCP?

Background: An exploratory analysis of a prospective study of risk factors for acute pancreatitis after ERCP combined with endoscopic sphincterotomy showed that the frequency of acute pancreatitis was lower in patients who received heparin compared with patients not treated with heparin. The study was continued to further analyze the effect of heparin on the frequency of acute pancreatitis. Methods: Potential risk factors for acute pancreatitis and outcomes were evaluated prospectively for all ERCP procedures with endoscopic sphincterotomy performed between September 1994 and December 1998. The results were analyzed by univariate and multivariate methods to determine risk factors for complications. Heparin was administered to 32.9% of the patients (heparin group [HEP group], n = 268) for various clinical reasons (low-molecular-weight heparin, n = 208, unfractionated heparin n = 60). A group of 547 patients who did not receive heparin served as control patients (CON group). Results: Eight hundred fifteen patients underwent ERCP with endoscopic sphincterotomy; acute pancreatitis occurred in 6.4% (n = 52). The frequency of acute pancreatitis was significantly lower in the HEP group versus the CON group in the final multivariate model, which included significant risk factors for acute pancreatitis (HEP group: 3.4%, 9/268 vs. CON group: 7.9%, 43/547; p = 0.005). HEP did not increase the risk of hemorrhage (HEP group: 1.1%, 3/268, 2 severe, none fatal vs. CON group: 2.0%, 11/547, 3 severe, 2 fatal). HEP (p = 0.005; OR 0.3: 95% CI [0.16, 0.73]) and the number of risk factors present (p = 0.0001; OR 2.5: 95% CI [1.80, 3.50]) influenced the frequency of acute pancreatitis independently. Conclusions: Heparin was significantly associated with an extremely low frequency of post-ERCP pancreatitis without increasing the risk of hemorrhage after endoscopic sphincterotomy. Because this effect could not be attributed to other known or suspected confounders, our conclusion was that heparin administration before ERCP reduces the risk of pancreatitis. (Gastrointest Endosc 2002;55:476-83.)

Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis

Background: Endoscopic sphincterotomy can benefit patients with suspected biliary pancreatitis, although there are procedure-related complications. EUS can be used to select patients for endoscopic sphincterotomy. The results of this strategy were assessed. Methods: Information on patients referred for EUS were recorded in a database. One hundred twenty-three patients with suspected biliary pancreatitis (57 men, 66 women; median age 55 years) were included and followed. All underwent EUS followed by endoscopic sphincterotomy during the same procedure if choledocholithiasis was identified. Outcomes were studied in relation to the initial severity of biliary pancreatitis (Ranson and Balthazar scores), presence of stones, and time span between onset of biliary pancreatitis and EUS plus endoscopic sphincterotomy. Results: Thirty-five patients (28%) had a Ranson score greater than 3 on admission and 38 (31%) were Balthazar D-E. The median time from admission to EUS was 3 days. EUS imaging of the bile duct was complete in all but 3 patients. Thirty-three patients (27%) had choledocholithiasis on EUS and underwent endoscopic sphincterotomy. Stones were more frequent in patients with jaundice ( p < 0.005) and when EUS was performed less than 3 days after admission ( p < 0.05). One hundred patients (81%) recovered without complication. Two patients (1.6%) died, 1 had recurrent BP develop, 6 (5%) had further biliary symptoms, and 16 (13%) had complications of pancreatitis develop (9 pseudocysts). There were 3 mild endoscopic sphincterotomy-related complications (complication rate 6.5%). Conclusions: In this series in which endoscopic sphincterotomy was performed selectively depending on the endosonographic presence or absence of ductal stones early in the course of the pancreatitis, and not according to its predicted severity, mortality and complications of endoscopic sphincterotomy were low and unrelated to the predicted severity of biliary pancreatitis or the presence of choledocholithiasis. Controlled trials are needed to confirm the superiority of this strategy compared with ERCP alone for the management of biliary pancreatitis. (Gastrointest Endosc 2001;54:724-9.)

4619 Hemorrhage after endoscopic sphincterotomy: risk factors and endoscopic managenent - final results of a prospective study.

To determine risk factors (RF) for hemorrhage after endoscopic sphincterotomy (EST) and to evaluate the outcome of therapeutic modalities. METHODS: In all consecutive EST procedures between 09/94 and 12/98 indications, techniques, success, complications of EST, and possible RF for hemorrhage were evaluated prospectively. Pts. were followed up by physical examination and blood samples at 4, 24 and 48 hours after EST. Complications were classified according to commonly accepted criteria (Gastrointest Endosc 1991: 338). Risk factor analysis was performed using univariate methods. RESULTS: In 815 pts. (53.3% m, 46.7% f, 61±17 y); complications occured in 9.9% (81/815; 69 mild-moderate; 11 severe; 4 fatal). Bleeding during the procedure was seen in 50 pt. (self-limiting in 35 cases, successful injection therapy in 15 pt). The incidence of hemorrhage (drop of hemoglobin of at least 2 g/dl and clinical signs of hemorrhage) was 1.6% (14/815; 7 mild-moderate; 5 severe; 2 fatal). Hemorrhage was detected only in 2 pt., who showed bleeding during EST (both with prior injection therapy), and in 12 pt. without signs of bleeding during EST. The clinical onset of hemorrhage was within 4 hours after EST in 5 pt., within 2 days in 4 pt., and within 4 to 10 days in 5 pt. Univariate analysis obtained 2 RF for hemorrhage: coagulopathy (thrombocytes<50.000 or prothrombintime<50%; 2/11, p=0.019) and intensive-care-pt. before EST (2/13, p<0.014). Additionally prior gastrectomy (2/28, p<0.080) increased the incidence of hemorrhage, and EST<5mm decreased the incidence (1/256; p=0.076). CONCLUSIONS: Bleeding during EST mainly stops spontaneously, and if not, injection therapy is effective. However bleeding was no significant risk factor for later hemorrhage. Hemorrhage showed in up to one third of pt. a late onset, and was significantly associated with risk factors. Thus, in pts. with risk factors for hemorrhage, alternative access procedures like papillary dilation should be considered.