Distal Common Bile Duct Obstruction Research Articles

Acetylsalicylic acid for metal stent in malignant distal common bile duct obstruction: A randomized controlled trial

BackgroundEndoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction. Self-expandable metal stents have clinical advantages including an increased duration of patency that may be prolonged by acetylsalicylic acid (ASA) use. The aim of this study was to investigate whether ASA had a positive effect on the patency of self-expandable metal stents compared with placebo. MethodsThis prospective, multicenter, double-blinded, and randomized placebo-controlled trial was conducted from October 2017 to May 2020 in Korea. Patients who underwent palliative endoscopic biliary drainage with self-expandable metal stents for malignant distal bile duct obstruction were enrolled, and allocated to ASA treatment or placebo. The study outcomes were the rate of stent dysfunction at 6 months, duration of stent patency, risk factors for stent dysfunction, and any adverse events. ResultsInterim analysis included 24 and 28 patients in the ASA and placebo groups, respectively. There was no significant difference between the ASA and placebo groups in stent dysfunction (25.0% vs. 20.7%, P = 0.761) or the duration of stent patency (150.97 ± 10.55 vs. 158.07 ± 8.70 days, P = 0.497). Six patients experienced suspected ASA-related adverse events, and there was one lethal case. ConclusionsASA did not prolong stent patency. This study was terminated early because of the possibility of serious adverse events related to ASA treatment of these patients receiving palliative care.

Triple cancer of gallbladder, common bile duct and papilla of Vater: Report of a case and review of literature.

Introduction and importanceSynchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.Case presentationAn 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice.Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction.An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD.Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD.Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI.A cephalic duodenopancreatectomy and radical gallbladder resection was performed.Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla.Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.Clinical discussionLiterature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma.In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported.Although the real incidence remain unknown, it was reported to occur in 5–10% of CBD cancers.ConclusionSuspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree.

S2332 Complete Occlusion of the Common Bile Duct Due to Erosion of a Gastroduodenal Artery Coil

INTRODUCTION: Endoscopic intervention remains the first-line method for treating upper gastrointestinal bleeding. In the case of bleeding duodenal ulcers and failed endoscopic hemostasis, visceral artery embolization has become standard of care at many centers because of its high efficacy and minimal side-effect profile. We present a patient who presented with ascending cholangitis due to complete occlusion of the CBD after migration of a gastroduodenal (GDA) coil. CASE DESCRIPTION/METHODS: 53-year-old male with history of duodenal ulceration and massive hemorrhage status post graham patch repair and suture ligation of the GDA followed by elective embolization of the GDA, complicated by disruption of the common bile duct (CBD) and hepatic artery hemorrhage status post stenting, presented 30 months after GDA embolization with transaminitis and recent hospitalization with Klebsiella bacteremia of unclear etiology. Subsequent outpatient ERCP revealed complete obstruction of the CBD at the level of the GDA coils. Manipulation of wires allowed for passage through a fistula that ended on the bulb side of the pylorus. Cholangioscopy revealed erosion of nearly the entire GDA coil into the bile duct entrapping multiple portions of the biliary wall. Various sites were probed with wire but without ability to pass. Patient was referred for percutaneous biliary tube placement and initial plan was to repeat ERCP after PTC to try to pull coils out of the duct with forceps. However, subsequent cholangiogram and intervention resulted in successful recanalization of distal CBD obstruction and placement of internal/external biliary drain. Intraluminal portion of the coil pack had migrated into the duodenum and was removed. A 10 mm × 60 mm covered stent was positioned under fluoroscopic guidance to reconnect the ducts. DISCUSSION: Percutaneous endovascular embolization is generally safe and capable of achieving hemostasis in 93% of emergent cases of GI bleeding nonamenable to endoscopic therapy. Coil migration causing biliary obstruction, although rare, has been previously reported including a few case reports involving the embolization of the hepatic arteries and one case in the English literature involving the GDA. ERCP with removal of the coils is the best management. When ERCP fails, as in our case, decompression of the biliary system by PTC or surgery should be considered.Figure 1.: ERCP showing GDA coils in the CBD.Figure 2.: ERCP cholangiogram showing complete obstruction of the CBD.Figure 3.: IR Cholangiogram showing recanalization of CBD.

Aspirin for metal stent in malignant distal common bile duct obstruction (AIMS): study protocol for a multicenter randomized controlled trial

BackgroundEndoscopic retrograde biliary drainage (ERBD) is the treatment of choice for patients with malignant distal common bile duct (CBD) obstruction. Self-expandable metal stents (SEMS), which are commonly used in unresectable cases, have many clinical advantages, including longer stent patency. Although the expected patency of SEMS is around 8 months, it has recently been reported that the duration of SEMS’ patency in patients using aspirin is prolonged. Our study, therefore, aims to investigate the effect of aspirin on SEMS’ patency.Methods/designThis is an investigator-initiated, prospective, multicenter, double-blind, randomized placebo-controlled trial that will be conducted from November 2017 in four tertiary centers in South Korea. We intend to include in our study 184 adult (aged ≥ 20 years) patients with malignant distal CBD obstruction for whom ERBD with SEMS was successfully performed. The patients will be randomly allocated to two groups, which will comprise patients who have either taken 100 mg aspirin or a placebo for 6 months after index ERBD. The primary outcome will be the rate of stent dysfunction, and the secondary outcomes will be the duration of patency, the rate of reintervention, and the occurrence of adverse events.DiscussionThe aspirin for metal stents in malignant distal common bile duct obstruction (AIMS) study should determine the efficacy of aspirin in maintaining metal-stent patency in patients with malignant distal CBD obstructive.Trial registrationClinicalTrials.gov, ID: NCT03279809. Registered on 5 September 2017.

Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe?

The aim of this study was to evaluate the outcomes following upfront pancreaticoduodenectomy (PD) in severely jaundiced (serum bilirubin level ≥15mg/dl) patients with malignant distal common bile duct (CBD) obstruction. Recent studies have failed to show the benefits of preoperative biliary drainage (PBD) before PD. In addition, there is limited data on the impact of upfront PD on perioperative outcomes in severely jaundiced patients. We reviewed the prospectively collected data of 177 patients who had undergone PD for the malignant distal CBD obstruction from May 2009 to May 2018. Study subjects were divided into Group A (severely jaundiced patients with upfront PD; n=20), Group B (patients with serum bilirubin<15mg/dl and no PBD; n=88) and Group C (PBD prior to PD; n=69). Overall morbidity, in-hospital mortality, and postoperative hospital stay were compared. No significant differences were noted between the three groups regarding sex, tumor size and stage, comorbidities, and surgical technique. The intra-operative blood loss was more in severely jaundiced patients as compared to Groups B and C (605 vs. 300 vs. 350ml, P=0.0001), but similar operative times, blood transfusions, and rates of post-pancreatectomy leak and hemorrhage. The infective complications were significantly less with upfront surgery. The overall morbidity, in-hospital mortality, and hospital stay were comparable between the three groups. Multiple logistic regression analysis failed to identify both the presence of preoperative jaundice and hyperbilirubinemia≥15mg/dl as independent risk factors for post-PD major morbidity. Upfront PD can be performed safely in the selected severely jaundiced patients and is associated with significantly lower infective complications.

1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia. CASE DESCRIPTION/METHODS: A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery. DISCUSSION: Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.

Metastatic Breast Cancer Presenting as Painless Jaundice

Jaundice carries with it a wide-ranging differential diagnosis, including etiologies relating to infection, autoimmune, toxins, malignancy, and metabolic derangements. We present a case involving a female with history of breast cancer and relapse-free interval of 15 years who presented with an initial complaint of painless jaundice and was unfortunately diagnosed with metastatic disease involving the liver, bone, and lymph nodes. A 56-year-old female presented to the emergency department for evaluation of painless jaundice, first noticed by family members one day prior to arrival. The patient has a history of breast cancer at age 36, treated with chemotherapy, radiation, and right mastectomy. Physical exam revealed jaundice and scleral icterus and a firm, non-tender liver, palpable beyond the costal border with a negative Murphy's sign. Laboratory findings were consistent with a cholestatic process. A right upper quadrant abdominal ultrasound revealed a 4.1 x 3.6 cm poorly defined mass in the right lobe of the liver, common bile duct measuring 8.6 mm, and intrahepatic ductal dilatation, suggestive of distal common bile duct obstruction. A follow up MRCP showed extensive hepatic metastases with innumerable liver lesions of varying shape and size. The patient underwent an ERCP, where a pancreatic duct stent was deployed but the common bile duct could not be cannulated. The patient subsequently underwent a hepatic lesion biopsy and placement of an internal/external biliary drainage catheter by Interventional Radiology secondary to complete, abrupt obstruction of the distal common bile duct. Biopsy results were positive for primary mammary malignancy. A review of the literature revealed only a select number of cases where patients presented with painless jaundice deemed secondary to metastatic breast cancer. This is the first such case in which the patient already had a known diagnosis of breast cancer, irrespective of prior treatment. In patients with malignant obstruction, biliary stenting has been shown to improve jaundice and deliver improved quality of life. In conclusion, in patients with known malignancy, the development of jaundice may indicate hepatic or biliary metastasis with bile duct obstruction. While a multidisciplinary approach to treatment is necessary, biliary stenting to relieve obstruction is a viable option for palliation.1364_A.tif Figure 1: Papanicolaou stain, (A, 40x) showing numerous large atypical atypical cells with high nuclear to cytoplasmic ratios. H&E stain (B, 10x) of the core biopsy showing this infiltrate within the liver parenchyma. Additional immunohistochemical stains show these cells are positive for GATA3 (C, 10x), GDCDFP-15 (D, 10x), mammaglobin (E, 10x), and ER (F, 10x).1364_B.tif Figure 2: MRI of abdomen: axial image showing extensive hepatic metastases with innumerable liver lesions of varying shape and size.

Pancreatic tuberculosis causing biliary obstruction and mimicking pancreatic malignancy

Tuberculosis (TB) is a bacterial infection which can affect any part of the body from head to toe and has various presentations depending on the site of the infection. Pancreatic TB is very rare and usually happens as a part of disseminated or miliary TB, whereas isolated pancreatic TB is even rarer. Here, we present a case of pancreatic TB at a TB endemic zone which presented with obstructive jaundice and pancreatic lesions mimicking pancreatic malignancy. A 46-year-old Saudi female patient presented with right upper quadrant abdominal pain associated with dark coloured urine and pale stool. The patient had been admitted to the surgical ward as a case of acute cholecystitis for further evaluation. On abdominal ultrasound (US), findings demonstrated dilated common bile duct (CBD), but the distal part was difficult to be visualised; hence, further evaluation by magnetic resonance cholangiopancreatography (MRCP) was recommended to look for CBD stones. The MRCP showed two focal pancreatic lesions causing the distal CBD obstruction with no stones at CBD. Based on these findings, malignancy was considered and computed tomography-guided fine-needle aspiration biopsy from the pancreatic neck lesion was performed. This demonstrated multiple granulomas and lymphocytes with no malignant cell which indicated pancreatic TB. The patient became well after a course of anti-TB medications. pancreatic TB should be included in the differential diagnosis of pancreatic masses, especially in those patients who live in an endemic area of TB. A biopsy is necessary to establish the diagnosis and start the appropriate treatment for this curable disease as soon as possible.

Portal Cavernoma Mimicking Pancreatic Malignancy

Portal Cavernoma Colangiopathy (PCC) is characterized by biliary tract abnormalities due to extrahepatic portal vein obstruction (EHPVO). EHPVO can also cause pre-hepatic portal hypertension. Portal cavernoma refers to the expanded network of collateral vessels, sometimes mimicking a neoplasm. We report a 65-year-old man with past medical history of portal hypertension, who was admitted due to jaundice and abdominal distension. Laboratory tests were impressive for alkaline phosphatase 674 U/L, total bilirubin 6.8 mg/dL and transaminases 60 U/L. Computed tomography (CT) of the abdomen and pelvis revealed biliary ductal dilatation and a hepatic lesion suggestive of hemangioma. Magnetic resonance cholangiopancreatography (MRCP) revealed intra and extra hepatic biliary dilatation, and an irregular narrowing of the common bile duct (CBD) at the level of the porta hepatis surrounded by an ill-defined soft tissue lesion. To better asses the stricture at the CBD and unclear mass at porta hepatis, endoscopic ultrasonography (EUS) was performed. A hypoechoic mass was seen at the pancreatic head region with associated distal CBD obstruction and extensive collateral circulation. Given biliary dilation seen on CT and EUS with CBD stricture, endoscopic retrograde cholangio-pancreatography (ERCP) was performed and demonstrated a localized biliary stricture with malignant appearance. Sphincterotomy was performed and a metal stent was placed into the CBD. Fine needle aspiration from the EUS and brush cytology from ERCP were negative for malignancy. A repeat EUS showed stable vascular lesion in the peripancreatic area. A liver biopsy showed mild nodular regenerative hyperplasia (NRH) with minimal fibrosis. These cholangiographic findings were determined to be due to chronic PVT with cavernous transformation. Our paper illustrates a patient with non-cirrhotic portal hypertension associated with PVT and cavernous transformation, known as PCC. The hypoechoic mass at the peripancreatic region and biliary stricture were radiologic features of PCC. Symptomatic patients with PCC are at high-risk for sustained biliary obstruction complications, including secondary biliary cirrhosis. An association between PCC and NRH has not been previously described and likely contributed to the portal hypertension in this case. One must be aware of PCC as an important differential diagnosis with malignancy and a cause of pre-cirrhotic portal hypertension.Figure

A Tale of a 4-year-old Biliary Stent: Lessons to Learn

FigureComplications associated with biliary stents are rare and include stent occlusion, stent migration and cholangitis. Despite the high success rate, limited data is available about their long term complications. We report the case of a 47 y.o. woman presenting with biliary colic secondary to an impacted forgotten BS. Only few cases were reported in the English literature where biliary duct obstruction resulted from forgotten BSs that promoted the formation of new bile stones. A 47 y.o. woman presented for 2 week history of postprandial right upper quadrant abdominal pain that radiated to her back. Medical history was significant for a benign common bile duct (CBD) stricture that was treated with balloon dilatation and a 10 Fr x 7.5 cm CBD stent placement 53 months ago. The patient was asymptomatic since and never followed up. Laboratory tests showed cholestasis. A contrast abdominal Magnetic Resonance Imaging showed central intrahepatic and CBD dilatation up to 1.2 cm. Attempts to remove the old BS were unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a non mobile filling defect consistent with small stones causing moderate distal CBD obstruction. The retained BS appeared to be embedded in the filling defect. A new 7FR x 12cm BS was placed. Another ERCP was performed. A 6mm x 4cm biliary balloon was used to dilate the CBD under fluoroscopic guidance. After dilation, the retained BS was successfully removed with a snare. Small stone fragments and gravel were also removed by a wire guided biliary basket. Spyglass cholangioscopy demonstrated large solid casting of stones in the CBD where the distal end of the old stent resided. A wireguided 10Fr x 10cm plastic BS was placed to facilitate biliary drainage. The remaining stones were removed with electrodynamic lithotripsy in 2 sessions. The ultimate goal of biliary endoprosthesis is the prevention of cholangitis through the maintenance of an uninterrupted biliary flow. However patients usually fail to follow up view the resolution of their symptoms. The most feared complication of retained biliary stents remains cholangitis therefore plastic stents need to be removed or replaced every 3-6 months to prevent flow disruption and superimposed bacterial infection. Management of retained stents includes endoscopic stent retrieval, especially in uncomplicated cases However in case of stent impaction and development of large stentolith, surgical intervention may be the only therapeutic choice.

Continuing Medical Education Exam: April 2015

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Holt BA, Jayasekeran V, Williams SJ, et al. Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett’s excision for high-grade dysplasia and early cancer. Gastrointest Endosc 2015;81:857-64. Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015;81:882-8. Schlag C, Menzel C, Nennstiel S, et al. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015;81:889-95. Dhir V, Itoi T, Khashab MA, et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc 2015;81:913-23. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach

A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study comparing EUS-BD andERCP for the relief of distal malignant biliary obstruction. To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD. Multicenter, retrospective analysis. Tertiary referral centers. Patients with malignant distal CBD obstruction requiring SEMS placement. Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement. Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks). The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P= 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P= .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P= .05). Retrospective analysis. In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.

Comparison of transhepatic and extrahepatic routes for EUS-guided rendezvous procedure for distal CBD obstruction.

EUS-guided rendezvous procedure (EUS-RV) can be done by the transhepatic (TH) or the extrahepatic (EH) route. There is no data on the preferred access route when both routes are available. To compare the success, complications, and duration of hospitalization for patients undergoing EUS-RV by the TH or the EH route. Patients with distal common bile duct (CBD) obstruction, who failed selective cannulation, underwent EUS-RV by the TH route through the stomach or the EH route through the duodenum. A total of 35 patients were analysed (17 TH, 18 EH). The mean procedure time was significantly longer for the TH group (34.4 vs. 25.7 min; p = 0.0004). There was no difference in the technical success (94.1 vs. 100%). However, the TH group had a higher incidence of post-procedure pain (44.1 vs. 5.5%; p = 0.017), bile leak (11.7 vs. 0; p = 0.228), and air under diaphragm (11.7 vs. 0; p = 0.228). All bile leaks were small and managed conservatively. Duration of hospitalization was significantly higher for the TH group (2.52 vs. 0.17 days; p = 0.015). EUS-RV has similar success rate by the TH or the EH route. However, the TH route has higher post-procedure pain, longer procedure time, and longer duration of hospitalization. The EH route should be preferred for EUS-RV in patients with distal CBD obstruction when both access routes are technically feasible.

A Case of Adenocarcinomain situof the Distal Common Bile Duct Diagnosed by Percutaneous Transhepatic Cholangioscopy

Extrahepatic cholangiocarcinoma is often clinically challenging to diagnose. Even multidisciplinary approaches which include computed tomography, magnetic resonance imaging, and endoscopic retrograde cholangiography are unsatisfactory in some cases, especially with biliary stricture. Percutaneous transhepatic cholangioscopy (PTCS) with its direct visualization for biopsy appears to be a promising technique for detecting cholangiocarcinoma at an early stage. We report a case of adenocarcinoma in situ of the distal common bile duct (CBD) that was confirmed by PTCS. This case suggests the useful role of PTCS in the differential diagnosis of a distal CBD obstruction, particularly when other diagnostic modalities do not provide definitive information.

The Clip That Got Away: A Migrated Cholecystectomy Clip as a Nidus for Distal Common Bile Duct Obstruction and Stone Formation

Purpose: 43 year old male presented with a one week history of fatty food intolerance, clay colored stools, and right upper quadrant pain. He underwent cholecystectomy 2 years ago for cholelithiasis and similar pain. A right upper quadrant ultrasound showed no ductal dilation, no intraductal lesion, and confirmed a previous cholecystectomy. Within 6 hours of admission, his bilirubin and alkaline phosphatase were double the normal values and his transaminases were seven times the normal values. A CT scan of the abdomen and pelvis with IV contrast showed no abnormalities from the AP view. Based on his clinical picture, ERCP was performed. The initial endoscopic image showed a clip encased in a stone at the ampulla (A). After wire cannulation past the stone, bile and pus began to flow out of the ampulla. A sphincterotomy was performed and the stone and clip were removed by balloon sweeps (B). Upon further review of the CT, a metal object was seen at the ampulla on sagital images (C)(box). Within 24 hours, the patient was back to his baseline and was discharged home. One similar case of a cholecystectomy clip causing obstruction and cholangitis was published in OVID (1).FigureFigureFigure

Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction

Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction. A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival. The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design. Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.

Endoscopic Sphincterotomy Before Deployment of Covered Metal Stent is Associated With Greater Complication Rate

Endoscopic sphincterotomy (ES) may facilitate insertion of self expandable metal stent (SEMS) and also help avert the development of pancreatitis from stent-related occlusion of the pancreatic duct. On the other hand, ES is also independently associated with pancreatitis, bleeding, and perforation. We evaluated whether ES before SEMS placement was associated with a greater likelihood of stent migration and other complications in patients with malignant obstruction of the distal common bile duct. Seventy-four patients with unresectable distal bile duct obstruction were prospectively randomized to biliary stenting following ES (group 1) and without ES (group 2). Main outcome measures included overall procedure complications rates including stent migration, stent occlusion, oxygen desaturation, bleeding, perforation, and pancreatitis. Covered SEMS were successfully deployed in all patients in both groups. Stent migration occurred in 6 patients (16%) in group 1 and 1 patient (3%) in group 2, P=0.075. Overall, complications occurred in 18 patients in group 1 and 4 patients in group 2, P=0.006. There was no pancreatitis in either group. Deployment of covered SEMS without prior ES in patients with distal common bile duct obstruction owing to pancreatic cancer is feasible and prevents the development of complications such as stent migration, bleeding, and perforation.

Common bile duct perforation resulting from a gastric duplication cyst

Gastric duplication cysts are a rare cause of abdominal masses in infants. Most children present with a gastric outlet obstruction or some vague abdominal complaints. We present an unusual case of a gastric duplication cyst that created a distal common bile duct obstruction which led to a proximal common bile duct perforation.

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. In this study, 47 patients (median age, 73 years, range, 56-86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.

Should surgeons operate on the evidence of ultrasound alone in jaundiced patients?

The biliary ultrasound scans of 132 patients having a laparotomy for jaundice have been reviewed to assess the role of ultrasound in the selection of patients for surgery. When scans were technically satisfactory the finding of a dilated extrahepatic duct (EHD) indicated obstructive jaundice in all cases, but the obstructing lesion in 5 per cent of such cases was too proximal for jaundice to be relieved by direct surgical decompression. Scans were further classified on the basis of abnormalities detected in the gallbladder. When EHD dilation was associated with gall bladder findings 'typical' of distal common bile duct (CBD) obstruction due to gall stones (small gallbladder with multiple gallstones) or tumour (dilated gallbladder without gallstones), surgically remediable obstruction was always present. Although ultrasound identified the obstructing lesion itself in a minority of cases, the cause of obstruction could be correctly inferred in 95 per cent of 'typical' scans. These results suggest that it is safe to proceed directly to surgery only when an experienced ultrasonographer demonstrates findings 'typical' of distal CBD obstruction due to gallstones or tumour.