Downstream Stricture Research Articles

Su1422 CHOLANGIOPANCREATOSCOPY-GUIDED SOFT TISSUE LASER DISSECTION AND ABLATION FOR REFRACTORY STRICTURES AND NEOPLASIA

Benign pancreas and biliary strictures may be refractory to stenting. Safety data exists for laser tissue dissection in ex vivo biliary studies. Cholangiopancreatoscopy-guided laser dissection or ablation (CPL) provides a novel therapeutic modality that could be an alternative to surgical intervention. The primary aim of this study is to describe the safety and efficacy of CPL for a variety of pancreas and biliary disorders. A single-center retrospective review of patients who underwent CPL between 7/16-10/19. Holmium (Litho, Quanta System) or Thulium (Cyber TM, Quanta System) laser units with a 200-272μm fiber (International Medical Lasers) were used under saline immersion (frequency 8-20 Hz, energy 0.5 joules, power 5-20 Watts). Compared to holmium, thulium provides a continuous wave that has a shallow depth of penetration beneficial in dissection or ablation. For stricture dissection, gentle contact of the laser from a distal to proximal stroke was applied until lumen patency permitted advancement of the 10.5Fr cholangiopancreatoscope (SpyGlass DS, Boston Scientific) followed by balloon dilation and stenting. The definition of immediate technical success was the ability to traverse the stricture with the cholangiopancreatoscope after CPL and short-term technical success was improvement of the stricture from pre-CPL compared to subsequent ERCP. Descriptive statistics were used for patient characteristics and treatment details. In all, 11 patients (mean age of 58, 90.9% female) underwent a mean of 3.6 ERCP’s (mean total diameter of 14.2 Fr of stenting) prior to CPL (Table 1). Indications included pancreatic duct stricture (n=8, 72.7%), pancreaticojejunostomy anastomotic stricture (n=1), bile duct stricture (n=1) and pancreatic intraductal papillary mucinous neoplasm ablation (IPMN) in a medically inoperable patient with recurrent acute pancreatitis (n=1). 17 (median 1, range 1-3) CPL sessions were performed and holmium was used most frequently (73.3%) with a median energy delivered of 8.5 KJ (Table 2). There was one adverse event of pneumonia; no post-ERCP pancreatitis was noted. At mean follow-up of 11.5 months, immediate and short-term technical success rates were 92.9% (13/14 strictures) and 85.7% (12/14 strictures). In 63.6% (n=7) of patients, CPL of strictures permitted access to impacted pancreatic duct stones for concomitant laser lithotripsy. The patient with IPMN had no further hospitalizations for pancreatitis. 1) CPL for strictures of the pancreatic duct refractory to conventional dilation and multiple stenting carries a high rate of technical success and is safe. 2) CPL of downstream strictures can facilitate access to impacted stones for laser lithotripsy. 3) Larger studies with a control population are required to further validate this technique.Laser treatment detailsView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Proposal for Endoscopic Ultrasonography Classification for Small Pancreatic Cancer.

Backgrounds: Endoscopic ultrasonography (EUS) is used to observe the stricture of the main pancreatic duct (MPD) and in diagnosing pancreatic cancer (PC). We investigate the findings on EUS by referring to the histopathological findings of resected specimens. Materials and Methods: Six patients with carcinoma in situ (CIS) and 30 patients with invasive carcinoma of 20 mm or less were included. The preoperative EUS findings were classified as follows. A1: Simple stricture type—no findings around the stricture; A2: Hypoecho stricture type—localized hypoechoic area without demarcation around the stricture; A3: Tumor stricture type—tumor on the stricture; B: Dilation type—the dilation of the pancreatic duct without a downstream stricture; C: Parenchymal tumor type—tumor located apart from the MPD. Results: Classes A1 and A2 consisted of 2 CISs, and 4 invasive carcinomas included two cases smaller than 5 mm in diameter. Most of the cancers classified as A3 or C were of invasive carcinoma larger than 5 mm in diameter. All cancers classified as B involved CIS. Serial pancreatic-juice aspiration cytologic examination (SPACE) was selected for all types of cases, with a sensitivity of 92.0%, while EUS-guided fine needle aspiration cytology (EUS-FNA) was only useful for invasive carcinoma, and its sensitivity was 66.7%. Conclusions: Stricture without a tumor could be a finding for invasive PC and pancreatic duct dilation without a downstream stricture could be a finding indicative of CIS. Carcinoma smaller than 5 mm in diameter could not be recognized by EUS. SPACE had a high sensitivity for diagnosing small PC.

Su1400 EUS-GUIDED HEPATICOENTEROSTOMY: A SINGLE CENTER U.S. EXPERIENCE IN A COHORT WITH PRIMARILY BENIGN DISEASE AND ALTERED SURGICAL ANATOMY

Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HE) is typically used to treat malignant biliary obstruction when conventional ERCP fails. Limited data exist on use of EUS-HE for benign biliary obstruction. Describe outcome of EUS-HE using a fully covered biliary non-foreshortening self-expandable metal stent (FCSEMS) and assess patient and procedural characteristics on technical success. Retrospective review of 35 consecutive patients considered for EUS-HE performed by one endoscopist from 1/2015 - 11/2017. 35 patients were considered for EUS-HE. 27 had surgically-altered anatomy; 20 Roux-en-Y (16 gastric bypass, 4 hepaticojejunostomy), 2 Billroth II, 1 gastrojejunostomy, 3 Whipple and 1 other. 23 were outpatients at time of EUS-HE. 3 were excluded due to lack of intrahepatic ductal dilation on EUS. Of 32 patients undergoing EUS-HE, 21 were female, (median age 68 years) and only 7 (22%) had malignant biliary obstruction. General anesthesia was used for all cases. EUS-HE was technically successful in 25 patients (78%). In 7 failed EUS-HE there was lack of intrahepatic ductal dilation; 5 underwent balloon-assisted ERCP, 1 underwent surgery and 1 was observed. In the 25 technically successful cases stent(s) were deployed into the left hepatic duct; electrocautery was only used in 4 patients; the tract was dilated via tapered catheters and biliary balloon dilators (mean diameter 4.3 mm) followed by placement of a FCSEMS (VIABIL® Biliary Endoprosthesis, W.L. Gore & Associates). Stent diameters were: 8 mm (N=18) or 10 mm (N=7). Lengths were 40 mm (N=1), 60 mm (N=3), 80 mm (N=16), and 100 mm (N=5); plastic stents were variably placed through the SEMS. The average duct diameter in technically successful HE was 9.4 mm vs 1.4 mm when failed (p=0.001). In 17 patients antegrade ERCP (mean procedures 3.1) was subsequently performed via HE for stone clearance and downstream stricture treatment (6 benign anastomotic, 1 malignant hilar). Stone clearance was achieved in all using balloon sphincteroplasty, cholangioscopy and antegrade sweeping. One severe adverse event (perforation) occurred at a site remote from the HE, surgically managed. 18/23 remained outpatient. Mean inpatient hospital stay was 1.6 days. EUS-HG stents were removed in 15 patients at a mean duration of 86 days, without adverse events. 3 deaths during the follow-up period were due to underlying malignancy. EUS-HE using a commercially available, fully covered self-expandable biliary stent is safe and effective in managing benign and malignant biliary obstruction in patients with otherwise inaccessible biliary anatomy. Left hepatic ductal diameter > 5 mm was a statistically significant predictor of technical success. Studies are needed to determine optimal patient selection and procedural technique.

EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy

EUS-guided hepaticoenterostomy (EUS-HE) usually is reserved for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiography (ERC) or inaccessible biliary tree in surgically altered anatomy (SAA). We describe the outcome of EUS-HE and antegrade therapy for benign biliary disease in patients with SAA. Retrospective review of 20 consecutive patients with surgically altered anatomy and benign biliary obstruction who underwent EUS-HE performed by 1 endoscopist at a tertiary-care center over a 3-year period. During the study period, 37 patients underwent EUS-HE; 24 for benign disease. Of these, 20 patients had SAA and were analyzed (15 women, mean age, 62 years). SAA consisted of 9 Roux-en-Y gastric bypasses, 6 Roux-en-Y hepaticojejunostomy, 2 Billroth II procedures, and 3 Whipple procedures. Indications for ERC were common bile duct stones (n= 8), benign postoperative strictures (n= 7), chronic pancreatitis (n= 3), inflammatory stricture (n=1), and treatment of a bile leak (n= 1). Five patients had previously failed balloon enteroscopy-assisted ERCs. The approach was transgastric in 15 and transjejunal in 5. In all cases, a branch of the left hepatic duct with a mean diameter of 7.8mm was accessed. Median stent length was 80mm, with diameters of 8 or 10mm. Antegrade, definitive endoscopic therapy via the HE was performed in 18 patients, with an average of 2.7 procedures performed for resolution of stones and/or downstream strictures. HE stents were removed in 17 patients after a mean of 91 days without adverse events. Three patients experienced mild adverse events (1 with postprocedural pancreatitis after placement of a 10F transpapillary stent, 1 with postprocedural abdominal pain, and 1 with postprocedural cholangitis) requiring hospitalization for fewer than 3 nights; no severe adverse events occurred. The average postprocedural hospital stay was 1.3 days. No deaths occurred during follow-up. EUS-HE is safe and effective in the management of benign biliary obstruction in patients with surgically altered anatomy. It creates a portal to allow definitive, antegrade therapy and is a viable alternative to other endoscopic methods in this patient population.

Endoscopic ultrasound as a predictor and guide to successful endotherapy in chronic pancreatitis

Background:Pancreatic calculi are sequelae of chronic pancreatitis (CP) and may obstruct pancreatic ducts leading to pain. Indications for endotherapy include nonimpacted <5 mm stones in the head of pancreas with the absence of downstream strictures. The assessment before endotherapy is done by magnetic resonance cholangiopancreatography/computed tomography.Objectives:To assess the modality of endoscopic ultrasound (EUS) as a roadmap before endoscopic retrograde cholangiopancreatography (ERCP) in patients planned for endotherapy in CP.Methods:The data of 412 patients with CP were retrospectively analyzed. A total of 143 were associated with stones in the head/papillary region of pancreas. Of these, around 75 were excluded and remaining 68 were evaluated by EUS using a linear/radial echoendoscope before ERCP.Results:Of 68 cases, 48 were associated with hard stones with acoustic shadowing while twenty were associated with soft stones without acoustic shadowing. In twenty soft stones cases, ERCP was successful in 18 patients. In 48 patients with hard stones, there was failure of endotherapy in forty patients which required extracorporeal shock wave lithotripsy/surgery. The presence of large, hard, immobile stones was negative predictors of successful endotherapy. Small, ampullary/papillary stones were positive predictors.Conclusions:EUS can influence therapeutic decisions before endotherapy and can prevent unsuccessful attempts improving overall success/prognosis. EUS has an additional advantage of making a diagnosis of ampullary/papillary stones and biliary obstruction which can be treated endoscopically. It can guide whether endotherapy needs to be performed through major or minor papilla. EUS by diagnosing pancreatic tumor/strictures missed on other imaging modalities allows early surgical reference and hence improves long-term prognosis.

Endoscopic ultrasound as a predictor and guide to successful endotherapy in chronic pancreatitis

Background and Objectives:Pancreatic calculi (PCs) are sequelae of chronic pancreatitis (CP) and may obstruct and produce ductal hypertension leading to pain, the cardinal feature of CP. Indications for endotherapy include stones <5 mm size, stones in the head of pancreas which are not impacted and absence of downstream strictures. The assessment before the procedure is done by magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT). However, problems are encountered during endoscopic retrograde cholangiopancreatography (ERCP) clearance which are not anticipated despite MRCP/CT. The problems are possible impacted stones, hard stones, indeterminate stricture, and change of finding during ERCP. Hence, controversy exists. Endoscopic ultrasound (EUS) can help by providing concordance or discordance with MRCP images and may help in further clarification. The aim of this study is to evaluate the role, feasibility, and management changes of EUS before ERCP in patients planned for endotherapy in CP. Another objective was to evaluate whether EUS features of pancreatic duct (PD) stones can serve as a predictor of successful removal during ERCP.Methods:The data of 412 patients during the study period (2009–2016) with CP were retrospectively analyzed. A total of 143 were associated with stones in head/papillary region of pancreas. Out of these, 75 were excluded and remaining 68 were evaluated by EUS using a linear/radial echoendoscope before ERCP.Results:Out of 68 cases, 48 were associated with hard stones with acoustic shadowing while 20 were associated with soft stones without acoustic shadowing. In 20 soft stones cases, ERCP was successful in 18 patients. In 48 with hard stones, there was failure of endotherapy in 40 which required extracorporeal shock wave lithotripsy (ESWL)/surgery. The presence of large (≥5mm), hard, immobile stones were negative predictors of successful endotherapy. Small, ampullary/papillary stones were positive predictors.Conclusion:The present study suggests that EUS can differentiate “soft PD stones” (without an acoustic shadow) from “hard PD stones”(with acoustic shadow). “Hard PD stones” are better managed by ESWL. An EUS can influence important therapeutic decisions before endotherapy and can prevent unsuccessful attempts at ERCP and thus improve overall success/prognosis. An EUS has an additional advantage of making a diagnosis of ampullary/papillary stones and biliary obstruction which can be treated endoscopically. It can guide whether endotherapy needs to be performed through major or minor papilla. EUS by diagnosing pancreatic tumor/strictures missed on other imaging modalities allows early surgical reference and hence improves long term prognosis.

Use of endoscopic septotomy for the treatment of late staple-line leaks after laparoscopic sleeve gastrectomy.

Background Staple-line leak following laparoscopic sleeve gastrectomy is a dire adverse event. While the treatment of acute and early leaks is well established, there is still dispute regarding late and chronic leaks. We describe an endoscopic approach combining septotomy and sleeve stricture dilation for treating late/chronic leaks. Methods Ten consecutive patients with late/chronic proximal leaks were treated at our center. The septum separating the sleeve lumen from the perigastric cavity was progressively dissected over several sessions and the downstream stricture was pneumatically dilated. The technical and clinical success rates were evaluated. Results: All ten patients were treated successfully. Eight patients had sleeve strictures that were dilated in conjunction with septotomy. A mean of five sessions over the course of 43 days was needed to complete treatment. In two patients with a small perigastric cavity and no stricture, septotomy was achieved with through-the-scope balloon dilation of the fistula. No adverse events were encountered. Conclusions Septotomy accompanied by stricture dilation seems highly effective and safe in late and chronic leaks following sleeve gastrectomy.

PTH-102 Treatment Of Benign Pancreatic Duct Strictures With Fully Covered Self Expandable Metal Stents (fc-sems) Is Feasible, Safe And Effective In Patients With Symptomatic Chronic Pancreatitis (cp)

IntroductionFC-SEMS have been used for treatment of benigh biliary strictures (BBS) with excellent results. Pancreatic duct strictures (PDS) of CP vary in length and complexity and associated with upstream dilatation...

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Laparoscopically assisted extrahepatic bile duct excision with ductoplasty and a widened hepaticojejunostomy for complicated hepatobiliary dilatation

Complicated hepatobiliary dilatation is characterized by congenital cystic dilatation of the biliary tree extending to involve the intrahepatic biliary channels. Some studies have reported on laparoscopic excision for common choledochal cyst, yet there are little reports on laparoscopic surgery for congenital choledochal cyst with intrahepatic bile duct dilatation. In this paper, we present our experiences in laparoscopic extrahepatic bile duct excision combined with ductoplasty and hepaticojejunostomy for complicated hepatobiliary dilatation. We retrospectively studied 153 children (age ranged between 3months and 12years) who had undergone laparoscopic cholangiopancreatography and radical choledochal resection in our institute from 2002 to 2012. A co-existing extra- and intra-hepatic dilatation was found in 26 patients. After resecting the extrahepatic dilated duct and widening the portohepatic or intrahepatic ductal lumen (ductoplasty) under the laparoscopic video, a widened hepaticojejunostomy at the hilum was performed using a Roux-en-Y jejunal limb. Laparoscopic procedures were successfully performed in all children with complicated hepatobiliary dilatation and their ductal stenoses at the hilum were corrected. In 13 patients with a stricture that converged into the common hepatic duct, the stenotic segment was incised and a wide hepaticojejunostomy was completed at the porta hepatis. A constrictive confluence of the right and left hepatic duct was observed in eight cases, a bi-ductal portojejunostomy was achieved at the bifurcation after making incision in the bilateral stenotic hepatic ducts to create a large stoma. A downstream stricture of the left hepatic duct was identified and incised from the hilum to the dilated segment along the lateral wall in three cases, so that a long hepaticojejunostomy to left intrahepatic duct lay in an oblique orientation. In two cases, a septum was found in the right hepatic ductal terminal and excised through the hilar orifice. Postoperative complications were observed in two children including temporary bile leakage and hepaticojejunal anastomotic stricture each one. The intrahepatic duct dilatation was remarkably reduced in size during the follow-up. Laparoscopic cholangiopancreatography is a valuable method in offering an accurate delineation of complicated hepatobiliary dilatation associated pancreaticobiliary maljunction and only necessitates simple equipments. With the aid of the magnified laparoscopic view, the radical resection of extrahepatic biliary duct and correction of the portohepatic bile ductal stenosis can be exactly performed. Laparoscopic hepaticojejunostomy at the hilum is effective and safe for children with complicated hepatobiliary dilatation.

Pancreatoscopic Removal of a Large Impacted Pancreatic Duct Stone

Pancreatic duct stones are a common complication of chronic pancreatitis. Although most pancreatic duct stones can be targeted by extracorporeal shock wave lithotripsy and extracted by endoscopic retrograde cholangiopancreatography, large and radiolucent stones remain a therapeutic challenge. The author describes a case of a 54-year-old man with chronic pancreatitis and a large pancreatic duct stone with a downstream stricture within the pancreatic head. After balloon dilation of the obstruction, direct pancreatoscopy with an ultraslim endoscope was performed and the stone under direct vision was extracted successfully. This article is part of an expert video encyclopedia.

Sphincterotome Stricturoplasty for Ampullary Stenoses and Biliary Strictures

Endoscopic sphincterotomy (ES) is performed frequently during therapeutic endoscopic retrograde cholangiopancreatography (ERCP).1 On cholangiogram, long ampullary stenoses and fibrotic distal biliary strictures are not encountered infrequently and they are defined as a significant narrowing of the common bile duct (CBD) from the level of duodenal wall into CBD after initial ES.2 The upstream CBD is dilated. Despite adequate ES, the contrast drainage is poor due to the downstream stricture. Instead of balloon stricturoplasty and stenting,3,4 these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP.2The SS is performed using the same sphincterotome in a slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire is placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS, the majority of the cutting wire is inside the biliary opening. This differs from ES where about one-third to one-half of the length of cutting wire is outside the ampulla. Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP. This article is part of an expert video encyclopedia.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

Sphincterotome stricturoplasty for long ampullary stenoses and benign biliary strictures (with video)

Long ampullary stenoses and fibrotic distal biliary strictures are not infrequently encountered during endoscopic retrograde cholangiopancreatography (ERCP). Instead of balloon dilation and stenting, we propose that these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP. To report our clinical experience with SS for benign distal biliary strictures. Review on prospectively collected data. All (consecutive) patients who underwent ERCP and SS performed by the authors in a 12-month period. Long ampullary stenosis and/or distal biliary stricture is defined as significant narrowing of CBD from the level of duodenal wall into the common bile duct (CBD) after initial sphincterotomy. The upstream CBD is dilated. Despite adequate ES, contrast drainage is poor due to the downstream stricture. SS was performed using the same sphincterotome in slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire was placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS the majority of the cutting wire was inside the biliary opening. This differs from ES, where about one-third to one-half of the length of cutting wire is outside the ampulla. Clinical data, hospital course, procedure-related complication rates, and outcomes were prospectively collected in a database. During the study period, 308 ERCPs were performed. Benign and short (≤15 mm in length) distal biliary strictures were observed in 25 patients. Mean ± SD stricture length was 7.4 ± 3.0 mm. The presumed etiologies for these strictures were choledocholithiasis (n = 22) and postsphincterotomy stenosis (n = 3). There was no perforation, post-ERCP pancreatitis, postsphincterotomy bleeding, or cholangitis. To date, none of these patients who had SS have needed follow-up ERCP. Single-operator experience, limited follow-up period. Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP.

Hepaticojejunostomy and intrahepatic cystojejunostomy for type IV-A choledochal cyst

Background The incidence of choledochal cyst with intrahepatic involvement (Todani's type IV-A cyst) is considerably high. Dilatation of the intrahepatic bile duct is frequently observed around the hepatic hilum, occasionally in the umbilical portion, and rarely in the more upstream intrahepatic bile duct, associated with or without downstream stricture. We recently encountered 2 children with type IV-A cyst associated with upstream intrahepatic ductal dilatation; one with a cystic dilatation of the medial branch arising from the left hepatic duct and another with a cyst of the medial branch arising from the anterior hepatic duct. Methods After excision of the extrahepatic bile duct cyst at the hilum and making a large fenestration of the intrahepatic duct cyst, hepaticojejunostomy and intrahepatic cystojejunostomy were performed using a Roux-en-Y jejunal loop in both children. Results Postoperatively, both intrahepatic cysts were remarkably reduced in size, and recurrent bouts of abdominal pain did not occur for up to 4 or 5 years. Conclusion Hepaticojejunostomy at the hepatic hilum, combined with intrahepatic cystojejunostomy, appears to be a recommendable procedure for an upstream intrahepatic ductal cyst of type IV-A, preventing postoperative cholangitis owing to bile stone formation.

Cholangioscopy (CP) with Electrohydraulic Lithotripsy (EHL) in Patients (PTS) with Difficult Bile Duct Stones

Background: Large, adherent, and intrahepatic stones may be refractory to conventional stone extraction methods. The aim of this study was to determine 1) the efficacy of CP +/− EHL for stones and 2) pt characteristics associated with stone recurrence. Methods: Prospective cohort of consecutive pts referred for CP to treat difficult bile duct stones. A data collection sheet was used to obtain: pt/stone characteristics; prior ERCP/PTC; CP interventions; stone recurrence. Follow-up was by chart review/phone. Results: Between 2/00 and 10/04, 44 pts (27M/17F; mean age 63 yrs, 9 with PSC) had 69 CPs (64 transpapillary, 5 percutaneous) for management of difficult stones or evaluation of associated strictures. A mean of 2.8 (range 1-13) ERCP/PTCs were performed prior to index CP. Stone location: intrahepatics (N=11); extrahepatics (N=23); both (N=10). Stone type: pigmented (N=12); cholesterol (N=8); mixed (N=15); unknown (N=9). Mean stone size was 13 mm (range 4-27). 11/44 (25%) pts had downstream strictures. 10/44 (23%) pts had stones detected by CP only and missed by cholangiography. 11/39 (28%) pts had extension of a previous biliary sphincterotomy. 35/44 (80%) pts had CP-directed lithotripsy: 33 EHL; 2 mechanical. 6/44 (14%) had balloon/basket sweep following CP visualization of stones. 3/44 (7%) had CP immediately following conventional methods of stone extraction to confirm stone clearance. From time of referral, pts required a mean of 1.7 (range 1-3) CPs +/− ERCPs to achieve complete (N=32), partial (N=10), or failed (N=2) stone clearance. 26/32 (81%) pts with complete clearance required a mean of 1.4 (range 1-3) CP-directed lithotripsy sessions. Failed cases were due to prior biliary bypass limiting access of CP to intrahepatic stones and early termination of CP due to inadequate sedation. Follow-up was obtained in 38/44 (86%) pts for a mean of 20.7 months. In pts with complete clearance, stones recurred in 6/32 (19%) requiring a mean 2.3 (range 1-5) subsequent biliary procedures; 5/6 had associated strictures or intrahepatic stones. Surgery: partial hepatectomy (N=1) and biliary bypass (N=2). Complications: 1 mild cholangitis. Conclusions: 1) CP-directed lithotripsy is safe and achieves stone clearance in most patients referred for difficult bile duct stones. 2) Following stone clearance, most pts with recurrence had intrahepatic stones or associated biliary strictures. 3) Nearly one in four pts had stones seen on CP that were missed by cholangiography. Background: Large, adherent, and intrahepatic stones may be refractory to conventional stone extraction methods. The aim of this study was to determine 1) the efficacy of CP +/− EHL for stones and 2) pt characteristics associated with stone recurrence. Methods: Prospective cohort of consecutive pts referred for CP to treat difficult bile duct stones. A data collection sheet was used to obtain: pt/stone characteristics; prior ERCP/PTC; CP interventions; stone recurrence. Follow-up was by chart review/phone. Results: Between 2/00 and 10/04, 44 pts (27M/17F; mean age 63 yrs, 9 with PSC) had 69 CPs (64 transpapillary, 5 percutaneous) for management of difficult stones or evaluation of associated strictures. A mean of 2.8 (range 1-13) ERCP/PTCs were performed prior to index CP. Stone location: intrahepatics (N=11); extrahepatics (N=23); both (N=10). Stone type: pigmented (N=12); cholesterol (N=8); mixed (N=15); unknown (N=9). Mean stone size was 13 mm (range 4-27). 11/44 (25%) pts had downstream strictures. 10/44 (23%) pts had stones detected by CP only and missed by cholangiography. 11/39 (28%) pts had extension of a previous biliary sphincterotomy. 35/44 (80%) pts had CP-directed lithotripsy: 33 EHL; 2 mechanical. 6/44 (14%) had balloon/basket sweep following CP visualization of stones. 3/44 (7%) had CP immediately following conventional methods of stone extraction to confirm stone clearance. From time of referral, pts required a mean of 1.7 (range 1-3) CPs +/− ERCPs to achieve complete (N=32), partial (N=10), or failed (N=2) stone clearance. 26/32 (81%) pts with complete clearance required a mean of 1.4 (range 1-3) CP-directed lithotripsy sessions. Failed cases were due to prior biliary bypass limiting access of CP to intrahepatic stones and early termination of CP due to inadequate sedation. Follow-up was obtained in 38/44 (86%) pts for a mean of 20.7 months. In pts with complete clearance, stones recurred in 6/32 (19%) requiring a mean 2.3 (range 1-5) subsequent biliary procedures; 5/6 had associated strictures or intrahepatic stones. Surgery: partial hepatectomy (N=1) and biliary bypass (N=2). Complications: 1 mild cholangitis. Conclusions: 1) CP-directed lithotripsy is safe and achieves stone clearance in most patients referred for difficult bile duct stones. 2) Following stone clearance, most pts with recurrence had intrahepatic stones or associated biliary strictures. 3) Nearly one in four pts had stones seen on CP that were missed by cholangiography.

Pancreatic ductal stones: frequency of successful endoscopic removal and improvement in symptoms

Pancreatic ductal stones may be responsible for attacks of acute pancreatitis (chronic relapsing pancreatitis) or exacerbations of chronic pain in patients with chronic pancreatitis. This study was undertaken to identify those patients with predominantly main pancreatic duct stones most amenable to endoscopic removal and to determine the effects on the patients' clinical course with such removal. Thirty-two patients with ductographic evidence of chronic pancreatitis and pancreatic duct stones underwent attempted endoscopic removal. Of the patients, 71.9% had complete or partial stone removal and 67.7% improved after endoscopic therapy. Symptomatic improvement was most evident in the group of patients with chronic relapsing pancreatitis. Factors favoring stone removal included (1) three or less stones, (2) stones confined to the head and/or body of the pancreas, (3) absence of a downstream stricture, (4) stone diameter less than or equal to 10 mm, and (5) absence of impacted stones. After successful stone removal, 25% of patients had regression of the ductographic changes of chronic pancreatitis and 41.7% had a decrease in the main pancreatic duct diameter. The only complication from therapy was mild pancreatitis in 8.2%. These data suggest that removal of pancreatic duct stones may result in symptomatic improvement. A longer follow-up will be necessary to determine whether endoscopic success results in long-standing clinical improvement and/or permanent regression of the morphologic changes of chronic pancreatitis.