Endoscopic Biliary Sphincterotomy Research Articles

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy–associated pancreatitis? A randomized, prospective study

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. Single-center, randomized, prospective study. Tertiary care ERCP referral center. Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). Single center. Randomization scheme not optimal. These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.

Electrosurgical Current for Endoscopic Biliary Sphincterotomy (EBS) for the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Cochrane Collaboration Meta-analysis of Randomized Controlled Trials

Electrosurgical Current for Endoscopic Biliary Sphincterotomy (EBS) for the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Cochrane Collaboration Meta-analysis of Randomized Controlled Trials

The Safety and Utility of Pancreatic Duct Stents in the Emergency ERCP of Acute Biliary Pancreatitis but Difficult Sphincterotomy

The aims of this study were to assess the feasibility and safety of emergency ERCP and pancreatic duct (PD) stenting in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy proved difficult, and to compare the clinical outcome of those patients having emergency ERCP without pancreatic stent. One hundred and ninety-one consecutive patients with ABP were included in this study. Patients were randomly assigned to either the stent group (n=78) or the no-stent group (n=113). In the stent group, 3-5Fr,5-7cm-long pancreatic stent insertion was initially applied and removed endoscopically 1-2 weeks post-ER-CP. All patients were hospitalized for medical therapy and were followed-up. Mean age, initial symptom-to-ERCP times, Glasgow severity scores and peak amylase and CRP levels at initial presentation were not significantly different in the stent group vs. the no-stent group, and the selective biliary cannulation was achieved in 80% of the stent group and in 94% of the no-stent group (p=0.15). More importantly, the complication rate was significantly lower in the stent group (7.7% vs. 31.9%). There was no difference in mortality between the two groups statistically(1.3% vs. 3.5%). Pancreatic duct stent-ing is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP, show better outcomes as compared to no-stent group. It is recommended to reduce the incidence of the complication in the emergency ERCP of ABP but difficult sphincterotomy. However, further prospective trials are needed.

Endoscopic biliary sphincterotomy dilation

Endoscopic biliary sphincterotomy dilation

Fully Covered Self-expandable Metal Stents for Treatment of Post-sphincterotomy Bleeding

Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP); however, serious complications are not uncommon. Post-sphincterotomy bleeding is one of the most frequent complications following ES and may occur in up to 10% of the patients. The spectrum of presentation may range from self-limited to severe live threatening hemorrhage. Different endoscopic treatment options are available. Angiographic embolisation and surgery are preserved for refractory cases not controlled by endoscopic means. Recently, completely covered self-expandable metal stents (CSEMS) have been applied to achieve hemostasis in severe post-sphincterotomy bleeding not controlled by other measures. We present our experience with this method to control delayed bleeding after ES in two patients requiring continuous therapeutic anticoagulation due to high cardiovascular embolic risk.

Su1403 The Quality of Bowel Preparation for Screening Colonoscopy in an Inner City Health Care Center

excluded. PEP was diagnosed by typical pancreatic-type abdominal pain and elevation of amylase/lipase 3X ULN following ERCP. Severity of PEP was defined by established criteria4. Results: 549 OLTs with duct-to-duct anastomosis were performed during the study period. Of the OLT recipients, 100 patients (63% male; 89% Caucasian; mean age 51 13) underwent ERCP (122 total ERCPs). ERCP was performed at a median of 96 days (IQ range, 30-387) following OLT. Findings at ERCP included: anastomotic stricture in 29% (35/122), bile leak in 16% (19/122), stones/sludge in 9% (11/122), and papillary stenosis in 6% (7/122). Difficult cannulation was noted in 22% (27/122) and biliary sphincterotomy was performed during 66% (81/122) of the ERCPs. Prophylactic pancreatic stents were placed during 12 procedures (10%). PEP occurred following 5 cases (4 male, 1 female). Of the PEP cases, ERCP finding of anastomotic stricture was observed in 4 of 5 cases. Four cases of PEP occurred after documented difficult cannulation and 2 cases occurred despite pancreatic stent placement. Two patients developed PEP during a repeat ERCP after a post-transplant ERCP had been performed previously without sphincterotomy. There were no episodes of severe acute pancreatitis; three were moderate in severity, and 2 were mild. Conclusions: The rate of PEP in patients following liver transplant is comparable to that previously documented in the general population1,2. However, ERCP evidence of an anastomotic stricture and difficult bile duct cannulation appear to be risk factors for development of PEP in the OLT population.

Electrosurgical current for endoscopic biliary sphincterotomy (EBS) for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

Electrosurgical current for endoscopic biliary sphincterotomy (EBS) for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

Complications of ERCP

Complications of ERCP

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate efficacy and cost-effectiveness.

The role of endoscopy in the management of choledocholithiasis

The role of endoscopy in the management of choledocholithiasis

Bleeding after Endoscopic Biliary Sphincterotomy

Bleeding during endoscopic sphincterotomy is a common complication. Sometimes bleeding occurs as a late complication after endoscopic retrograde cholangiopancreatography (ERCP). We describe a case in which bleeding happened during ERCP but detection was done after the completion of the procedure. The detection of bleeding allowed further evaluation and detection of hemobilia in this case. The removal of blood clots from inside common bile duct by repeat ERCP however led to an uneventful recovery without any morbidity.

Sa1487 Biliary Sphincterotomy Is Not Required for Bile Duct Stent Placement

Endoscopic biliary sphincterotomy (EBS) is commonly performed prior to bile duct stent placement. However, bile duct stents can be deployed without EBS thereby minimizing the risk of post sphincterotomy bleeding. Over a 9 year period, all patients undergoing ERCP were prospectively identified. During this period, bile duct stent placement was routinely performed without EBS unless additional therapy (stone removal, multiple stenting) was anticipated. Following the procedure, all patients were followed-up at one and four weeks to assess for complications graded by consensus criteria. During the 105 month study period, 4193 patients underwent ERCP. Excluding patients with prior sphincterotomy or precut and those undergoing EBS for additional endoscopic therapy, bile duct stents were placed in 658 patients (42% female, 75% white, mean age 59 years). The most common indications for ERCP were: 40.3% jaundice, 14.7% pancreatic mass, and 8% bile leak after liver transplantation. Stent size was 80% 10 French, 20% 7 French with 15.1% metal stents). 160 of these patients underwent ERCP for stent exchange. Stents were successfully placed in all patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.31% vs 2.34% p=0.228) but post-sphincterotomy bleeding, generally mild to moderate, was noted in 17 of 1407 patients who did undergo EBS during the study period. Single bile duct stents, both plastic and metal, should be deployed without EBS unless additional endoscopic therapy is required.

Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding

Severe bleeding following endoscopic biliary sphincterotomy (EBS) can sometimes be difficult to manage, resulting in the need for an invasive intervention. The aim of this study was to retrospectively evaluate the feasibility and efficacy of endoscopic hemostasis using covered self-expandable metallic stents (SEMSs) for severe post- EBS bleeding. Eleven patients with bile duct stones underwent standard EBS using a standard sphincterotome-based technique at 4 endoscopic units of a university-affiliated hospital and a general hospital. Monotherapy or combined therapy were used to achieve hemostasis with either balloon tamponade, hypertonic saline epinephrine injection, or endoclip placement. When active bleeding could not be controlled, covered SEMSs were placed across the major papilla. Emergency endoscopy was performed on the day of admission or the subsequent day (ranging from 6 to 35 h after admission). Bleeding was classified as mild in 6 cases (54.5 %) and moderate in 5 (45.5 %). A covered SEMS 10mm in diameter and 6 cm long was placed across the papilla. After placement, complete hemostasis was achieved. The mean duration of stent placement was 8.2 days (range 5–10 days), and the SEMS was successfully removed in all cases. Although the present study has the limitations of a small sample size and lack of control patients, covered SEMS placement for endoscopic hemostasis may be useful in selected patients with uncontrolled post-EBS bleeding.

Endoscopic Biliary Sphincterotomy is Not Required for Transpapillary SEMS Placement for Biliary Obstruction

Endoscopic Biliary Sphincterotomy is Not Required for Transpapillary SEMS Placement for Biliary Obstruction

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledocholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.

Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report

IntroductionCases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.Case presentationWe report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.ConclusionIn patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.

New large-diameter balloon-equipped sphincterotome for removal of large bile duct stones (with videos)

Recently, endoscopic biliary sphincterotomy (EBS) followed by large-diameter balloon dilation has been used for the removal of large bile duct stones. A limitation is the need for 2 accessories: a sphincterotome and a dilating balloon. To evaluate a new device, a combination of a large-diameter dilating balloon and sphincterotome (LDDBS). Retrospective study. University hospital. Eighteen patients with large bile duct stones. After performing EBS by using the LDDBS, the catheter was then advanced into the bile duct and balloon dilation was performed by gradual inflation with diluted contrast medium under endoscopic and fluoroscopic guidance until it reached a diameter adequate to allow stone removal. Feasibility and efficacy of stone removal by using an LDDBS. Technical success of large-diameter balloon dilation after EBS was achieved in all cases. Bile duct clearance was accomplished in 94% (17/18) of cases in the first session. Bile duct clearance was eventually completed in all patients. Mechanical lithotripsy was required in 4 patients (22%). There were no major intraprocedural or postprocedural complications. Single-institution study, small sample size. The prototype LDDBS is safe and effective to facilitate the removal of large bile duct stones by using one accessory.

Botulinum toxin-induced relaxation of the sphincter of Oddi may select patients with acalculous biliary pain who will benefit from cholecystectomy

Acalculous biliary pain may be due to gallbladder dyskinesia or sphincter of Oddi (SO) hypertension. These two etiologies are difficult to differentiate because the gallbladder ejection fraction may be low and the SO manometry results may be abnormal in both. Cholecystectomy is advised for patients with biliary dyskinesia, but it often exacerbates biliary pain for patients with SO hypertension. The biliary pain response to relaxation of the SO using botulinum toxin may indicate appropriate treatment for patients with acalculous biliary pain. The protocol-based management of 25 patients with acalculous biliary pain and two gallbladder ejection fraction estimations less than 40% who had 100 units of botulinum toxin injected into their SO musculature to relax the sphincter has been audited. Patients whose pain was temporarily relieved after botulinum toxin injection were offered endoscopic biliary sphincterotomy, and patients who failed to experience benefit after botulinum toxin injection were assessed for laparoscopic cholecystectomy. Botulinum toxin was injected into the SO of 25 patients, with 11 experiencing temporary biliary pain relief. Of these patients, 10 consented to undergo endoscopic biliary sphincterotomy, with relief of biliary pain in all cases. A total of 14 patients had a negative response to botulinum toxin treatment, with 10 of these patients progressing to laparoscopic cholecystectomy, which resulted in biliary pain relief in eight cases. Botulinum toxin-induced relaxation of the SO may help to direct appropriate therapy for patients with acalculous biliary pain. The data from this study supports the establishment of a randomized clinical trial.

Endoscopic Biliary Sphincterotomy Is Not Required for Transpapillary SEMS Placement for Biliary Obstruction

Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement. Our hypothesis was that biliary sphincterotomy has no effect on the success rate of transpapillary self-expanding metal stent placement and increases procedure-related complications. In a retrospective analysis, outcomes of two groups were compared: (1) self-expanding metal stent placement without biliary sphincterotomy, (2) self-expanding metal stent placement with biliary sphincterotomy during the same procedure. Complications and stent patency rates were evaluated. There were 104 subjects included in the study. Post-sphincterotomy bleeding (p = 0.001) was associated with biliary sphincterotomy performed immediately prior to self-expanding metal stent placement. Importantly, self-expanding metal stent placement without biliary sphincterotomy was always technically successful and self-expanding metal stent placement without biliary sphincterotomy was not associated with pancreatitis. Patients who undergo biliary sphincterotomy during transpapillary self-expanding metal stent placement experience more immediate complications than those who do not. Biliary sphincterotomy was not associated with longer stent patency. Self-expanding metal stent placement without a biliary sphincterotomy was not associated with pancreatitis regardless of the type of self-expanding metal stent used (covered or uncovered). Of the patients without a biliary sphincterotomy, 100% had successful stent placement, further arguing against its use in this setting.

Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie

A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.