Endoscopic Nasobiliary Research Articles

Simultaneous bilateral biliary metal stents versus plastic stents under endoscope for treatment of malignant hilar biliary obstruction

Objective To compare the safety and efficacy of simultaneous bilateral biliary metal stents with plastic stents under endoscope for treatment of malignant hilar biliary obstruction(MHBO).MethodsFrom May 2007 to December 2011,142 MHBO patients were selected for this study,with 32 receiving bilateral metal stent drainage and 110 receiving bilateral plastic stent drainage.The success rate of endoscopic operations,postoperative jaundice-reducing effect,post-endoscopic retrograde cholangiopancreatography(ERCP) complications,and stent patency period were observed.ResultsThe procedures were successful in all patients in the two groups.The postoperative jaundice-reducing effect rates were 96.9%(31/32) in the metal stent group and 88.2%(97/110) in the plastic stent group(P0.05).Two patients in the metal stent group and six in the plastic stent group had post-ERCP cholangitis,which was relieved by anti-inflammatory intervention,replacement of stents or endoscopic nasobiliary drainage.Two patients in the plastic stent group had stent slip.There were no pancreatitis,gastrointestinal bleeding,perforation or ERCP-related deaths in the two groups.Two patients in the metal stent group and 4 in the plastic stent group died,and the biliary stents were patent until they died.Eight patients in metal stent group and 29 patients in the plastic stent group developed recurrent obstructive jaundice,which were treated by reimplantation or replacement of the plastic stents.The post-ERCP complication rates were similar in the two groups(P0.05).The median patency period of the metal stent was(248.53±138.61) d and that of the plastic stent was(101.76±38.53) d,showing significant difference by Log-rank test(P0.001).ConclusionFor Bismuth Ⅱ-type,bilateral bile duct invaded,or non-resectable MHBO patients,if biliary drainage range permits and the expected survival period 3 months,double metal stent biliary drainage has more advantages.

Diagnosis and management of duodenal perforation after endoscopic retrograde cholangio-pancreatography: clinical analysis of 15 cases

To summarize the experience with duodenal perforations to determine a systematic management approach. A total of 11 250 patients who received endoscopic retrograde cholangiopancreatography(ERCP) in The First People's Hospital of Hangzhou from January 2005 to December 2011 and 15(0.13%) patients developed duodenal perforation. The clinical data of these 15 cases were analyzed. There were 6 males and 9 females. The age ranged from 45 to 87 years. Seven patients developed perforation after sphincterotomy of the duodenal papilla. Five patients perforated due to the endoscope, and 3 due to guide wire and net basket. All the patients presented varying degree of abdominal pain and distention. CT scan of the upper abdomen showed peripancreatic and retroperitoneal air or fluid. Diagnosis was confirmed in 7 patients using abdominal X-ray. Eight patients developed postoperative abdominal pain and distention, subcutaneous emphysema, and fever 3 hours to 5 days after surgery, and diagnosis was confirmed using plain abdominal X-ray or upper abdominal CT scan. Nine patients were managed conservatively, 4 of whom were diagnosed within 3 hours after perforation and were managed by endoscopic metal clip and nasobiliary drainage and no abdominal abscesses developed. The length of hospital stay ranged from 10 to 15 days. Five patients were diagnosed 10 hour to 5 days after perforation, of whom 2 had intestinal fistula, 4 had abscess, and one died, the length of hospital stay ranged from 15 to 105 days. Six patients were managed surgically, 4 received surgery within 4 to 8 hours after perforation and no abscess developed, and the length of hospital stay ranged from 18 to 21 days. The other 2 patients were operated at 24 hours and 30 hours after perforation respectively, one of whom had recurrent intra-abdominal bleeding after surgery and one died from intra-abdominal abscess and multiple organ failure. For duodenal perforations related to ERCP, early diagnosis can be made by prompt intraoperative identification and postoperative CT scan. Endoscopic metal clip and nasobiliary drainage should be considered aside from surgical intervention.

Usefulness of Double Balloon Endoscopy in Patients With Surgically Distorted Intestinal Anatomy

Double balloon endoscopy (DBE) is a new endoscopic method with the capability for complete observation of whole small bowel. This study evaluated the feasibility and usefulness of DBE for the diagnosis and therapy of small bowel diseases in patients with distorted intestinal anatomy by previous surgeries. From January 2005 to August 2007, 15 patients with Roux-en-Y anastomosis underwent DBE in Asan Medical Center. Eight were men and the median age was 57 years (range, 40 to 68 y). Indications of DBE were suspected small bowel bleeding, chronic diarrhea, and recurrent acute pancreatitis. The main outcome measurements included completeness of the observation of afferent loop and DBE findings. Because 1 patient underwent DBE twice separately owing to recurrent bleeding, a total of 16 cases were analyzed. The observation of afferent loop was complete in 13 (81%) of 16 cases. The overall diagnostic yield of DBE was 69% (11/16). Out of 11 cases in which DBE detected abnormalities, 6 (55%) showed definite lesions and 5 (45%) probable lesions. Of the 11 cases in which abnormalities were found, 7 (64%) showed lesions in afferent loop. Of the 6 cases in which definite lesions were found, 4 (67%) showed lesions in afferent loop. Therapeutic endoscopic procedures were performed in 4 cases, which include argon plasma coagulation, foreign body removal, and endoscopic nasobiliary drainage. DBE in patients with distorted intestinal anatomy such as Roux-en-Y anastomosis is a useful tool for the management of small bowel lesions, especially those in the afferent loop.

Treatment of endoscopic sphincterotomy by endoscope to the patients with common duct stones after their gallbladders resected

Objective To evaluate the safety and therapeutic value of endoscopic sphincterotomy by endoscope to the patients with common duct stones after their gallbladders resected. Methods 158 patients with common duct stones after their gallbladders resected were given the treatments of endoscopic sphincterotomy and nasobiliary drainage in recent 4 years. Results 153 of 158 patients got succeed. The symptoms obviously improved such as jaundice and fever and epigastric distention and so on. As for the postoperative complications, the hyperamylasemia occurred in 85 patients of all patients,and active hemorrhage in 2 patients,and acute pancreatitis in 16 patients,and cholangitis in 5 patients,but no one occurred biliary fistula,no one died,too. Conclusion EST is the best way for us to treat the patients with common duct stones after their gallhladders resected by endoscope,and its curative effect is sure and its safety coefficient is higher. Key words: Custic Duct; Calculi Endoscopes

Retroperitoneoscopic nephroureterectomy of a horseshoe kidney in a child

Laparoscopic cholecystectomy is sometimes difficult due to complicated biliary anatomy including gallbladder duplication, a rare anomaly of the biliary tract. We report a case of duplicated gallbladder successfully removed under laparoscopy using endoscopic nasobiliary (ENB) tube cholangiography. A 61-year-old Japanese woman presented us with right upper abdominal pain. Ultrasonography revealed two cystic structures lying in the gallbladder fossa, and the upper one contained multiple stones. Endoscopic retrograde cholangiography showed two gallbladders, each of which has a cystic duct draining into the common bile duct separately. Laparoscopic cholecystectomy was planned under the preoperative diagnosis of double gallbladder with gallstones in the accessory gallbladder. The ENB tube was inserted just before the operation. Laparoscopic removal of the double gallbladder was successfully done using the ENB tube to identify the biliary tree anatomy and to close the stump of the cystic duct. In this communication, we would like to stress the usefulness of the ENB tube at the time of laparoscopic biliary surgery in patients with biliary anomalies including gallbladder duplication.

Endoscopic retrograde cholangiopancreatography in the management of pancreaticobiliary disorders in children.

The role of endoscopic retrograde cholangiopancreatography (ERCP) is not yet fully established in children. The purpose of this study was to assess the use of ERCP in the diagnosis and management of various pancreaticobiliary disorders in children. Eighty-four ERCPs were performed over 5.5 years in 72 children with suspected pancreaticobiliary tract disorders with an adult-type duodenoscope. In all cases, indications, procedure time, ERCP findings, complications, patients course and therapeutic intervention (if any) were recorded. The mean (+/- SD) age of these children was 8.8 +/- 3.3 years. Successful cannulation was possible in 70 (97%) cases. Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain). Therapeutic ERCP was performed in 22 children, endoscopic nasobiliary or a nasocystic drain was placed in 16, biliary stenting was conducted in two, pancreatic duct stenting was conducted in three, and minor papilla dilation was conducted in one child. Six children had mild procedure-related complications. Endoscopic retrograde cholangiopancreatography is very useful in the treatment of cholangitis, bile leak, pseudocyst and pancreatic fistulae in children. However, its role in unexplained abdominal pain is doubtful.

Extracorporeal shock-wave lithotripsy for retained common bile duct stones

Retained common bile duct stones (CBDS) become a challenging problem when percutaneous and endoscopic methods fail. Extracorporeal shock-wave lithotripsy (ESWL) is a noninvasive and effective treatment modality, and can be used as an alternative treatment of retained CBDS. We report our experience with 20 patients who had retained CBDS, using a second-generation electromagnetic lithotriptor. Thirteen patients who had cholecystectomy and common bile duct exploration, with stone extraction and T-tube drainage, were in the early postoperative period. Seven patients had undergone previous endoscopic sphincterotomy and nasobiliary drainage. Fourteen patients had only one ESWL session. Stone fragmentation rates were 100% and 57% in patients with T-tube and nasobiliary catheter, respectively. The overall stone fragmentation rate was 85% and complete stone clearance was achieved in all these patients (85%). Complications were mild and relatively infrequent (20%). There was no mortality. We conclude that ESWL for retained CBDS is a safe, effective and minimally-invasive treatment modality. ESWL should be considered as a significant alternative to surgery when endoscopic and percutaneous treatment modalities are not successful.