Endoscopic Biliary Stent Placement Research Articles

Endoscopic management of the liver transplant patient

Endoscopic management of the liver transplant patient

Endoscopic management of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is an uncommon malignant tumor arising from the biliary epithelium. The incidence increases with age and usually affects individuals in their 6th or 7th decade of life. Those patients with underlying risk factors such as primary sclerosing cholangitis (PSC) and choledochal cysts generally present 2 decades earlier. Most patients clinically present with painless jaundice; however, other common symptoms include pruritus, weight loss, and abdominal pain. Although surgical resection offers the only hope for cure, most patients are found to have unresectable disease on initial presentation and have an extremely grim prognosis. This has led to an emphasis on the role of palliative care, with relief of biliary obstruction, in the management of these patients. Surgical bypass was once the primary means of palliation of jaundice in patients with unresectable cholangiocarcinoma but in the last 2 decades has been superseded by less invasive and less morbid nonsurgical procedures such as endoscopic and percutaneous biliary stent placement. Newer modalities of palliation such as endoscopic delivery of photodynamic therapy and high-intensity ultrasound therapy are emerging nonsurgical modalities that may result in improved survival and may play a future role as an adjunctive therapy to surgical resection.

Preoperative Biliary Stenting for Pancreatic Cancer

Studies of the effects of preoperative endoscopic biliary stent (EBS) placement on postoperative morbidity and mortality after pancreaticoduodenectomy have yielded conflicting results. To further evaluate postoperative outcomes that are associated with preoperative EBS in patients who undergo curative procedures for pancreatic cancer, researchers in Denmark …

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

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

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

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

Sphincter of Oddi injection with botulinum toxin is as effective as endobiliary stent in resolving cystic duct leaks in a canine model

Background: Current management of biliary fistulae includes percutaneous drainage and transpapillary endoscopic biliary stent placement. This study compared time to bile leak resolution for endoscopic stent insertion versus injection of botulinum toxin into the sphincter of Oddi. Methods: Thirty dogs underwent laparotomy and cholecystectomy without cystic duct closure. After a duodenotomy, dogs were randomized to the control group (Group 1) or one of two treatment groups. Treated dogs either underwent transpapillary stent placement (Group 2) or botulinum toxin injection into the sphincter of Oddi (Group 3). Drains were placed adjacent to the cystic duct stump and output was recorded daily. Resolution of bile leaks was defined as an output of less than 10 mL/day. Necropsy was performed to identify undrained intraperitoneal bile. Results: Data from 28 dogs were available for analysis. The numbers of days for resolution of bile leaks in Groups 1, 2, and 3 were, respectively, 9.3 (2.1) days, 2.3 (1.1) days, and 2.6 (1.1) days. There were significant differences in time to resolution of bile leak between Group 1 and both Groups 2 ( p < 0.001) and 3 ( p < 0.001). There was no significant difference between Groups 2 and 3 ( p > 0.25). Conclusion: Sphincter of Oddi injection with botulinum toxin is as effective as endobiliary stent placement in resolving cystic duct leaks in this canine model. (Gastrointest Endosc 2002;56:849-51.)

Preoperative endoscopic stent placement before pancreaticoduodenectomy: A meta-analysis of the effect on morbidity and mortality

Background: Pancreaticoduodenectomy is the only potentially curative treatment for peripapillary pancreatic tumors. However, postoperative morbidity and mortality are high, and different approaches have been tried to improve results, such as preoperative biliary drainage in patients with jaundice. This meta-analysis investigated the effect on postoperative outcome of preoperative biliary drainage by endoscopic biliary stent placement in patients who are jaundiced and who have peripapillary pancreatic tumors. Methods: A Medline search for the period 1985 to 2001 was performed. Eight retrospective studies and 2 prospective randomized controlled trials were included. Selection criteria for the primary analysis were as follows: patients with peripapillary pancreatic cancer, endoscopic stent placement versus no stent, radical surgery, and assessment of postoperative morbidity and mortality. A secondary analysis included both radical and palliative surgery. Results: In the primary analysis, 337 patients underwent preoperative endoscopic biliary stent placement, and 412 patients had no endoscopic biliary stent placement (controls). The overall odds ratio for postoperative complications (stent vs. no stent) is estimated as 0.79: 95% CI [0.36, 1.73] and the estimated odds ratio for postoperative mortality is 0.81: 95% CI [0.33, 1.99]. In the secondary analysis, 1008 patients underwent preoperative EBS versus 720 control patients. The odds ratio for postoperative complications in this analysis was 0.93: 95% CI [0.65, 1.33] and for postoperative mortality is 1.12: 95% CI [0.62, 2.01]. Conclusion: No evidence was found of either a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery in patients with pancreatic cancer. (Gastrointest Endosc 2002;56:529-34.)

Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbidity and mortality.

Pancreaticoduodenectomy is the only potentially curative treatment for peripapillary pancreatic tumors. However, postoperative morbidity and mortality are high, and different approaches have been tried to improve results, such as preoperative biliary drainage in patients with jaundice. This meta-analysis investigated the effect on postoperative outcome of preoperative biliary drainage by endoscopic biliary stent placement in patients who are jaundiced and who have peripapillary pancreatic tumors. A Medline search for the period 1985 to 2001 was performed. Eight retrospective studies and 2 prospective randomized controlled trials were included. Selection criteria for the primary analysis were as follows: patients with peripapillary pancreatic cancer, endoscopic stent placement versus no stent, radical surgery, and assessment of postoperative morbidity and mortality. A secondary analysis included both radical and palliative surgery. In the primary analysis, 337 patients underwent preoperative endoscopic biliary stent placement, and 412 patients had no endoscopic biliary stent placement (controls). The overall odds ratio for postoperative complications (stent vs. no stent) is estimated as 0.79: 95% CI [0.36, 1.73] and the estimated odds ratio for postoperative mortality is 0.81: 95% CI [0.33, 1.99]. In the secondary analysis, 1008 patients underwent preoperative EBS versus 720 control patients. The odds ratio for postoperative complications in this analysis was 0.93: 95% CI [0.65, 1.33] and for postoperative mortality is 1.12: 95% CI [0.62, 2.01]. No evidence was found of either a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery in patients with pancreatic cancer.

Pyogenic hepatic abscess with biliary communication

Background: The aims of this study were to compare the effectiveness of percutaneous drainage between pyogenic hepatic abscesses with and those without biliary communication and to evaluate the role of endoscopic biliary stent placement in the treatment of communicating abscesses. Methods: Sixty-one patients with hepatic abscesses underwent percutaneous drainage. For communicating abscesses refractory to drainage alone, endoscopic biliary stenting was performed. Results: After drainage, all patients showed improvement in their clinical condition and reduction in abscess size. Drainage alone completely cured abscesses in none of 10 patients with biliary communication and obstruction, in 3 of 10 with communication but without obstruction, and in 37 of 41 without communication. Endoscopic stenting was completely effective in all 7 patients with persistent discharge from a communicating abscess without biliary obstruction. Conclusions: Percutaneous drainage is less effective for communicating abscesses without biliary obstruction than for noncommunicating abscesses. Endoscopic biliary stenting is recommended, if drainage does not achieve a cure.

Endosonography-guided pseudocyst drainage with a new large-channel linear scanning echoendoscope

Endoscopic-guided pancreatic pseudocyst drainage has been reported to be an effective means for alleviating symptoms related to pancreatic fluid collections.1-3 Several investigators have suggested that performance of the procedure with EUS guidance may allow drainage of pseudocysts that cannot be drained with a purely endoscopic method because of the absence of an intraluminal bulge or the presence of adjacent vascular structures that preclude safe entry.4-7 In both of these circumstances, EUS guidance of the drainage procedure may theoretically reduce the risk for perforation and/or bleeding. Previously, EUS-guided pancreatic pseudocyst drainage was limited by the lack of echoendoscopes with elevators and/or sufficiently large accessory channels to allow passage of a large-caliber endoprosthesis (10F or greater in size). This report describes the technical features and operating characteristics of a recently introduced large-channel linear scanning echoendoscope with an elevator (XGF-UCT30, Olympus America, Inc., Melville, N.Y., Fig. 1) when used for pseudocyst drainage. CASE REPORT A 46-year-old man with alcohol-induced chronic pancreatitis complicated by partial gastric outlet obstruction and biliary obstruction was referred for endoscopic drainage of a 6.5 cm pseudocyst posterior to the antrum and duodenum. Institutional Review Board approval as required under Minnesota law was obtained for review of the medical record. Initial contrast CT of the abdomen demonstrated peripancreatic inflammatory changes, pancreatic calcification, and biliary dilation. The patient was treated with an endoscopically placed venting gastrotomy, endoscopic biliary stent placement, and nutritional support while abstaining from alcohol ingestion. The gastric outlet obstruction resolved but he required interval stent changes over the ensuing 12 months because of clogging and persistence of the biliary stricture. Enteral intake was resumed and the gastrostomy tube was removed. Follow-up over this interval with CT imaging demonstrated conversion of the inflammatory changes in the head region of the pancreas into a 6.5 cm

Endoscopic biliary stent placement for treatment of gallbladder perforation due to blunt abdominal injury

Gallbladder trauma from blunt abdominal injury is rare.1-4 The incidence was only 2.1% in 1449 patients with blunt abdominal trauma in a review by Soderstrom et al.1 Gallbladder injuries include perforation (also termed laceration or rupture), contusion, avulsion, and traumatic cholecystitis.1-4 According to a collective review by Sharma3, perforation is the most common gallbladder injury (51%). For gallbladder perforation, cholecystectomy is the treatment of choice.1-3 Cholecystorrhaphy alone or with cholecystostomy may be useful in patients with obscured anatomy in the porta hepatis or in desperately ill patients.

Endoscopic biliary stenting for treatment of persistent biliary fistula after blunt hepatic injury

Background: Surgical treatment for persistent biliary fistula after blunt hepatic injury is often technically difficult. Endoscopic treatment for such fistulas has been described only infrequently. Methods: We reviewed 6 patients who underwent endoscopic biliary stent placement with (n = 1) or without (n = 5) sphincterotomy for persistent (12 to 138 days; mean 48 days) biliary fistula after blunt hepatic injury. Results: ERCP showed bile leakage from a second-order or more peripheral branch of the intrahepatic bile ducts in 5 patients but failed to reveal the fistula in 1. Stent placement was successful without complications in all patients. Bile leakage resolved within 1 to 3 days in 5 patients. After 36 to 86 days, the stent was removed and ERCP confirmed disappearance of the fistula. These patients have remained asymptomatic for a mean of 2.6 years since stent removal. In the patient in whom ERCP had not shown a fistula, bile leakage continued despite successful stent placement. Conclusions: Endoscopic biliary stent placement is a rapid, safe and effective treatment for persistent post-traumatic biliary fistula demonstrated by ERCP. (Gastrointest Endosc 2000;51:42-4.)

Pancreatic fistula without pancreatitis after endoscopic biliary stent placement for bile leak after orthotopic liver transplantation

Biliary tract complications are common after orthotopic liver transplantation (OLT), with an incidence of 9% to 34%.1-4 Biliary strictures and bile leaks are the most common complications; bile peritonitis may occur after 3% to 23% of all OLTs.1,2 Although there is no consensus on optimal management,5 bile leaks may be treated endoscopically by sphincterotomy6 or placement of nasobiliary catheters7 or stents.8 Endoscopic biliary stent placement can be performed with or without endoscopic sphincterotomy and generally has a low complication rate.

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis.

For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n = 6, 37.5%), percutaneous access (n = 5, 31%) or bilioenteric anastomosis (n = 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent.

The challenge of therapy for pancreatitis-related common bile duct stricture

Background: Opinions regarding the appropriate clinical management of pancreatitis-related common bile duct (CBD) stricture vary considerably. Patients and methods: Nineteen patients with chronic pancreatitis and proven stricture of their CBD were included in this study. Their mean duct diameter was 16 mm, bilirubin was 8.4 mg/dL, and alkaline phosphatase was 784 mlU/mL. Results: Five patients initially treated with endoscopic biliary stent placement are doing well at a mean follow-up of 7 months with only 1 patient requiring a biliary-enteric bypass. Four patients underwent a pancreaticoduodenectomy and the other 10 patients underwent a biliary-enteric bypass. Mean bilirubin and alkaline phosphatase at 13 months after therapy were 0.9 mg/dL and 144 mlU/mL. Conclusion: An endoscopically placed biliary stent will relieve obstruction due to the stricture for several months and allow the inflammatory process to follow its natural course. In patients with long-standing permanent biliary stricture, pancreatitis limited to the head of the pancreas, duodenal obstruction, or suspected pancreatic head carcinoma, pancreaticoduodenectomy is the operation of choice. Biliary-enteric bypass in association with gastric or pancreatic bypasses should be reserved for patients with severe inflammatory changes preventing a safe pancreaticoduodenectomy.

Endoscopic Treatment of Biliary Leakage after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is an effective and safe treatment for uncomplicated symptomatic cholelithiasis. However, biliary tract injury may be more common with this procedure than with open cholecystectomy. We have encountered 17 patients with a biliary leak among 465 patients undergoing laparoscopic cholecystectomy, the diagnosis being established by clinical and radiographic parameters. The most common site of leakage was the cystic duct stump. Patients underwent endoscopic sphincterotomy and biliary stent placement, with an overall success rate of 96%. No morbidity or mortality related to the endoscopic procedures was encountered. We conclude that biliary leakage after laparoscopic cholecystectomy is uncommon. When it occurs, it can be treated safely and efficaciously by endoscopic means.

Percutaneous endoscopic biliary stent placement after Whipple resection

Percutaneous endoscopic biliary stent placement after Whipple resection

A Combined Percutaneous Endoscopic Placement of Biliary Stent for Malignant Obstructive Jaundice: “A Few Practical Hints Make it Safe”

A Combined Percutaneous Endoscopic Placement of Biliary Stent for Malignant Obstructive Jaundice: “A Few Practical Hints Make it Safe”