Endoscopic Retrograde Cholangiopancreatography Sphincterotomy Research Articles

Management of Common Bile Duct Stones: Evaluation of the Effect of Size of Stones as the Determinant for the Procedure for Treatment in Era of Laparoscopic and Endoscopic Surgery

Abstract Background Common bile duct stones (CBDS) are estimated to be present in 10–20% of individuals with symptomatic gallstones. A variety of imaging modalities can be employed to identify the condition while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography (ERCP), surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to treat individuals with suspected CBDS. Objective To determine if ERCP sphincterotomy and extraction is effective in management of CBDS ranging from 10 to 20 mm or if surgical intervention is preferred in a sample of patients with common bile duct stones. Patients and Methods In this study, the data of (30) patients with CBDS who presented for the first time to the department of General surgery at Ain Shams University hospitals, Cairo, Egypt. Were collected during the period of August 2021 to February 2022. Results In the current study, all patients received proper pre-operative assessment and were operated on using same endoscope set and by experienced operators. Also, all patients were observed for post ERCP complications. The current study found that ERCP stone extraction in stones ranging from 10-20 mm success rate shows no significant difference in comparison with results that were published in different recent researches studying ERCP success rate in different stone sizes. Conclusion The current study found that success rate of ERCP in CBD stones extraction in stones ranging from 10-20 mm in size is similar to success rate in stone extraction compared to other studies not specifying stone size range. Also, complication rate was comparable to other recent published studies’ complication rate.

Endoscopic retrograde cholangiopancreatography versus conservative treatment of biliary leakage due to injury of Luschka duct during laparoscopic cholecystectomy

Background Gallstones remain the most common disease of gastrointestinal tract in the world. Laparoscopic cholecystectomy is one of the most common performed surgical operations. Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy and these occur in 0.3–0.8% of cases. The ducts of Luschka, or subvesical ducts, are small ducts originate from the right hepatic lobe, course along the gallbladder bed, and usually drain into the extrahepatic bile ducts. Injury of these ducts is the second most frequent cause of postcholecystectomy bile leakage after cystic duct leak. Aim The aim of this study is to compare between conservative and endoscopic retrograde cholangiopancreatography (ERCP) treatment of leaked injured Luschka duct as regarding outcomes, effectiveness, and cost. Patients and methods Retrospective study included patients with postcholecystectomy biliary leakage due to Luschka duct injury from June 2015 to December 2022. Results A total of 20 patients were included in this study and classified into two groups: group A with conservative treatment was successful in eight cases within 2–3 weeks and two cases reoperated, one with relaparoscopy with drainage and one cases reoperated with open exploration and ligation of leaked duct while group B with 10 cases treated with ERCP, all patients treated successfully with ERCP sphincterotomy and stent placement and leaks stopped and discharged within third or fourth day without any morbidity, no mortality in both groups. Conclusion Treatment of biliary leakage due to injured Luschka (subvesical duct) with ERCP sphincterotomy and stent placement is safe and effective without any morbidity or mortality.

S1034 The Efficacy and Safety of Fully Covered Self Expandible Metal Biliary Stent for the Treatment of Post ERCP Sphincterotomy Bleeding: A Systematic Review and Meta-Analysis

S1034 The Efficacy and Safety of Fully Covered Self Expandible Metal Biliary Stent for the Treatment of Post ERCP Sphincterotomy Bleeding: A Systematic Review and Meta-Analysis

Success Rate of Wire Control-Assisted ERCP Sphincterotomy Versus Non-assisted ERCP Cannulation of Common Bile Duct in a Secondary Care Unit During the First COVID-19 Peak: A Retrospective Observational Study of 281 Patients

BackgroundThe British Society of Gastroenterology (BSG) recommended that during the COVID-19 pandemic, endoscopy units perform endoscopic retrograde cholangiopancreatography (ERCP) for obstructive biliary pathologies in an emergency. We assessed the local performance of ERCP during the first wave of COVID-19 at our local endoscopy center, in particular the technique to common bile duct (CBD) cannulation.MethodologyAll ERCP procedures performed from January to June 2020 were retrospectively assessed and compared with procedures performed between January and June 2019 at the Royal Lancaster Infirmary. The indications for ERCP, success rate, and complications were studied separately. Correlation analysis was conducted using Spearman's rank correlation coefficient. The binary logistic regression model was used to compute the factors associated with successful ERCP. Significance was established when the two-sided P-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 25 for Windows (SPSS Inc., Chicago, IL, USA, 2017).ResultsA total of 281 ERCP were included in this study, with 169 and 112 performed during the first six months of 2019 and 2020, respectively. A statistically significant (0.0087) higher proportion of cases with liver dysfunction presented for ERCP before the COVID-19 outbreak (152, 89.94%). All patients before COVID-19 underwent wire control-assisted ERCP, while 82 (73.21%) received assisted ERCP during the first wave (P < 0.001). There was no statistically significant difference (P = 0.10) in the number of patients who underwent sphincterotomy before and during the first wave of COVID-19, with 97 (57.39%) and 76 (67.85%), respectively. The success rate of ERCP before COVID-19 was relatively high, accounting for 146 (86.39%) patients in contrast to 87 (77.67%) patients during the first wave (P = 0.074). Sphincterotomy (β = 2.800, P = 0.028) and stent insertion (β = 0.852, P = 0.046) were statistically significant predictors of ERCP outcomes. There was no statistically significant impact of cholangitis on the success of ERCP (β = 1.672, P = 0.109).ConclusionThe first wave of COVID-19 had a statistically proven negative impact on the expected standards of ERCP performance. Although the complication rate was significantly higher during the first wave case difficulty, the American Society of Anesthesia (ASA) status was not assessed on an individual basis. Both ASA status and case difficulty are now included in our endoscopy selection process. We recommend adding the complexity of cases and ASA to the local and national recording databases. This is a rare study on UK-based hospitals.

A Case Report of Intraoperatively Diagnosed Cholangiocarcinoma after Unsuccessful Conservative Treatment of ERCP Complicated with Hemorrhage

[full article, abstract in English; abstract in Lithuanian] Background Cholangiocarcinoma is a malignant tumor arising from the epithelium of the bile ducts. Most of these tumors are adenocarcinomas [1]. Intrahepatic cholangiocarcinoma accounts for 10% of all cholangiocarcinomas, hilar cholangiocarcinoma for 25%, and extrahepatic cholangiocarcinoma for 65% [2, 3]. Cholangiocarcinoma can develop in any part of the extrahepatic duct, occurring in 50–75% of reported cases in the upper third of the duct including the hepatic hilum, in 10–25% in the middle third, and in 10–20% in the lower third [4–6]. Approximately 95% of cases show extrahepatic obstruction at the time of diagnosis [7]. In a meta-analysis of 21 prospective trials, the rate of hemorrhage as a complication of ERCP was 1.3% (95% CI, 1.2%–1.5%) with 70% of the bleeding episodes classified as mild [8]. Hemorrhagic complications may be immediate or delayed, with recognition of occurring up to 2 weeks after the procedure. The risk of severe hemorrhage (ie, requiring >5 units of blood, surgery or angiography) is estimated to occur in fewer than1 per 1 000 sphincterotomies [9]. Despite new and advanced diagnostic methods, sometimes this type of tumor is finally diagnosed from pathological findings on excised tissue. Case report We present one case with cholangiocarcinoma diagnosed after surgical treatment of hemorrhage as post procedural complication from ERCP. With MRCP intraluminal stenosis of the upper part of common bile duct has been noticed and suspicious presence of substrate with consecutive dilatation of the upper billiary tract. ERCP was performed and sphincterotomy have been made without evacuation of any intraluminal substrate from common bile duct. Insufficient ERCP cholangiography was made and biopsy of the part with stenosis could not be taken due to permanent bleeding from performed sphincterotomy. Despite all attempts for conservative treatment of the hemorrhage, patient was still with permanent decreases of hemoglobin levels and with persistent hemorrhagic anemia. With decision from medical council the patient has been transferred to the Department of abdominal surgery for further immediate surgical treatment. Conclusion Patient with extrahepatic bile duct carcinoma initially diagnosed as a calculus in the common bile duct. Looking back, the patient had symptoms which differential diagnosis for bile duct cholangiocarcinoma should be established. Clinical symptoms such as right hypochondrium pain, itchy skin, vomiting and diarrhea. The laboratory findings showed constantly elevated bilirubin and liver enzymes also elevated tumor markers as CA19-9 and CEA. Hemorrhage that occurs after ERCP sphincterotomy and attempt for biopsy could not been controlled with conservative measures. Patient with consequently caused hemorrhagic anemia has been transferred for surgical treatment, which stopped the bleeding, made final diagnosis and treatment of proximal stenosis of common bile duct.

A RARE CAUSE OF BRONCHOBILIARY FISTULA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bronchobiliary fistula (BBF) is a rare medical condition that presents a diagnostic dilemma. It may be congenital or acquired, with the former having a prevalence of less than 1 million. Once diagnosed its etiology is often evident, however with its incidence due to echinococcal origin being < 2 percent, patients often have multiple hospitalizations prior to diagnosis. We present a rare case of a BBF, treated successfully with a minimally invasive approach. CASE PRESENTATION: 74 year old Syrian female with prior of history of a liver cyst drained of 200 millimeters 3 years prior at another institution comes with right upper quadrant abdominal pain, nausea and vomiting. She has an abdominal magnetic resonance imaging, subsequent CT-guided fine-needle aspiration and is diagnosed with hydatid cyst, treated conservatively with albendazole. She is discharged and presents 3 days later, with productive cough of yellow/green mucus, malaise and fever. She is treated as a healthcare associated pneumonia. Sputum culture shows gram positive cocci and antibiotics are tailored from cefepime and vancomycin to cephalexin in view of MSSA. The patient improves clinically and is discharged on albendazole plus cephalexin and scheduled for elective hepatic cyst resection. She returns 8 days later for fever and productive cough. She is found to have persistent pneumonia with elevated right hemidiaphragm on chest x-ray, treated with piperacillin-tazobactam and vancomycin empirically along with albendazole for hydatid cyst. She has a laparoscopic echinococcal cyst resection with some hepatic resection to facilitate cyst removal. While on the medical floor, she develops bilioptysis and leukocytosis. A BBF is suspected and confirmed with DISIDA scan. An endoscopic retrograde cholangiopancreatography (ERCP) is done with sphincterotomy and stent placement. She continues to clinically improve and is subsequently discharged with no cough for outpatient follow-up. DISCUSSION: Acquired BBF is a rare complication of echinococcal origin. While bilioptysis is the hallmark sign of BBF it may not always be present. This poses a diagnostic dilemma for physicians and potential life threatening complications for patients. The diagnosis is made with a DISIDA. Historically treatment has been surgical, but conservative options such as embolization and stent placement have been proposed. In this case, an ERCP sphincterotomy and stent placement is successfully used. This intervention results in a decrease in the transpapillary pressure gradient, thereby facilitating biliary flow to the intestine and healing of the BBF. CONCLUSIONS: BBF of echinococcal origin has an incidence of < 2%. Bilioptysis, a clinical hallmark, maybe absent posing a clinical dilemma resulting in multiple hospitalizations. This case highlights a rare diagnosis of BBF secondary to hydatid cyst and a successful conservative option, to a once surgical problem. Reference #1: Mohammadreza Seyyedmajidi MD, Mojtaba Kiani MD, Hamid Javadi MD, Alireza Raeisi MD, Majid Assadi MD. Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst. Hellenic Journal of Nuclear Medicine. 2015 May - August; 18(2):160-162. Reference #2: Guan-Qun Liao, Hao Wang, Guang-Yong Zhu, Kai-Bin Zhu, Fu-Xin Lv, Sheng Tai. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World Journal of Gastroenterology. 2011 September; 17(33): 3842-3849. Reference #3: Anton Crnjac, Vid Pivec, Arpad Ivanecz. Thoracobiliary fistulas: literature review and a case report of fistula closure with omentum majus. 2013 Radiol Oncol; 47(1): 77-85. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by Shanta Shrestha, source=Web Response

Management of cysto-biliary communication in hydatid cyst of liver

Introduction: Biliary communication of hepatic hydatosis is one of the important complications. It may be minor or major communication. Minor communication is usually diagnosed during operation by the presence of bile stained hydatid fluid on aspiration or bile leak during surgery. However, in major communication, patients present with obstructive jaundice, abdominal pain and cholangitis. Surgical management of major communication is difficult and is associated with high morbidity and mortality.Methods: This is a retrospective study at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two year (April 15th 2012 to April 15th 2014) and analyzed the medical records of 30 patients admitted and treated for hydatid cyst of liver in surgical ward during that period. Demography, clinical features, management and outcome were analyzed.Results: Of 30 patients with hepatic hydatid cyst operated over a period of two years, thirteen patients had cystobiliary communication. Amongst them, five minor communications were diagnosed during operation and managed with suture plication and omentopexy. Out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid cyst of gallbladder and was diagnosed intraoperatively. Among six cases of major communication, five cases required CBD exploration and bile duct reconstruction while partial cholecystectomy was done for hydatid cyst of gall bladder and one case was managed by ERCP sphincterotomy, evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had infected hydatid cyst and not fit for surgery.Conclusion: Cystobiliary communication is a common complication of hydatid cyst of liver. Therapeutic options are related to size and location of the cyst and size of communication.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 31-34

Diagnosis and Management of Choledochal Cyst in Adult : An Experience in a Tertiary Level Hospital in China

The cystic dilatation of the biliary tract is a rare disease and uncertain origin. It is recognized more frequently in children; however, its incidence comes increasing in adults, representing 20% of the cases. The aims of this study to demonstrate our experience with choledochal cyst and to evaluate morbimortality rates, discuss the aetiopathogenesis, presentation, management, and outcome with review of the literature. A retrospective study and review of the records of all the patients above 15 years, who underwent therapeutic intervention of choledochal cyst in Qillu Hospital of Jinan, China, was carried out. Ten cases of choledochal cyst were found, 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (Type I) excision of the diverticulum (Type II) and ERCP sphincterotomy (Type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Biliary tract cystic dilatation is a rare disease. However, its incidence is increasing in the adult population; so, it must be thought as differential diagnosis when facing obstructive jaundice. &#x0D; JCMCTA 2015 ; 26 (2) : 67 - 72

PTH-034 Hemospray may not reliably achieve hemostasis beyond 48 hours in acute upper gastrointestinal bleeding

Introduction Hemospray (Cook labs, Birmingham, USA) has been shown in multiple case series to be a useful and effective tool 1 in the management of acute GI bleeding where existing therapies fail to achieve hemostasis 2 or are impractical. It is as yet unclear whether treatment with Hemospray provides temporary or definitive benefit. Method We prospectively followed 9 consecutive cases in which Hemospray was used to control acute upper GI bleeding. Each case was followed to 30 days at which point the primary end-points of rebleeding and mortality were documented. Data was sourced from case notes and the local endoscopy database. All patients were treated at Southmead Hospital, Bristol, United Kingdom – a large endoscopy unit serving a population of around 620,000. Statistical analysis was by chi-squared and unpaired t-test. Results 9 patients (7 males, 2 females) were included in the study with a mean age of 60.1 years (range 18–86 years). Endoscopic diagnoses included duodenal ulcer (3), gastric ulcer (1), gastric tumour (1), oeosophageal varices (1), Dieulafoy lesion (1), ERCP sphincterotomy site bleed (1) and angiodysplasia (1). Hemospray was used as the only therapeutic modality in 7 cases. Hemostasis was achieved in 6/9 cases at the index endoscopy. In 3/9 cases bleeding continued: 2 patients underwent further endotherapy and 1 patient required a Sengstaken-Blakemore tube and subsequently died. 3/9 patients experienced rebleeding. 1 patient required further endotherapy and 2 patients required laparotomy. 2 patients experienced rebleeding more than 48 h after the index endoscopy. Rebleeding did not vary across the range of endoscopic diagnoses (p = 0.423) or age of patient (p = 0.302). At 30 days only 3/9 patients treated with Hemospray did not require further intervention. 8/9 patients survived to 30 days. Conclusion Our case series indicates that apparent initial hemostasis after application of Hemospray may be a temporary outcome only. In the UK, where physicians are urged to discharge patients soon after clinical stability has been achieved, this is a particularly important message. There may be benefit from relook endoscopy at 48 h or prolonged inpatient observation although this has not been suggested elsewhere. Larger studies are required and a region-wide series is planned. Disclosure of interest None Declared. References Bustamante-Balen M, Plume G. Role of hemostatic powders in the endoscopic management of gastrointestinal bleeding. World J Gastrointest Pathophysiol . 2014;5(3):284–92 Smith LA, Morris AJ, Stanley AJ. The use of hemospray in portal hypertensive bleeding; a case series. J Hepatol . 2014 Feb;60(2):457–60

Choledochal Cyst in Adults: Etiopathogenesis, Presentation, Management, and Outcome-Case Series and Review.

Background. Choledochal cyst, a rare congenital cystic dilatation of biliary tree, is uncommon in adults. Their presentations differ from children and surgical management has evolved. Methods. A retrospective review of the records of all the patients above 15 years, who underwent therapeutic intervention in our hospital, was carried out. Results. Ten cases of choledochal cyst were found; 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (type I), excision of the diverticulum (type II), and ERCP sphincterotomy (type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Conclusion. Choledochal cyst is rare in adults. The typical triad of abdominal pain, jaundice, and mass is uncommon in adults. The surgical strategy aims for single stage complete excision of the cyst with hepaticojejunostomy.

Su1346 Prophalactic Hemoclip Application At ERCP to Prevent Post-ES Bleeding in Patients Receiving Anticoagulation or Antiplatelet Therapy

The risk of immediate or delayed post-endoscopic sphincterotomy bleeding (PESB) is reported to range from 2.0-5.3%, but can be as high as 10% to 25% in the setting of high risk patients (pts) receiving anti-platelet agents or anti-coagulation therapy. These pts present a particular challenge when definitive ERCP sphincterotomy (ES) is indicated. Mechanical clipping of PESB has been reported but infrequently used due to the difficulty in placing the current generation of clips using ERCP endoscopes as well as the potential risk of inadvertent application of clips on the pancreatic orifice. However, hemoclip placement has been shown to be highly effective in mechanical closure of a wide variety of bleeding and potential bleeding lesions of the GI tract. We present our single center experience with prophylactic hemoclip placement to prevent PESB in the setting of antiplatelet/anticoagulation Rx.

Su1355 Hemoclip Application to Treat and Prevent Post-Sphincterotomy Bleeding in High-Risk Patients Undergoing Therapeutic ERCP

Following ERCP sphincterotomy (ES), the risk of immediate or delayed bleeding is reported to be 2.0 - 5.3 %, but can rise to greater than 10% and perhaps as great as 25% in the setting of anti-coagulation therapy. In addition, patients with underlying liver disease or hematologic disorders, are at markedly greater risk of bleeding in this setting. Studies with epinephrine have not been conclusive, and although widely used it has not been demonstrated to be effective monotherapy. Treatment of a variety of GI bleeding disorders, including peptic ulcer, vascular anomalies, and post-polypectomy hemorrhage, has been increasingly performed using hemostatic clips.

Mo1442 Long-Term Follow-Up of a Randomized Trial of Laparascopic Cholecystectomy and Laparascopic Common Bile Duct Exploration vs. ERCP With Sphincterotomy and Laparascopic Cholecystectomy for Common Bile Duct Stone Disease

Common bile duct stone disease can be treated endoscopically with ERCP sphincterotomy (ERCP/S) or surgically via laparascopic common bile duct exploration (LCBDE). Published data on the long-term follow-up of patients undergoing these two techniques in a controlled clinical trial is limited.

Prospective Randomized Trial of LC+LCBDE vs ERCP/S+LC for Common Bile Duct Stone Disease

To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC). Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique. Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California. We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed. Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE. The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores. The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups. Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE. clinicaltrials.gov Identifier: NCT00807729.

Catheter probe extraductal ultrasonography vs. conventional endoscopic ultrasonography for detection of bile duct stones

Endoscopic ultrasonography (EUS) has been established as a valuable diagnostic tool for the detection of bile duct stones (BDS). The recently introduced extraductal endoscopic ultrasonography (EDUS) using miniprobes has the advantage that it can be performed with a duodenoscope, and if therapeutic interventions become necessary, there is no need to change the scope. Consecutive patients with acute biliary pain and a dilated bile duct and/or elevated liver function tests, in whom the origin of biliary obstruction could not be identified by US and CT, were enrolled. The patients were investigated with a linear-array echoendoscope, and an additional transduodenal EDUS examination was performed with a 12-MHz miniprobe via the instrumentation channel of the echoendoscope. The presence or absence of BDS was afterwards evaluated by endoscopic retrograde cholangiopancreatography (ERCP)/sphincterotomy (EST) and by instrumental bile duct exploration (in the case of a positive EUS/EDUS finding), or by magnetic resonance cholangiopancreatography (MRCP) and ERCP with additional clinical follow-up (in the case of negative findings on EUS/EDUS). One hundred and fifty-five patients (55 +/- 12 years old, 98 female) were enrolled. In six cases, the distal bile duct could not be successfully visualized by EDUS, whereas with EUS visualization failed in only one patient ( P = 0.13). Choledocholithiasis was proven in 75 cases (48 %). The diagnostic accuracy of EUS for the detection of BDS (sensitivity 92 %, specificity 100 %, PPV 1.0, NPV 0.93, accuracy 95 %) was comparable to that of EDUS (sensitivity 90 %, specificity 98 %, PPV 0.99, NPV 0.93, accuracy 91 %, P = 0.17 vs. EUS). In patients at intermediate risk of BDS it seems to be justified to perform EDUS instead of EUS, and to proceed with ERCP and EST immediately when findings are positive.

Complications chirurgicalesdes pancréatectomies

The mortality for pancreatectomy has decreased to a very low level in recent years but morbidity remains high. The most frequent post-operative complications of pancreaticoduodenectomy (PD) are delayed gastric emptying (DGE) in 20% and pancreatic fistula (PF) in 10-15%. DGE is associated with other abdominal complications in half the cases; these must be delineated by CT scan and specifically treated. Isolated DGE usually resolves within three weeks with the use of nasogastric suction and pro-kinetic drugs. FP following PD may be preventable with the use of temporary trans-jejunal intubation of Wirsung's duct or by intussusception of the pancreatic margin into the jejunal lumen. FP occurring after PD will heal with conservative management (total parenteral nutrition, peripancreatic drainage, somatostatin analogues) in 80-90% of cases but secondary complications such as peritonitis, arterial erosion and pseudo-aneurysm may be life-threatening. Early hemorrhage (in the first 48-72 hours) must be treated by re-operation. Late hemorrhage (usually secondary to PF) and ischemic complications are rare (3% and 1% respectively), difficult to treat, and associated with high mortality. PF is also the main complication of distal pancreatectomy and enucleation of pancreatic tumors (10-20% and 30% respectively). These PF resolve with conservative treatment in more than 95% of cases but may justify an ERCP sphincterotomy if drainage is prolonged. After medial pancreatectomy, PF occurs in 20-30% of cases, arising from either of the two transected pancreatic surfaces.

Bile Duct Injuries during Laparoscopic Cholecystectomy: Management and Outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Endoscopic and Histologic Evidence of Cholesterolosis of the Sphincter of Oddi At ERCP Sphincterotomy: A Possible Cause of Fibrotic Stenosis

Bakground: Cholesterolosis of the gallbladder mucosa is frequently found in patients with cholelithiasis. Sphincter of Oddi dysfunction (SOD) is of unknown cause but is frequently associated with previous cholesterol gallstone disease. A presumed etiology has been the recurrent passage of small gallstones and/or microlithiasis. Biopsies of the sphincter in SOD patients have shown variable histology in the few reported studies. We report the new finding of intrasphincteric cholesterolosis as a possible cause of fibrotic SOD. Patients: Between 9/01 – 12/04, 12 patients (pts) undergoing biliary endoscopic sphincterotomy (BES) were recognized to have obvious light-yellow adherent crystals in the posterior wall of the sphincter. Repeated washing with forceful irrigation failed to dislodge the material. Photo documentation was obtained in all pts and directed forceps biopsy was obtained in 10 of the 12 pts. Histology revealed florid cholesterolosis evident by clusters of lipid-laden macrophages in the lamina propria. Indications for BES for these 12 pts were SOD (Type I, n= 8) (Type II, n=3) (Type III, n=1). Six pts had associated complicating choledocholithiasis. Pancreatitis was a presenting sign in 5 and elevated liver tests in 4. Five of 12 pts had previous cholecystectomy for gallstone disease. In one pt, removal of a normal functioning gallbladder revealed extensive mucosal cholesterolosis. One pt has subsequently undergone repeat investigation for unresolving pain and complete disappearance of the adherent cholesterol crystals was noted. Repeat biopsies revealed resolution of the cholesterolosis. Over this time period, 1115 BES cases were performed and 292 had SOD. 12/292 (4%) had cholesterolosis compared to 0/823 (p=0.0001). Conclusion: Cholesterolosis of the sphincter of Oddi appears to be unique to patients with underlying sphincter of Oddi dysfunction and may represent a pathological mechanism for the development of this clinical entity, at least in a proportion of cases. Improved optical endoscopy may permit better recognition of what may be a more common finding not heretofore described. A systematic evaluation with routine biopsy at the time of sphincterotomy from the inner aspect of the sphincter may uncover the true incidence of this important finding. Bakground: Cholesterolosis of the gallbladder mucosa is frequently found in patients with cholelithiasis. Sphincter of Oddi dysfunction (SOD) is of unknown cause but is frequently associated with previous cholesterol gallstone disease. A presumed etiology has been the recurrent passage of small gallstones and/or microlithiasis. Biopsies of the sphincter in SOD patients have shown variable histology in the few reported studies. We report the new finding of intrasphincteric cholesterolosis as a possible cause of fibrotic SOD. Patients: Between 9/01 – 12/04, 12 patients (pts) undergoing biliary endoscopic sphincterotomy (BES) were recognized to have obvious light-yellow adherent crystals in the posterior wall of the sphincter. Repeated washing with forceful irrigation failed to dislodge the material. Photo documentation was obtained in all pts and directed forceps biopsy was obtained in 10 of the 12 pts. Histology revealed florid cholesterolosis evident by clusters of lipid-laden macrophages in the lamina propria. Indications for BES for these 12 pts were SOD (Type I, n= 8) (Type II, n=3) (Type III, n=1). Six pts had associated complicating choledocholithiasis. Pancreatitis was a presenting sign in 5 and elevated liver tests in 4. Five of 12 pts had previous cholecystectomy for gallstone disease. In one pt, removal of a normal functioning gallbladder revealed extensive mucosal cholesterolosis. One pt has subsequently undergone repeat investigation for unresolving pain and complete disappearance of the adherent cholesterol crystals was noted. Repeat biopsies revealed resolution of the cholesterolosis. Over this time period, 1115 BES cases were performed and 292 had SOD. 12/292 (4%) had cholesterolosis compared to 0/823 (p=0.0001). Conclusion: Cholesterolosis of the sphincter of Oddi appears to be unique to patients with underlying sphincter of Oddi dysfunction and may represent a pathological mechanism for the development of this clinical entity, at least in a proportion of cases. Improved optical endoscopy may permit better recognition of what may be a more common finding not heretofore described. A systematic evaluation with routine biopsy at the time of sphincterotomy from the inner aspect of the sphincter may uncover the true incidence of this important finding.

ERCP Sphincterotomy Without Initial Manometry for Type II Sphincter of Oddi Dysfunction Patients: A Safe and Effective Strategy

Background: Type II Sphincter of Oddi dysfunction (SOD II) is associated with recurrent pancreatitis, pancreatic or biliary-type pain, and with either a dilated duct or abnormal LFTs. There remains debate as to the role of manometry in these pts since at least some objective evidence of obstruction exists. We present our experience of treating these patients using a clinically-based approach without initial manometry, emphasizing both its safety and long-term effectiveness. Patients & Methods: Our ERCP database identified all cases of SOD II from 01/91 - 7/03. Transient mild LFT elevation, ducts ≥8mm, and relapsing pancreatitis were accepted as SOD II Dx criteria. Identification of post-ERCP complications were based on published consensus criteria. Long-term f/u was at office visit and/or telephone contact. Results: 262 pts (ages 21-90+, mean=60) were identified with SOD II. Indications included pain with dilated ducts 49% (n=124), recurrent pancreatitis 30% (n=81), elevation of LFTs 21% (n=57). 99% (261/262) of pts underwent biliary sphincterotomy (ES); 22% (59/262) had pancreatic ES [ 32 had simultaneous with biliary ES; 27 received later pancreatic ES for persistent symptoms]. Pts who underwent pancreatic ES were treated with overnight nasopancreatic drainage or 5Fr PD barbless stents. Biductal manometry was selectively used in 16 cases for persistent symptoms following previous biliary or panc ES and was abnormal in 10, directing further endoscopic Rx. Complications were observed in 4.3% (12/273) of ERCP cases; [pancreatitis- (mild=5, mod=2, severe=1); perforation-(mild=4)]. Over the same time interval, 5,633 therapeutic ERCPs were performed on patients without SOD II; the complication rate in this cohort was 3.8% vs. 4.3% among SOD II pts (p=0.8). Long-term follow-up (mean=30 mo, range 6-79 mo) was available for 83% (215/262) of pts. Overall, 59% (129/215) of pts reported resolution of abdominal pain, 27% (58/215) improved, and only 13% (28/215) were worse or unchanged. Conclusions: In expert hands, type II Sphincter of Oddi dysfunction patients can be managed without initial manometry with a high degree of safety, similar to type I SOD patients. The clinical response rate of over 80% reported here is unlikely to be bettered by a manometry-based algorithm. Manometry should be reserved to evaluate failure of response to initial sphincterotomy in type II Sphincter of Oddi dysfunction patients.

AIDS-Related Biliary Tract Disease

Increasingly, specialists caring for patients with AIDS have reported relatively small numbers of patients with biliary tract disease. These conditions fall into three general categories: (1) non-HIV-associated conditions of the bile duct, (2) acalculous cholecystitis, and (3) AIDS cholangiopathy. Whatever the cause, a sizable percentage of patients with AIDS are found to have abnormal biliary tract morphology. It is essential for the clinician first to exclude biliary tract conditions such as gallstone disease and then to clearly investigate those patients with clinical, biochemical, or radiographic features suggestive of papillary stenosis. Patients with AIDS-associated papillary stenosis do respond symptomatically to ERCP sphincterotomy.