Follow-up Endoscopic Retrograde Cholangiopancreatography Research Articles

Outcome of the Endoscopic Biliary Stenting for Irretrievable Common Bile Duct Stones in an Academic Hospital – A Prospective Study

Background: Choledocholithiasis is characterized by the existence of a stone in the common bile duct. Based on findings published in the Medical Clinics of North America, around 10-15% of individuals with gallstones experience the development of choledocholithiasis. Presently, the established approach for addressing common bile duct stones involves the implementation of endoscopic papillotomy and stone extraction. The combined utilization of Dormia basket, balloon catheter, and lithotripsy achieves a success rate of approximately 90%. In cases where traditional endoscopic removal methods prove ineffective, biliary stenting plays a crucial role in the conservative management of CBD stones. Objectives: The main goal of the study was to evaluate the outcome of biliary stenting in irretrievable common bile duct stones. Materials and Methods: This observational study took place at the Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, from January 2018 to December 2018. The study included consecutive patients who were 18 years or older and diagnosed with common bile duct stones. These patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The study specifically focused on patients who received biliary stenting for irretrievable common bile duct stones, and they were enrolled as participants in the study. Results: Out of the 83 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction, 29 patients (35%) were deemed as having irretrievable stones, necessitating the implementation of stenting. Among these irretrievable stone cases, the average age was 46.69, and there was a predominance of females with 17 patients (58.6%). Of the 29 cases, 22 patients completed the follow-up. During the follow-up ERCP, a significant reduction was observed in both the average number of stones (3.14 vs. 1.9; P=0.002) and their size (16.32 vs. 12.4; P=0.005). Successful stone extraction was achieved in 14 patients (63.64%) during the second ERCP. In one patient (4.55%), spontaneous clearance of the stone occurred, while in 7 patients (31.81%), stone extraction was not possible during the second ERCP. The reduction in mean stone size was the only significant factor affecting the success of the second ERCP. However, there was no correlation found between the duration of stenting and the reduction in stone size (r=-0.193, p=0.401). Conclusion: Our study shows that repeat ERCP can successfully extract stones regardless of stenting duration. Unlike Western data, we emphasize the effectiveness of endoscopic biliary stenting in a context with limited access to advanced techniques, where initial stone extraction rates are lower. This approach is particularly beneficial for patients with stone sizes over 15 mm, avoiding the need for complex surgical procedures.

A78 BILIARY STENT USE IN ERCP: A QUALITY ASSURANCE STUDY ASSESSING ADHERENCE TO CLINICAL GUIDELINES AND COST OUTCOMES

Abstract Background A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy. Purpose To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost. Method A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes. Result(s) A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%). Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000. Conclusion(s) Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A81 OPTIMIZING THE INDICATIONS FOR BILIARY STENT PLACEMENT IN PATIENTS WITH CBD STONES: A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE PATIENT CARE AND REDUCE HEALTHCARE RESOURCE UTILIZATION

Abstract Background A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed. Purpose To reduce the number of inappropriately inserted biliary stents in patients with CBD stones. Method The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers. Result(s) A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p<0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p<0.0001). Image Conclusion(s) Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

S1690 A Slow Gut Can Hold up Recovery for Cholecystectomy-Induced Bile Leak

Introduction: Bile leak (BL) can occur in up to 0.5% of open cholecystectomies (CCY) and up to 2.7% of laparoscopic CCY. Strasberg types A and D post-CCY BL can be treated with endoscopic retrograde cholangiopancreatography (ERCP) with excellent success rates > 90%. ERCP interventions can decrease the pressure gradient between the bile duct and duodenum and facilitate transpapillary flow of bile. Case Description/Methods: An 81-year-old woman with dementia, recurrent deep vein thrombosis and coronary artery disease presented to an outside hospital with severe abdominal pain and was diagnosed with acute cholecystitis. CCY was delayed by 6 days because she was on ticagrelor and rivaroxaban. Intraoperatively, a gangrenous perforated gallbladder was found, and a surgical drain (SD) was left in-situ. Post CCY she had persistent output from her SD and was transferred to our center for ERCP evaluation of suspected BL. On initial ERCP we found a high-grade Strasberg type A BL from the cystic duct (Figure A). Her major papilla was entirely located within a large duodenal diverticulum. Due to difficulty identifying safe cutting margins within the diverticulum, biliary sphincterotomy (Bsc) was not performed, and a 7 Fr plastic biliary stent was placed which resulted in good flow of bile into the duodenum. Her SD output decreased, and she was discharged the next day. Unfortunately, she was re-admitted to another hospital 3 days later with bile leakage around her SD, vomiting and constipation. An upper gastrointestinal (GI) series excluded a gastric outlet obstruction (Figure B). She was transferred back to our center for ERCP. The scout film showed that oral contrast that was ingested 3 days prior was still present within the proximal jejunum (Figure C). The biliary stent was patent and in good position, but a persistent high-grade BL was seen. Bsc was performed, and an 8mm by 6 cm fully covered self-expanding metal stent (FCSEMS) was placed. The patient was started on an aggressive bowel regimen with resolution of ileus. The SD output ceased, and the SD was removed 3 days later. Unfortunately, patient passed away in hospice before her follow-up ERCP from other causes. Discussion: Despite successful diversion of bile to the duodenum via a biliary stent, small bowel ileus can increase the pressure gradient across the major papilla, resulting in a persistent BL. More aggressive ERCP interventions using FCSEMS, along with aggressive medical treatment of ileus, allowed the BL to heal expeditiously.Figure 1.: A: High-grade cystic duct bile leak on initial ERCP evaluation. B: Contrast flowing from stomach to duodenum in upper gastrointestinal series. The plastic biliary stent is in-situ. C: the oral contrast ingested approximately 3 days prior is still visible within the proximal jejunum on ERCP scout film.

Diffuse Common Bile Duct Mural Thickening in a Patient With Pancreatitis

Question: A 64-year-old man experienced acute episodes of abdominal and back pain 5 months ago, followed by jaundice, which prompted him to seek evaluation at his local hospital. Laboratory evaluation was notable for elevated bilirubin 3.4 mg/dL (reference range, 0–1.2 mg/dL), alkaline phosphatase of 1352 U/L (reference range, 50–121 U/L), alanine aminotransferase of 219 U/L (reference range, 12–52 U/L), and lipase 361 U/L (reference range, 13–78 U/L). The patient underwent several endoscopic retrograde cholangiopancreatography (ERCP) procedures with brush cytology and common bile duct (CBD) stent placement for an indeterminate stricture, and endoscopic ultrasound (EUS) examination with fine needle aspiration of the stricture without an identifiable etiology. At presentation for a second opinion, the patient noted resolution of jaundice, but complained of pruritus, greasy stools, flatulence, and bloating, along with a 30-lb weight loss and fatigue. He denied excessive alcohol consumption, smoking, or a history of gallstones. On physical examination, the patient was without jaundice or abdominal pain. Routine laboratory evaluation was unremarkable except for a mildly elevated alanine aminotransferase of 56 U/L and alkaline phosphatase of 260 U/L. Carbohydrate antigen 19-9 and alpha fetoprotein levels were within normal limits. Hepatitis B and C serologies, anti–smooth muscle actin and anti–mitochondrial antibodies were unremarkable. IgG4 subclass was elevated at 172 mg/dL (reference range, 2.4–121 mg/dL). A magnetic resonance cholangiopancreatography showed enhancement of the CBD with mural thickening and pancreatic parenchymal atrophy (Figure A). A repeat ERCP did not show significant intrahepatic biliary duct dilation, but a stricture was noted in the distal CBD. EUS examination demonstrated pancreatic body and tail atrophy with pancreatic head changes consistent with moderate to severe chronic pancreatitis. The entire visualized CBD and cystic duct had circumferential wall thickening (Figure B). Cholangioscopy showed nonspecific findings. Based on the clinical scenario and images, what is the most likely diagnosis? Look on page 827 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Cholangioscopic biliary mucosal biopsies showed active chronic inflammation and increased IgG4-positive cells. Pancreatic head biopsies showed fibrosis with lymphoplasmacytic infiltrate and increased IgG4-positive cells with an IgG4 to IgG ratio of >40%. Cytology and fluorescence in situ hybridization of bile duct brushings were again unremarkable. The patient was initiated on pancreatic enzyme replacement therapy and a slow taper of prednisone. On follow-up 3 months later, his gastrointestinal symptoms had resolved, and weight had stabilized. Likewise, his liver chemistries and IgG4 subclass level had normalized. Follow-up ERCP revealed improvement in the CBD stricture. IgG4-related disease (IgG4-RD) is an immune-mediated, fibroinflammatory, multiorgan disease. It can present with regions of inflammatory thickening or mass formation that is often confused for a malignancy. The disease presents insidiously and is progressive. Most frequently involved organs include the pancreas resulting in type 1 autoimmune pancreatitis with diffuse enlargement, diabetes, and exocrine insufficiency; salivary and lacrimal glands resulting in asymptomatic symmetric enlargement; retroperitoneum resulting in soft tissue mass; and bile ducts resulting in intrahepatic and extrahepatic strictures.1Perugino C.A. Stone J.H. IgG4-related disease: an update on pathophysiology and implications for clinical care.Nat Rev Rheumatol. 2020; 16: 702-714Crossref PubMed Scopus (90) Google Scholar Additionally, our patient had a diffusely thickened CBD and cystic duct wall well-characterized by EUS examination (Figure B). The diagnosis is based on a comprehensive workup to distinguish from conditions presenting similarly. In this case, pancreatic cancer, cholangiocarcinoma, and primary sclerosing cholangitis were carefully ruled out. Various criteria have been proposed to diagnose IgG4-RD that predominantly rely on (1) imaging features, (2) an elevated serum IgG4 with various cut-off values, and (3) histological findings of lymphoplasmacytic infiltrate with fibrosis, a ratio of IgG4-positive plasma cells/IgG-positive cells of >40%, and the number of IgG4-positive plasma cells greater than 10 per high-powered fields, and typical fibrosis, storiform, or obliterative phlebitis.2Löhr J.M. Beuers U. Vujasinovic M. et al.European guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations.United European Gastroenterol J. 2020; 8: 637-666Crossref PubMed Scopus (0) Google Scholar,3Umehara H. Okazaki K. Kawa S. et al.The 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-RD.Mod Rheumatol. 2021; 31: 529-533Crossref PubMed Scopus (77) Google Scholar Multiple organ involvement and steroid responsiveness are also considered supportive of IgG4-RD. Our patient met the diagnostic criteria for IgG4-RD with excellent response to steroid treatment.

Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy.

Background and study aims Plastic biliary stents are standard therapy for treatment of post-cholecystectomy bile leaks. An increasing proportion of patients now undergo subtotal cholecystectomy and are at perceived risk for high-grade bile leak. Data are limited regarding the optimal endoscopic therapy following subtotal cholecystectomy. The aim of this study was to compare outcomes of endoscopic plastic stent therapy for treatment of bile leak following total vs subtotal cholecystectomy. Patients and methods A retrospective cohort of patients with bile leak following cholecystectomy and treated with biliary stent was identified from an institutional database. Primary outcome was defined as cholangiographic resolution of leak at follow-up endoscopic retrograde cholangiopancreatography (ERCP). Results Sixty-one subjects met study inclusion criteria, 27 following total cholecystectomy and 34 following subtotal cholecystectomy. A single plastic biliary stent was placed in 87 % of subjects (53/61), while a fully covered self-expanding metal stent (FCSEMS) was placed in 13 % (8/61). Leak resolution was evident at first follow-up ERCP in 96 % of subjects (26/27) who had undergone total cholecystectomy and 91 % of subjects (31/34) who had undergone subtotal cholecystectomy ( P = 0.25). Among subjects who had received a plastic stent at index ERCP, leak resolution was evident at first follow-up ERCP in 96 % (23/24) of those who had undergone total cholecystectomy and 90 % (26/29) of those who had undergone subtotal cholecystectomy ( P = 0.62). Conclusions High rates of leak resolution can be achieved with placement of a single plastic biliary stent for treatment of post-cholecystectomy bile leaks, including after subtotal cholecystectomy.

1412 A Rare Case of Post-ERCP Panniculitis

INTRODUCTION: Pancreatic panniculitis affects 0.3-3% of patients with a wide variety of pancreatic disorders. It is characterized by subcutaneous fat necrosis following the release of pancreatic enzymes into the circulation. Endoscopic retrograde cholangiopancreatography (ERCP) is a rare cause of panniculitis. Based on our literature review, this is the fourth case report of post-ERCP panniculitis. CASE DESCRIPTION/METHODS: An 80-year-old female with a history of choledocholithiasis with biliary stent placement presented for elective ERCP. The procedure demonstrated a moderate, inflammatory distal biliary stricture, a migrated biliary stent and choledocholithiasis. A biliary sphincterotomy, cholangioscopy and laser lithotripsy and stent exchange was performed with approximately 80% of stone removal. Post- procedure the patient noted tender erythematous raised nodules on her legs. Skin biopsy was performed with findings consistent with pancreatic pannicultitis. Follow-up ERCP was normal with trace sludge and removal of the biliary stent. At follow-up she was improved without abdominal pain and reported healing of the lower extremity cutaneous lesions. DISCUSSION: Pancreatic panniculitis is a rare skin finding that is independent of disease severity and can occur at any point during the disease process. Post-ERCP panniculitis is rare and only reported in three other cases. Pancreatic panniculitis is typically tender, ill-defined, red-brown nodules located in the lower extremities. The gold standard for diagnosis is biopsy with histopathology significant for a mostly lobular panniculitis without vasculitis with the presence of the typical ghost cells, necrotic and calcified adipocytes. Treatment is aimed at addressing the underlying pancreatic disease and the lesions typically resolve with improvement in pancreatic inflammation.

50 Prognostic Factors in Outcomes of Endoscopic Therapy for Biliary Leak Repair

INTRODUCTION: Despite advances, there is a 3–18% risk of bile leak after hepatobiliary surgery. Sepsis and repeat surgery have up to a 38% mortality rate. Therefore, endoscopic repair is preferred. This study evaluates efficacy of endoscopy and prognostic factors in success. METHODS: Of 41 patients who had endoscopic retrograde cholangiopancreatography (ERCP) for suspected post-surgery bile leak between 2015–19 at our hospital, 34 met inclusion with confirmed leak. Charts were reviewed for demographics, clinical and surgical parameters, ERCP findings, time to detection, to ERCP, to clinical improvement, and to resolution of bile leak. Success is defined as procedural (stent placement), clinical (improved leak), and resolution (no leak on follow-up). Two-tailed t test and chi square test were used in statistical analysis. RESULTS: Most patients were male (82.5%), average age 38, BMI 27, and pre-op CCI 0 (70.6%). 97.1% had emergent surgery and 67.6% had laparotomy; reasons and surgery types are in Table 1. In diagnosis, 70.6% of leaks were detected solely clinically (88% by bile in the JP drain, 21% had abdominal pain, 15% had fever, and 15% in the OR). 2.9% were found only on radiology and 26.5% were noted clinically and in imaging. Average surgery to diagnosis time was 8 days, from diagnosis to ERCP 4 days, to clinical success 8 days, and to confirmed resolution 98 days. 73.5% of leaks were identified at intrahepatic, 23.5% at cystic, and 3% at pancreatic ducts. After first ERCP, 28/34 patients had procedural and 27/34 had clinical success. 7/34 patients required further intervention following ERCP; 6 had CT guided drain and 1 had repeat surgery (Figure 1). 26/34 had confirmed resolution on repeat ERCP, while the other 8 were lost to follow up. 82.4% had no complications after ERCP; main complications were sphincterotomy site bleed, pancreatitis, further biliary injury, and infection. Median length of stay was 23.5 days among all patients. CONCLUSION: This study supports endoscopic repair in post-operative bile leak as safe and effective as all patients with follow-up ERCP had resolution. Surgery type and leak size may predict success. Bile leak after hepatic artery embolization/hemostasis (P = 0.024) and large bile leak (P = 0.007) were significantly more likely to need post-ERCP procedure (Table 2). A larger cohort will guide how to optimize care and warrants study.

Metal stents placement for refractory pancreatic duct stricture in children.

AIMTo evaluate the use of fully covered self-expandable metal stents (FCSEMSs) for pancreatic duct strictures in children with chronic pancreatitis.METHODSEight patients with refractory benign dominant stricture of the main pancreatic duct (MPD) were enrolled through chart reviews between December 2014 and June 2017 in a single center. Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a 6-mm FCSEMS with dual flaps was performed. Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps. All procedures were performed by a pediatric gastroenterologist. For the assessment of outcomes, technical and clinical success, adverse events, and stent patency were evaluated retrospectively.RESULTSThe placement and removal of the FCSEMSs were successful in all 8 patients. Five patients were boys and 3 were girls. The median age at initial FCSEMS placement was 12 years (range, 5-18 years). The diameters of all the inserted stents were 6 mm, and the lengths were 4-7 cm. The median indwelling time was 6 mo (range, 3-10 mo). No pancreatic sepsis, pancreatitis, cholestasis, or mortality occurred. There was no proximal and distal migration. All subjects showed a patent stent. On follow-up ERCP, the mean diameter of the stricture improved from 1.1 mm to 2.8 mm (P < 0.05), whereas that of upstream dilation improved from 8.4 mm to 6.3 mm (P < 0.05).CONCLUSIONThis initial experience showed that temporary FCSEMS placement is feasible and safe for the management of refractory benign MPD stricture in children.

Endoscopic Retrograde Cholangiopancreatography in Nonagenarians Patients

Introduction: As the average life expectancy continues to rise in the United States a significant number of procedures are carried out on an increasingly older population with little data regarding the safety in geriatric populations. Limited by small patient pools, literature on the safety of Endoscopic retrograde cholangiopancreatography (ERCP), in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients. Methods: A retrospective chart review of patients undergoing ERCP at an urban medical center was carried out. All patients undergoing primary diagnostic/therapeutic ERCP were included. Patients undergoing follow-up ERCP for stent removal were excluded. The patients were divided into two groups based on their age (group 1 aged 90 years and above and group 2 aged between 18-89 years). Results: A total of 904 patients undergoing primary ERCP were identified. The overall success rate was 90%, with a complication rate of 9% (2.4% major, 6.5% minor) and in-hospital mortality of 2.4%. Patients with a Charelson Comoridity Index (CCI) ≥ 2 had increased in-hospital mortality 5.0% vs. 1.2% (p < 0.001) and a trend towards increased complications 11.3% v/s 7.8% (p=0.08). However, CCI was not associated with age group. There were 74 patients (8%) aged 90 years or older with a mean age of 92.07±1.8 in Group 1, compared to 830 patients (92%) with a mean age of 62.09±19.2 in group 2. Success and complication rates were comparable between the two groups 89.2% v/s 90.1% (p=0.8) and 4.1% v/s 9.4% (p=0.12) respectively. However the older group had an increased in-patient mortality 12.2% v/s 1.6% (p=0.001). Logistic regression showed that patients in group 1 had a significantly increased odds of inpatient mortality (AOR=10.5, 95% CI=4.0, 25.2, p≤0.001); adjusting for CCI and emergency procedures. CCI was also an independent predictor of in-patient mortality (AOR=5.1, 95% CI=2.0, 13.1, p=0.001). Age ≥ 90 and CCI were not associated with complications; however emergency procedures were more likely to have complications when adjusted for age and CCI (AOR=2.3, 95% CI=1.4, 3.9, p=0.002). Conclusion: Age ≥ 90 and CCI ≥ 2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP; while emergency procedures are associated with an increased complication rate. Caution must be excised when considering ERCP in this subset of the population.

Risk Factors for Common Bile Duct Stent Occlusion after Endoscopic Retrograde Cholangiopancreatography

Introduction: Endoscopic biliary stenting is a common procedure performed in gastrointestinal endoscopy to manage various bile duct disorders. The safety and efficacy of common bile duct (CBD) stenting for relieving CBD obstruction and management of other complications is well established. One of the common complications of CBD stent placement is stent occlusion. The risk factors which can predict stent occlusion are not well studied in literature. Aim of our study was to identify potential risk factors that are associated with stent occlusion in patients with CBD stents. Methods: This case control study included all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stent placement at our institution from January 2009 to December 2014. The study group included all patients with CBD stents who were subsequently found to have an occluded stent. A control group was randomly selected in 1:1 ratio, and included all patients with CBD stent placement but without stent occlusion during the course of their management. Descriptive statistics were computed for all variables including means, medians, ranges for continuous variables. Data is presented as mean ± standard deviation, median [25th, 75th percentiles or interquartile range, IQR] or N (%). A univariate and multivariate analysis was performed to compare the groups; Results: A total of 394 patients were included in the analysis of which 197 were in the study group and 197 in the control group. Average age of the study cohort was 63.5 ± 14.8 years and 215 (54.8%) were males. The baseline and demographic data was similar in the two groups. On univariate analysis, patients with history of smoking were 1.52 times (1.14-2.04) more likely to have stent occlusion (p=0.04). Patients with cirrhosis were 1.91 times (1.42-2.57, p On multivariate analysis, history of smoking, pancreatic mass causing CBD obstruction, length of stricture and plastic stent placement were all associated with stent occlusion (Table 1).Table 1: Cox Proportional Hazards AnalysisConclusion: Patients with history of smoking, presence of pancreatic mass, and longer strictures are at higher risk for CBD stent occlusion after ERCP. Plastic stents are also at higher risk of stent occlusion compared to metal stents. Patients with these risk factors should have their follow-up ERCP scheduled appropriately early to prevent complications.

Sump Syndrome: Keeping the Diagnosis Relevant in the ERCP-Laden World

A 42-year-old Vietnamese male with history of choledochoduodenostomy 20 years prior complained of sudden onset of sharp, constant, non-radiating right upper quadrant pain for one day. The patient denied chest pain, shortness of breath, cough, fever, nausea, vomiting, diarrhea, constipation, jaundice, or dysuria. Laboratory analysis of liver function enzymes revealed elevated AST, ALT, alkaline phosphatase, and total bilirubin (294 U/L, 119 U/L, 213 U/L, 2.4 mg/dL, respectively). A computed tomography (CT) scan of the chest and abdomen showed areas of thickening near the second portion of the duodenum and moderate pneumobilia, suggestive of massive choledocholithiasis (Figure 1). In the medial aspect of the D-1/D-2 (C-loop), a large exposed stone was noted (Figure 2). The ampulla was noted to be inferior to this, suggestive of prior choledochoduodenostomy. MRCP (Figure 3) and ERCP noted a massive 4 x 3 cm filling defect noted occluding the surgical anastomosis. Direct endoscopic laser lithotripsy (12 Watts) was performed to help fragment the stone. The stone was unable to completely be removed, a biliary sphincterotomy was performed, and a double pigtail biliary stent was left in place. Follow-up ERCP and laser/mechanical lithotripsy were later performed.Figure 1Figure 2Figure 3Sump syndrome is a rare long-term complication first described in 1976 of side-to-side choledochoduodenostomy (CDD), a common procedure in patients with biliary tract disease before endoscopic retrograde cholangiopancreatography (ERCP). Its prevalence ranges from 2.5-17.5% after CDD. It results from accumulation of lithogenic bile, debris or calculi, and refluxed duodenal contents in the distal common bile duct, leading to biliary and/or pancreatic complications. The pathophysiology of this syndrome has been linked to reduced filling pressure and peristalsis and drainage of the distal common bile duct caused by the upstream anastomosis. Due to symptoms of sump syndrome not typically showing up until a few decades after the operation, many clinicians today do not consider this diagnosis in their differential. Thus, it is important to take a thorough surgical history when encountering patients with typical presenting symptoms and a suggestive medical history. In regions with high prevalence of patients migrating from underdeveloped countries, it is also important to keep sump syndrome in mind, as choledochoduodenostomy is still being performed in remote underdeveloped locations.

A Case of Successful Treatment for Obstructive Jaundice in Hepatocellular Carcinoma with A Biliary Invasion by Transcatheter Arterial Chemoembolization after Biliary Drainage

Biliary invasion by hepatocellular carcinoma (HCC) is much less common. Patients manifest obstructive jaundice as the initial complaint, but most of them are inoperable. We report a case of completely improved biliary invasion in HCC after transcatheter arterial chemoembolization (TACE). A 61-year-old woman was referred for evaluation of jaundice. A biliary invasion of huge HCC was confirmed by image of abdominal computerized tomography (CT) and biopsy specimen. After improvement of jaundice by endoscopic retrograde biliary drainage and percutaneous transhepatic biliary drainage, she underwent TACE as a palliative treatment. Follow-up CT showed partial lipiodol uptake in hepatic tumor and its bile duct invasion. In follow-up endoscopic retrograde cholangiopancreatography, occluded cholangiogram showed neither luminal obstruction nor filling defect after removal of biliary stent. Our case suggests that obstructive jaundice, caused by inoperable huge HCC with biliary invasion, may be expected to resolve successfully biliary obstruction by a choice of TACE. Korean J Pancreatobiliary 2014;19(1):31-36

Is a Follow-up Endoscopic Retrograde Cholangiopancreatography Procedure Necessary for Removal of Biliary Stents?

Is a Follow-up Endoscopic Retrograde Cholangiopancreatography Procedure Necessary for Removal of Biliary Stents?

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation

Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.

Endoscopic Ampullectomy

Advances in endoscopic ampullectomy continue to mitigate concerns regarding incomplete removal of ampullary neoplasias, postprocedure complications, and insufficient treatment of tumors with undetected malignant foci or intraductal invasion. Advanced T staging of these lesions with endoscopic ultrasound and intraductal ultrasound, while useful tools for selection of candidates for snare polypectomy, should be limited to lesions either greater than 3 cm, bearing the macroscopic appearance of malignancy or unamenable to endoscopic therapy. Intraductal ultrasound has demonstrated T-staging accuracy superior to endoscopic ultrasound. One prospective study of prophylactic pancreatic stent placement and a number of retrospective studies have reported reduced complication rates. Recent studies continue to propose follow-up endoscopic retrograde cholangiopancreatography at 3-month intervals after ampullectomy to evaluate for recurrence and ablate residual tissue, with the interval increased to 6 to 12 months for 5 years on obtaining negative biopsies for adenomatous tissue. The development of thermal ablation, notably argon plasma coagulation, for fulguration of residual unresectable tumor, biductal sphincterotomy and prophylactic pancreatic pancreatic stent placement, and advanced diagnostic imaging mitigate the concerns leveled against endoscopic ampullectomy. In experienced hands, endoscopic papillectomy of noninvasive, benign ampullary lesions is a safe, technically feasible, and effective alternative to surgical resection. This study will focus on diagnosis and staging of ampullary adenomas and reviews indications for, and outcomes and complications of, endoscopic papillectomy.

The Efficacy of Early Scheduled Follow-Up Endoscopic Retrograde Cholangiopancreatography after Common Bile Duct Stone Removal

To investigate the efficacy of early scheduled follow-up endoscopic retrograde cholangiopancreatography (ERCP) after common bile duct (CBD) stone removal. Patients who underwent endoscopic CBD stone removal and who had at least one risk factor for stone recurrence were enrolled. Six months after complete clearance of the CBD, patients underwent follow-up ERCP at an ambulatory care center, irrespective of symptoms. The incidence of symptoms and cholangitis at follow-up ERCP was significantly lower in Group A (ERCP at 6 months after stone removal) than that in Group B (ERCP at >6 months) (14.3% vs 71.4%, p=0.00; 9.5% vs 33.3%, p=0.02, respectively). However, the recurrence rates of CBD stones were not different between Groups A and B (33.3% vs 47.6%). When comparing the subgroups, Group AR (stone recurrence in Group A) displayed significantly fewer symptoms and lesser cholangitis and spent fewer days in the hospital than did Group BR (stone recurrence in Group B) (21.4% vs 70%, p=0.02; 14.3% vs 60%, p=0.02; 2.43±1.87 vs 6.10±3.35, p=0.00, respectively). Our data suggest that, irrespective of symptoms, early scheduled follow-up ERCP for patients who are at a high risk of recurrence is effective and safe.

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

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

Pancreatic Duct Disruption With Autosplenectomy

Question: A 64-year-old male patient visited our cardiovascular outpatient department for regular follow-up for hypertension and coronary artery disease on July 24, 2008. Hypotension was noted; his systolic and diastolic blood pressure of 89 and 34 mmHg, respectively. So he was referred to our emergent department (ED) for further evaluation. According to his previous medical records, he had a past history of gallbladder stones inducing acute pancreatitis with pseudocyst formation over the pancreatic tail region, which was initially managed by pigtail tube drainage initially on March 21, 2008 (Figure A). Endoscopic retrograde cholangiopancreatography (ERCP) revealed pancreatic duct disruption on April 25, 2008. Hence, endoscopic papillotomy, common bile duct stone extraction and 7-French (Fr) plastic stent pancreatic duct insertion were subsequently performed. Antibiotics were prescribed and the patient was examined by abdominal sonography every week until the pseudocyst completely resolved. The pigtail drainage tube was removed when there was no further drainage and he was discharged on July 3, 2008. In our ED, the physical examination did not reveal any fever, abdominal pain, jaundice, or other specific discomfort. Blood counts were as follows: white blood cell 32,900/mm3 (normal, 4800–10,800/mm3); hemoglobin, 12.5 g/dL (normal, 12–16); and platelets, 613,000/mm3 (normal, 130,000–400,000/mm3). The differential count of white blood cell was neutrophils, 74%; lymphocyte, 19%; monocyte, 7%; eosinophils, 0%; and basophils, 0%. Serum biochemistry test results were as follows: alanine aminotransferase, 78 IU/L (normal, 0–40); alkaline phosphatase, 175 U/L (normal, 10–100); γ-glutamyltransferase, 223 U/L (normal, 8–61); total bilirubin, 0.4 mg/dL (normal, 0.2–1.6); C-reactive protein, 11.79 mg/dL (normal, 0–0.5); and amylase, 218 U/L (normal, <180). An abdominal computed tomography (CT) scan in our ED is shown in Figures B and C. Pigtail drainage and antibiotics treatment were given immediately. A pus-like discharge was found from the pig-tail drainage tube. What is the possible diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Under the impression that the patient had persistent pancreatic duct disruption with autosplenectomy, ERCP was performed and the 7-Fr internal stent was replaced by an 8-Fr stent to decrease pancreatic duct pressure. The pigtail drainage tube was reimplanted from the pseudocyst to the pancreatic tail duct and gradually changed to a smaller size. However, persistent leukocytosis and thrombocytosis without clinical evidence of infectious disease were noted during this hospitalization. We consulted a hematologist and genetic studies showed mixed polyclonal blood cell counts. Hence, lymphoproliferative disease was less likely. Consequently, both functional and anatomic destruction of the spleen were highly suspected. Follow-up ERCP on October 22, 2008, disclosed a healed pancreatic duct (Figure D). Therefore, the external drainage tube was removed smoothly. Follow-up CT scan disclosed no recurrence of the pseudocyst and mild regeneration of spleen on February 22, 2009 (Figure E). The final diagnosis was pancreatic duct disruption with persistent pancreatic fluid leakage and splenic autodigestion. Autosplenectomy has been reported in a number of diseases, such as sickle cell anemia, idiopathic thrombocytopenic purpura, systemic lupus erythematosus, rheumatoid arthritis, celiac disease, amyloidosis, and splenic irradiation.1Caro J. Hypersplenism and hyposplenism.in: Lichtman M.A. Beutler E. Kipps T.J. Williams hematology. 7th ed. McGraw-Hill Medical, New York2006Google Scholar In acute pancreatitis, pseudocyst direct invasion or splenic vessel thrombosis with subsequent liquefaction of a splenic infarction are the causes of splenic parenchymal destruction.2Hastings O.M. Jain K.M. Khademi M. et al.Intrasplenic pancreatic pseudocyst complicating severe acute pancreatitis.Am J Gastroenterol. 1978; 69: 182-186PubMed Google Scholar In this case, CT scan disclosed pancreatic tail and splenic abscess without pseudocyst formation or splenic vessel thrombosis. Therefore, autosplenectomy was caused by persistent pancreatic fluid leak and local abscess formation. This case also disclosed mild splenic regeneration after autodigestion. Splenic autodigestion should be taken into consideration when duct disruption occurs at pancreatic tail. Acute pancreatitis with splenic involvement often required aggressive treatment, including repeated percutaneous drainage, pancreatectomy, and/or splenectomy.3Heider R. Behrns K.E. Pancreatic pseudocysts complicated by splenic parenchymal involvement: results of operative and percutaneous management.Pancreas. 2001; 23: 20-25Crossref PubMed Scopus (38) Google Scholar Although splenic autodigestion is rare, it may be lethal if undiagnosed. Clinicians should maintain a high index of suspicion of splenic autodigestion when patients had acute pancreatitis history with persistent leukocytosis and thrombocytosis.

Successful Endoscopic Therapy of Traumatic Bile Leaks: Report of Fourteen Cases

Purpose: Traumatic bile leaks often result in prolonged morbidity and an increased length of hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our objective was to evaluate the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the management of a traumatic bile leak with resolution of the bile leak on follow-up ERCP. Methods: This is a retrospective case review of fourteen patients who were referred for ERCP after traumatic bile duct injury secondary to blunt (motor vehicle accident or motorcycle accident) or penetrating (gunshot) trauma for management of bile leaks. The data was collected over a 5-year period from a tertiary academic referral center. All patients underwent ERCP with biliary stent placement. Results: Fourteen patients underwent ERCP for the management of a traumatic bile leak over a 5-year period. The etiology included blunt trauma from motor vehicle accident in eight patients, motorcycle accident in three patients and penetrating injury from a gunshot wound in 3 patients. Liver injuries were grade III in 1 patient, grade IV in 10 patients, and grade V in 3 patients. All patients were treated by biliary stent placement, and the outcome was successful in 14 of 14 cases (100%). The mean duration of follow-up was 85.6 days (range, 54 to 175 days). There were no ERCP-related complications. Conclusion: Endoscopic management with endobiliary stent placement was successful and resulted in resolution of the bile leak in all fourteen patients. Based on the results of this study, consideration should be given to ERCP being a first-line therapy in management of traumatic bile leaks.Table