Initial Endoscopic Retrograde Cholangiopancreatography Research Articles

An audit of the outcome of long-term biliary stenting in the treatment of common bile duct stones in a general hospital

This study audited the clinical outcome of a cohort of patients with choledocholithiasis treated with long-term biliary stenting in order to determine the feasibility of this practice. Over 2 years, 83 patients with symptomatic choledocholithiasis were treated with long-term stenting because they either refused further treatments or were medically unfit for further procedures after the initial endoscopic retrograde cholangiopancreatography (ERCP). Recurrence of clinical events, need for stent change, morbidity, and mortality were analyzed. As a secondary analysis, published data on long-term biliary stenting were reviewed. ERCP and biliary stenting were successful in all cases with no complications. The mean follow-up was 19 months (1-103 months). The median number of ERCPs performed was 1 (1-4). The mean duration of stent patency was 12.4 months (1-54.8 months). A total of 28 clinical events (cholangitis, 71%) occurred in 24 patients during follow-up, for a late complication rate of 33.7%. ERCP was repeated and the stents changed on 15 occasions in 11 asymptomatic patients with abnormal liver function tests detected on routine follow-up. No biliary-related mortality occurred. Review of published data revealed a mean late complication rate of 22.4% (0%-64%), a biliary-related mortality rate of 3.5% (0%-21.1%), and a nonbiliary-related mortality rate of 20.8% (0%-60.3%). Long-term biliary stenting is a feasible option for patients who decline or are medically unfit for further elective endoscopic or surgical procedures. Close follow-up is mandatory to detect and treat late complications.

EFFECTIVENESS OF CYTODIAGNOSIS WITH PANCREATIC DUCT LAVAGE FLUID FOR PANCREATIC DUCTAL CARCINOMA: NEW SAMPLING TECHNIQUE

Background: Pancreatic carcinoma is one of the most lethal cancers. Because pancreatic carcinoma is still very difficult to diagnose in its early stage, many of these patients will be considered unsuitable for surgery. If a cytological diagnosis is obtained at initial endoscopic retrograde cholangiopancreatography (ERCP), suitable treatment will be initiated without delay.Methods: To increase the number of exfoliated cells from the pancreatic duct, we devised a new technique, pancreatic duct lavage fluid (PDLF), following bronchoalveolar lavage fluid. The present paper reports the effectiveness of cytological examination using PDLF in the diagnosis of pancreatic carcinoma. We examined 18 pancreatic carcinoma cases. After the endoscopic retrograde pancreatography (ERP), PDLF was collected from a double‐lumen catheter inserted into the main pancreatic duct. Saline injected from the lumen for the injection, and PDLF was aspirated from the other lumen for the guidewire at the same time. The cytological examination was performed using PDLF.Results: Exfoliated cells were more frequently found in PDLF from all patients. In 15 cases (83%), cytological examination of PDLF revealed positive cytological results as the diagnosis of pancreatic carcinoma.Conclusion: Cytological examination using PDLF has a high sensitivity for detection of pancreatic carcinoma. The new examination, PDLF, is simple, safe and effective, so we expect PDLF to become widely popular.

Cholecystitis After Metallic Stent Placement in Patients With Malignant Distal Biliary Obstruction

Cholecystitis after metallic stent (MS) placement is an issue requiring attention. From our experience, cholecystitis seemed to occur mainly in patients with tumor involvement to the cystic duct orifice. The aim of the present study was to identify risk factors for cholecystitis in patients treated with covered or uncovered MS. We analyzed 246 patients who received MS placement (covered MS in 171 and uncovered in 75) between August 1997 and May 2005 for the treatment of unresectable distal malignant biliary obstruction. Causative diseases were as follows: pancreatic cancer in 162, papillary cancer in 10, bile duct cancer in 41, and metastatic nodes in 33 patients. Tumor involvement to orifice of the cystic duct (OCD) was diagnosed based on cholangiography and intraductal ultrasonography. Cholecystitis after MS placement was found in 13 patients (5.3%). There was no significant difference in the incidence of cholecystitis between covered (5.8%) and uncovered (4.0%) MS. By univariate analysis, tumor involvement of the OCD, MS placed above the papilla, and stricture located at midportion were associated significantly with cholecystitis. By multivariate analysis, only tumor involvement of the OCD was a risk factor, with an odds ratio of 47.206 (95% confidence interval, 5.84-381.60). Cholecystitis after MS placement is associated with tumor involvement to the orifice of the cystic duct, regardless of the type of stent.

Recurrence Rate of Anastomotic Biliary Strictures in Patients who have had Previous Successful Endoscopic Therapy for Anastomotic Narrowing after Orthotopic Liver Transplantation

The development of anastomotic strictures is one of the most common complications of orthotopic liver transplantation (OLT) with choledochocholedochostomy anastomosis. Endoscopic therapy with balloon dilation and/or stent placement is an effective therapy. The aim of this study was to assess the recurrence rate of anastomotic strictures and the features that predict recurrence after previously successful endoscopic therapy. We searched the endoscopic retrograde cholangiopancreatography (ERCP) database for all patients who had had an OLT who were undergoing ERCP. The study cohort consisted of post-OLT patients who had a recurrence of anastomotic stricture after initial resolution following a course of endoscopic therapy. A total of 916 OLT operations were performed during the study period from June 1994 to November 2004. Out of this group, 143 patients (15.6 %) were diagnosed with anastomotic stricture and underwent a total of 423 ERCPs for endoscopic treatment. Twelve patients who are still undergoing endoscopic therapy were excluded from the analysis. The technical success rate was 96.6 %, and the endoscopic therapy was successful in 82 % of patients; 18 % had a recurrence of cholestasis and ERCP revealed a recurrence of the anastomotic stricture that required intervention. The mean time of follow-up after stent removal was 28 months (range 1 - 114 months). The study did not reveal any clinical or endoscopic parameters that could predict recurrence, though the presence of a biliary leak at initial ERCP and a longer time to initial presentation were factors that showed a trend toward an increased likelihood of recurrence. Biliary strictures remain a common complication after OLT, and in nearly one in five patients these strictures recur after initially successful endoscopic therapy. There were no clinical or endoscopic parameters identified in this study that predicted recurrence. Further study is needed to determine what type of endoscopic therapy would minimize the risk of stricture recurrence.

Endoscopic Retrograde Cholangiopancreatography in Patients Aged 90 Years and Older: Single Center Experience in Japan

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is effective in the diagnosis and treatment of various panctreatobiliary diseases. However, few studies have assessed the effectiveness and safety in the very elderly. Retrospective data of ERCPs was analyzed to evaluate the effectiveness of ERCP and the complication rate of this procedure in patients aged 90 years and older. Methods: A total of 2243 ERCP procedures were performed at our institution between January 1999 and October 2005. A total of 95 endoscopic procedures (1-11 per patient) performed in 34 patients (6 males and 28 females) were analyzed. The mean age was 92 years (range 90-99). All patients had one or more concomitant diseases and 16 were bed-ridden. Two patients had prior sphincterotomies. Informed consent was obtained from each patient for ERCP. All patients underwent the following: a) clinical evaluation before and after the endoscopic exploration, b) evaluation of the success or failure of the endoscopic procedure and c) assessment of complications. Results: The main indications were bile duct stones (79.4%) and malignant biliary obstruction (15.6%). Therapeutic procedures were indicated in 94 explorations. Needle knife precut was performed in 5 patients failed in selective biliary cannulation. A selective bile duct cannulation was achieved after precut in 4 patients (80%) at the primary session and the final success rate was 100%. In one patient, biliary cannulation was unsuccessful and percutaneous transhepatic gallbladder drainage was performed. Initial ERCP was successful in 90 out of 95 explorations (94.7%). Twenty-six endoscopic sphincterotomies were performed, 59 biliary stents were inserted for benign disease and malignancy and 44 stone extractions were performed. The complication rates as follows: 1) mild pancreatitis in 3 explorations (3.1%), 2) moderate cholangitis in one exploration (1.0%), 3) aspiration pneumonia in two explorations, 4) cardiac failure worsened in two explorations, 5) hypoxemia in one exploration and 6) cerebral hemorrhage in one exploration. There were no hemorrhage, perforation and deaths related to the procedure. Conclusions: ERCP is a safe and effective procedure with low complication rate in the very elderly.

Patient with Markedly Elevated CA 19-9 Not Associated with Malignancy

A 66-year-old white male presented with jaundice, pruritus, and a 30-pound weight loss over two months. Physical examination revealed scleral icterus. Laboratory evaluation revealed ALT 161 U/L, AST 290 U/L, alkaline phosphatase 2004 U/L, GGT 2,552 U/L, total bilirubin 10.2 mg/dL, and a carbohydrate antigen 19-9 (CA 19-9) level of 4,374 U/mL. Initial endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful due to ulceration in the duodenum healed with esomeprazole therapy. Subsequent ERCP showed a possible filling defect in the common bile duct treated with sphincterotomy and balloon sweeping of the common bile duct. Symptoms and jaundice resolved five months after initial presentation with normal labs and studies. While elevated CA 19-9 levels occur in most patients with carcinoma of the pancreas, it can also be elevated in patients with extrapancreatic malignancies and acute cholangitis. This case illustrates the fact that a markedly elevated CA 19-9 can be secondary to causes other than carcinoma.

A Retrospective Comparison of Outcomes Using Three Different Precut Needle Knife Techniques for Biliary Cannulation

To assess the outcome differences following different precut biliary sphincterotomy needle-knife techniques. Precut biliary needle-knife sphincterotomy (NKS) allows biliary access when standard cannulation techniques fail. Little comparative data exist on the outcome of precut NKS. Retrospective comparison of outcome differences of three NKS techniques performed by three pancreaticobiliary endoscopists at a tertiary referral center. A total of 139 consecutive biliary NKS were performed. In 44 cases (technique A), NKS was performed using a precut fistulotomy technique avoiding the papillary orifice, with pure cutting current, and occasional pancreatic duct (PD) stenting (6 of 44). In 47 cases (technique B), NKS was performed starting from the papillary orifice cutting upward with blended current, and no PD stenting. In 48 cases (technique C), NKS was performed as B but using pure cutting current and frequent PD stenting (15 of 48). NKS was successful in 95.5%, 95.7%, and 89.6% at initial endoscopic retrograde cholangiopancreatography and 100%, 97.8%, and 95.6% after a second endoscopic retrograde cholangiopancreatography. Total complications were not significantly different between the three groups; however, a lower incidence of pancreatitis occurred using technique A compared with techniques B and C (not significant). NKS techniques result in a high success rate of biliary cannulation with a similar overall complication rate. Avoiding cutting at the papillary orifice may reduce the risk of pancreatitis. When cutting at the papillary orifice, pancreatic duct stenting, pure cutting current, or both may reduce the incidence of pancreatitis.

PERORAL CHOLANGIOSCOPY: AN IMPROVED PROCEDURE

Cholangioscopy provides direct visual assessment of the bile ducts, tissue sampling, and therapeutic interventions. Delineation of intraductal lesions equivocal with direct cholangiography, differentiation between malignant and benign biliary strictures, and assessment of longitudinal extent of cholangiocarcinoma are major indicators for diagnostic cholangioscopy. Peroral cholangioscopy is readily performed at an initial endoscopic retrograde cholangiopancreatography. Owing to substantial refinement in terms of image quality and technical feasibility achieved with the development of a new video cholangioscope, peroral cholangioscopy has become a powerful tool. However, compared with percutaneous cholangioscopy, there remain several disadvantages in peroral cholangioscopy: less favorable maneuverability, small instrumental channel, and limited therapeutic instrumentations. With further advances in endoscopic functions and increasing availability of suitable instruments, peroral cholangioscopy, because of its less invasiveness, will become mandatory for diagnostic and therapeutic biliary endoscopy.

PANCREATICOBILIARY OBSTRUCTION DUE TO PERIAMPULLARY DUODENAL DIVERTICULITIS

Purpose: Instances of duodenal diverticulitis are uncommon. Reports of biliary complications resulting form this are quite rare. The few reports of such have been treated surgically with biliary bypass. We present a series of two patients that presented with acute biliary obstruction as a result of duodenal diverticulitis and the endoscopic management of each. The first woman (36yo) presented with one to two days of right upper quadrant pain, fever, leukocytosis and elevated liver enzymes suggestive of biliary obstruction. She underwent endoscopic retrograde cholan-giopancreatography (ERCP) and was found to have periampullary duodenal diverticulitis (3cm in size) with purulent drainage from the diverticular os as well as evidence of extrinsic compression of the distal common bile duct CBD. Treatment consisted of placement of a nasobiliary drain into the diverticulum and a CBD stent. The diverticulum was irrigated every 8 hours via the naso-diverticular tube with radiographic resolution of the diverticular debris after 24 hours. The CBD stent was removed after one week with no further evidence of obstruction. The second woman (64 yo) presented similarly but with a concomitant rise in her pancreatic enzymes (lipase 4400IU). CT scan demonstrated a 4cm duodenal diverticulum with changes of diverticulitis and dilation of both the CBD and pancreatic duct (PD). She underwent endoscopic irrigation/debridement of the diverticulum during the initial ERCP with eventual clearance of all debris. Subsequently the CBD/PD were demonstrated to be widely patent and draining well and hence no stents were placed. Both patient's liver and/or pancreatic enzymes recovered to normal following endoscopic treatment and neither suffered further sequelae of obstruction. This is the first known report of endoscopic therapy for duodenal diverticulitis and it's biliary complications.

Sobrevida de pacientes com estenose biliar maligna baseada no escovado endoscópico e na bilirrubinemia

Pancreatic cancer and cholangiocarcinoma are the main causes of malignant biliary stricture. Both types of cancers have dismal survival rates, and treatment has little or no effect on prolonging the patients lives. Prognostic definition at initial endoscopic retrograde cholangiopancreatography is important to choose the most suitable management. To analyse endoscopic brushing and bilirubinemia importance in determination of the survival of patients with malignant biliary stricture. Patients with biliary strictures diagnosed during endoscopic retrograde cholangiopancreatography were submitted to double brushing cytology. Serum samples were taken from all patients for bilirubinemia assay. Patients were followed to determine the final diagnosis and survival rates. A total of 50 patients with biliary stricture underwent endoscopic retrograde cholangiopancreatography (40 ultimately found to have a final diagnosis of malignant disease). Hyperbilirubinemia or cytology brushing positive for malignancy was related to a shorter survival rate. This research data demonstrate the possibility of determining the prognosis of patients with malignant biliary stricture using endoscopic brushing results and bilirubinemia levels.

Improved stent characteristics for prophylaxis of post-ERCP pancreatitis

Background & Aims: Pancreatic stenting is an effective method to prevent post—endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. Methods: A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3–4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10–14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. Results: The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3–4F stents compared with 80% with 5–6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). Conclusions: Small diameter (3–4F), unflanged pancreatic stents are more effective than the traditionally used stents (5–6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3–4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.

Laparoscopic endobiliary stenting significantly improves success of postoperative endoscopic retrograde cholangiopancreatography in low-volume centers.

Occult common bile duct stones (CBDS) discovered during laparoscopic cholecystectomy with intraoperative cholangiography are most often managed by postoperative endoscopic retrograde cholangiopancreatography (ERCP). Expert endoscopists at high-volume centers achieve common bile duct cannulation in nearly all patients undergoing ERCP, but cannulation rates of less than 80% have been observed in low-volume centers. As many as 20% of patients with CBDS referred for postoperative ERCP in low-volume centers may require repeated attempts at ERCP, referral to a high-volume center, percutaneous transhepatic techniques, or reoperation for clearance of CBDS when postoperative ERCP fails. Laparoscopic cholecystectomy with intraoperative cholangiography performed in 511 consecutive patients over 80 months at a community hospital showed occult CBDS in 66 patients (12.9%). Laparoscopic endobiliary stent placement was successful in 65 patients (98.5%). As part of an earlier study, 16 patients underwent laparoscopic common bile duct exploration with clearance of CBDS before stent placement. Laparoscopic endobiliary stent placement failed in one patient for whom CBDS were cleared with intraoperative ERCP. Initial postoperative ERCP was successful in clearing CBDS in all 65 patients (100%) with laparoscopically placed stents. During the same period, 611 patients underwent ERCP for various indications including CBDS (43%). Selective cannulation was achieved in 78% of all patients during initial ERCP. Laparoscopic endobiliary stent placement is an effective adjunct to the management of occult CBDS. Laparoscopic endobiliary stenting ensures selective cannulation during postoperative ERCP and eliminates the need for repeated attempts at ERCP, referral to specialty centers, use of transhepatic techniques, or reoperation for retained CBDS. Laparoscopic endobiliary stent placement for treatment of occult CBDS significantly improves the success of postoperative ERCP in low-volume centers and eliminates the morbidity and expense of repeated procedures.

Potential Impact of Magnetic Resonance Cholangiopancreatography on Endoscopic Retrograde Cholangiopancreatography Workload and Complication Rate in Patients Referred Because of Abdominal Pain

Endoscopic retrograde cholangiopancreatography (ERCP) has a significant mortality, morbidity, and failed cannulation rate. Magnetic resonance cholangiopancreatography (MRCP) is a safer, noninvasive method of imaging the pancreaticobiliary tree. A substantial number of patients are referred for ERCP because of abdominal pain, a high proportion of whom have normal ducts or pathology not requiring interventional ERCP. The aim was to assess the potential impact of MRCP on overall ERCP workload and patient outcome if MRCP were the primary investigation in patients referred for ERCP because of abdominal pain. 1758 consecutive ERCPs performed in 1148 patients over a 3-year period in a single tertiary referral center in the pre-MRCP era were reviewed. Cannulation failure, ERCP findings, need for follow-up ERCP and all 30-day major complication rates were analyzed with regard to clinical indications. The overall workload comprised 1108 (63 %) successful initial ERCPs, 188 (11 %) failed cannulation attempts and 462 (26 %) follow-up ERCPs. Of the patients, 299 (27 %) had normal ERCP findings, 331 (30 %) had choledocholithiasis and 246 (22 %) had strictures. lf MRCP had been used as the primary imaging investigation in the 451 patients (39 %) referred for ERCP because of abdominal pain, we estimate that 197 patients (44 %) would have avoided ERCP, and the overall ERCP workload would have been reduced by 13 %. Initial MRCP in suspected gallstone pancreatitis and certain miscellaneous groups, it was estimated, would have further decreased ERCP workload by 9 %. Four of 40 major ERCP-related complications (3.5 %) and one of four ERCP-related deaths (0.35 %) would potentially have been avoided. Initial MRCP in patients referred with abdominal pain would potentially have avoided ERCP in 44 % of cases, reduced ERCP workload by 13 % and significantly reduced patient morbidity and mortality. The relatively small reduction in ERCP workload among these patients reflects the fact that over half of them had probable sphincter dysfunction, a significant proportion of whom might have benefited from biliary manometry and/or endoscopic intervention despite a normal MRCP. Furthermore, a small number of patients with calculi and subtle biliary and pancreatic strictures would be missed by this approach.

Diagnostic and therapeutic ERCP: a large single centre's experience.

Most large published series on endoscopic retrograde cholangiopancreatography (ERCP) are multicentre-based and consequently reflect varying experience. To assess morbidity and mortality rates of ERCP in a single tertiary referral centre. A series of 1,758 consecutive ERCPs performed in 1,148 patients between 1991 and 1994 were reviewed to evaluate indications, findings, procedures, success, complication and mortality rates. There were 1,108 (63%) successful initial ERCPs, 11% failed cannulation attempts and 26% follow-up ERCPs. The desired duct was successfully cannulated in 96.5% of cases. Initial cannulation failure rate was 8.8%. Twenty-seven per cent had normal ERCPs, 30% had choledocholithiasis and 22% had strictures. Fifty-five per cent had therapeutic ERCPs. Major complications occurred in 3.5% with four ERCP-related deaths (0.35%). Therapeutic ERCP had a higher incidence of major complications compared to diagnostic ERCP: 4.6% vs 2.1%, (p=0.02); and mortality rate was 0.5% vs 0.2%, (p=0.4). Significant haemorrhage secondary to biliary sphincterotomy, pre-cut papillotomy and snare papillectomy accounted for most of the difference (1.6%). The majority of ERCPs were performed in elderly patients, over half of whom required therapeutic ERCP. Therapeutic ERCP carried significantly higher complication rate compared with diagnostic ERCP. Unsuccessful cannulation and follow-up ERCP accounted for 11% and 26% of ERCP workload, respectively.

PANCREATIC PLEURAL EFFUSION SUCCESSFULLY TREATED BY ENDOSCOPIC PANCREATIC DUCT DRAINAGE COMBINED WITH EXTRACORPOREAL SHOCK‐WAVE LITHOTRIPSY: REPORT OF A CASE

A 52‐year‐old man was admitted with complaints of dyspnea. Physical examination revealed that the breath sounds were reduced at the left lung. The results of the abdominal examination were normal. Chest radiography showed massive left‐sided pleural effusion. His white blood cell count was 4600/mm3, serum amylase 666 IU/L, serum C‐reactive protein (CRP) 3.7 mg/dL. Thoracentesis yielded bloody fluid with a protein level of 3.7 g/dL and amylase level of 6250 IU/L. Computed tomography showed dilatation of the pancreatic duct with calcifications of the pancreas, mediastinal pancreatic pseudocysts and bilateral pleural effusion. Magnetic resonance cholangiopancreatography demonstrated dilated pancreatic duct with pancreatic calculi and pancreaticopleural fistula. Initial endoscopic retrograde cholangiopancreatography showed obstructing pancreatic calculi of the main pancreatic duct at the head; however, insertion of a naso‐pancreatic drain was unsuccessful. A naso‐pancreatic drain could be placed beyond the site of obstruction following three extracorporeal shock‐wave lithotripsy (ESWL) sessions. Pleural effusion was resolved and the chest tube was removed 5 days following placement of the drain. The naso‐pancreatic drain was replaced with a pancreatic stent 20 days later. Endoscopic retrograde cholangiopancreatography after a total of nine ESWL sessions showed a significant reduction of pancreatic calculi at the head. The pancreatic stent was removed 70 days following stent placement and there has been no recurrence during a follow‐up period of 2 years. We suggest that endoscopic treatment combined with ESWL is a first‐line treatment for pancreatic pleural effusion resulting from obstructing pancreatic calculi, and operation should be reserved as a second‐line treatment.

Palliation of hilar biliary obstruction from colorectal metastases by endoscopic stent insertion

Background: In patients with hepatic metastases from colorectal carcinoma there is a distinct subgroup in whom jaundice is not due to hepatic replacement but rather biliary obstruction. We reviewed our experience with stent insertion in patients with malignant proximal biliary obstruction from metastatic colorectal carcinoma. Methods: Thirty-three patients were treated between July 1992 and December 1996. Placement of a single stent was attempted at initial endoscopic retrograde cholangiopancreatography. Hilar biliary obstruction was classified according to Bismuth's classification. Results: Successful stent placement was possible in 94% overall and at initial endoscopic retrograde cholangiopancreatography in 39% of patients. Successful stent placement occurred significantly more often in patients with a type I stricture. Cholangitis was the principal complication occurring in 24% of patients. The 30-day mortality rate was 24%, with death occurring significantly less often in patients with a type I or II stricture. Overall, 45% of patients had a 30% fall in bilirubin at 1 week. The median survival was 81 days, with significantly longer survival seen in patients with a type I or II stricture. Conclusions: Endoscopic stent placement offers effective palliation in most patients with hilar obstruction from colorectal metastases. A subset of patients with type III strictures and greater than 3 intrahepatic metastases often do not benefit from stent insertion. (Gastrointest Endosc 2000;51:412-7.)

Recurrent pancreatitis in Gardner variant familial polyposis: etiology, diagnostic approach, and interventional results.

Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.

ERCP for intradiverticular papilla: two-devices-in-one-channel method

Background: The prevalence of biliopancreatic disorders is high in patients with periampullary diverticula. However, endoscopic retrograde cholangiopancreatography (ERCP) in patients with the papilla deep inside duodenal diverticula is difficult. Methods: Two patients were included in this study, each with the papilla deep inside a diverticulum and in whom an initial ERCP was unsuccessful. A biopsy forceps to pinch the duodenal mucosa distal to the papilla and pull the papilla out of the diverticulum and a cannula were inserted into the working channel of a duodenoscope together (the two-devices-in-one-channel method). With coordination of the two instruments, cannulation of the bile duct was attempted. Results: In both patients ERCP was successful using this procedure and no complications followed. Conclusions: The two-devices-in-one-channel method is useful when performing ERCP in patients with the papilla inside juxtapapillary diverticula.

Clinical Study on Causative Factors and Recurrence of Choledocholithiasis

To identify factors involved in choledocholithiasis, clinical characteristics were studied using univariate and multivariate analyses. Factors involved in recurrence were also investigated. The subjects consisted of 51 patients with calcium bilirubinate stones (B group) and 52 patients with cholesterol stones (C group). All patients had choledocholithiasis and underwent lithotripsy by endoscopic sphincterotomy (EST) during the past 9 years. Twenty variables, including clinical symptoms and endoscopic retrograde cholangiopancreatography (ERCP) findings, were analyzed using a Statistical Analysis System (SAS) software package. Univariate analysis were done using Student's t-test and the chi-square test. Multivariate analyses were done by stepwise logistic regression analysis. In univariate analyses, there were significant differences between the B group and C group in nine variables: age, common bile duct diameter, common hepatic duct diameter, common bile duct stone diameter, cystic duct diameter, and the presence of gallbladder stones, atypical arrangement of the hepatic duct, parapapillary diverticulum, and large parapapillary diverticulum. In multivariate analysis, the four variables of no gallbladder stone, large parapapillary diverticulum, cystic duct less than 8 mm, and atypical arrangement of the hepatic duct were significant independent factors for the development of stones in the B group, with relative risks of 37.75, 16.73, 5.56, and 5.49, respectively. The results indicated that calcium bilirubinate stones were frequently associated with parapapillary diverticulum and abnormal arrangement of the bile duct. The formation of these stones was attributed to chronic biliary stasis caused by dysfunction of the biliary tract, including the papilla. In contrast, most cholesterol stones found in the common bile duct had apparently descended from the gallbladder. Common bile duct stones recurred after EST in 9 patients, all of whom had calcium bilirubinate stones. On ERCP, recurrence was found to be frequently associated with gallbladder stones, large parapapillary diverticula, and atypical arrangement of the hepatic duct. Patients with these characteristics on initial ERCP should therefore receive appropriate treatment and undergo strict follow-up observations owing to the increased risk of recurrence caused by dysfunction of the biliary tract.

Management of Biliary Strictures Due to Laparoscopic Cholecystectomy

Injury to the extrahepatic bile ducts during laparoscopic cholecystectomy (LC) is a cause of serious long-term patient morbidity. In order to identify management strategies and outcome, we undertook a retrospective review and analysis of patients referred to the Department of Surgery and the Division of Gastroenterology for management of bile duct strictures due to injury at LC. Eighteen patients (15 women, 3 men) with a mean age of 41 years were identified over a 4-year period. Six patients had injuries identified at LC. Ten patients had previously undergone an attempt at operative repair (8 end-to-end anastomoses, 1 choledochoduodenostomy, 1 cystic duct jejunostomy). There were 5 Bismuth Grade I strictures, 6 Grade II, 2 Grade III and 5 Grade IV. Ten patients were managed nonoperatively with stents placed by radiologic or endoscopic techniques. Four patients were managed with operation alone (2 choledochojejunostomy, 1 hepaticojejunostomy, and 1 external T-tube drainage) and 4 patients with a combined endoscopic and operative approach (all 4 with hepaticojejunostomy after initial endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography management). Bile duct strictures due to LC are frequently located in the proximal bile ducts (Bismuth II-IV) and are technically difficult to repair. In the majority of cases, injuries are unrecognized at LC. Both immediate and delayed repair attempts prior to referral were frequently unsuccessful. Many bile duct strictures can be managed successfully in the early postoperative period with endoscopic and radiologic stenting techniques. Strictures which cannot be managed nonoperatively are repaired with Roux-en-Y hepaticojejunostomy. The high number of failures with previous end-to-end anastomosis suggests that LC bile duct transection injuries recognized at operation should be managed initially with Roux-en-Y hepaticojejunostomy.