Biliary Stent Insertion Research Articles

Modified Rendezvous Technique in Management of Biliary Leak in Right Lobe Live Donor Liver Transplant Recipients

Biliary complication is the Achilles' heel for live donor liver transplant. Bile leak is particularly difficult to manage as the anastomotic site was often angled acutely. We described a patient with bile leak managed by a modified rendezvous technique whereby the endoscopist and radiologist work simultaneously under fluoroscopy. Unlike the traditionally described rendezvous technique where the grasping of guidewire occurred at the duodenum, the grasping of guidewire occurred at the biloma in this modified technique. Insertion of biliary stent could then be performed over the guidewire through the duodenoscope. The bile leak resolved after keeping the biliary stents in situ for 12 months.

Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective

The British Society of Gastroenterology guidelines for the management of malignant obstructive jaundice state: "If a stent is placed prior to surgery, this should be of the plastic type and it should be placed endoscopically. Self-expanding metal stents should not be inserted in patients who are likely to proceed to resection." In 2003, a small series of complications after endoscopic intervention caused a change in the authors' practice. Currently, all patients requiring relief of biliary obstruction before surgical resection undergo attempted insertion of a short metal biliary stent. Retrospective analysis of the authors' prospective database containing all patients presenting with periampullary and pancreatic tumors between January 2004 and May 2008 was performed. The authors have attempted percutaneous placement of internal metal stents in 67 patients with resectable malignancies and biliary obstruction. Stenting was successful for 53 patients (79%), and 5 patients (9.4%) experienced complications. These five patients were successfully managed conservatively, and all proceeded to trial dissection. The mean bilirubin level was 253 mg/dl before intervention and 33 mg/dl before surgery for the stented patients compared with 308 mg/dl before intervention and 102 mg/dl before surgery for those who needed external drainage. Percutaneous insertion of short metal stents provides a safe and effective alternative to endoscopic stent placement for treating jaundice preoperatively in patients with potentially resectable tumors around the pancreatic head.

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY FOR PALLIATIVE BILIARY DRAINAGE IN CASES WITH INOPERABLE PANCREAS HEAD CARCINOMA

Endoscopic transpapillary biliary drainage (EBD) or stenting is the gold standard treatment for inoperable malignant biliary obstruction. When the papilla cannot be traversed because of pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous surgery, the usual alternative method is considered to be percutaneous transhepatic biliary drainage (PTBD). We herein report our experiences with four cases with inoperable pancreatic head carcinoma associated with obstructive jaundice treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). Between September 2006 and December 2007, methods of EUS-BD were performed in four cases with inoperable pancreas head carcinoma. In three out of four cases, EBD and PTBD were unsuccessful because of previous surgery, or duodenal stenosis, or nondilated intrahepatic bile ducts. In one case, although PTBD was successful, internal drainage could not be established. EUS-BD was successful for all cases. The obstructed biliary system was successfully decompressed by the creation of a choledochoduodenal fistula and the insertion of a transduodenal biliary plastic stent. No complication was encountered in all cases. EUS-BD may have the potential of replacing PTBD in cases with inoperable pancreatic head carcinoma associated with obstructive jaundice.

Endoscopic Retrograde Cholangiopancreatography Using the Single Balloon Enteroscope Technique in Patients with Roux-en-Y Anastomosis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging or impossible in patients with complex postsurgical anatomy. The aim of this cohort study was to assess the technical success of ERCP with the single balloon enteroscope (SBE) in patients with Roux-en-Y anastomosis. Patients: Patients with Roux-en-Y anastomosis presenting with cholestasis undergoing ERCP with the SBE technique in a tertiary university hospital. Diagnostic success was defined as successful duct cannulation or securing the diagnosis and therapeutic success was defined as the ability to successfully accomplish endoscopic therapy. Results: ERCP using the SBE was performed on 17 occasions in 13 patients (5 F, 8 M, mean age 66.5 years, range 25–77) with Roux-en-Y anastomosis. Indications for ERCP were biliary obstruction with common bile duct stones and/or cholangitis in all patients. The diagnostic success was 61.5% and the therapeutic success was 53.8%. Therapeutic interventions included dilation of common bile duct stenosis with a balloon (n = 4), biliary stent insertion (n = 2), removal of bile duct stones (n = 2), stent retrieval (n = 2), papillectomy (n = 1), and sphincterotomy (n = 1). No major complications occurred. Conclusions: ERCP using the SBE is feasible in patients with altered postsurgical anatomy presenting with biliary problems permitting diagnostic and therapeutic interventions.

Evaluation of Computer and Mechanical ERCP Simulators By Endoscopists with Different ERCP Experience - An Update

Background: We previously reported preliminary data of 7 GI trainees' evaluation of computer (CS) and mechanical (MS) ERCP simulators. Aim: To compare trainees' and trainers' evaluations after practice with MS and CS. Setting: Hands-on ERCP training workshops. Subjects: 15 GI trainees with varying ERCP experience and 3 trainers. Interventions: Participants perform scope insertion, selective bile duct cannulation, guide-wire negotiation of a bile duct stricture, biliary papillotomy and insertion of single biliary stent. Main outcome measurements: Evaluations of each simulator by participants based on modified published criteria (GIE 2003; 57: 886-90). Results: Overall practice with the MS resulted in significantly greater change in understanding [max=20] (4.29±0.93 vs. 2.12±0.80), confidence [max=20] (5.41±1.01 vs. 2.53±0.80) and credibility [max=50] (6.65±1.78 vs. 0.18±2.14) scores after the practice, respectively (p< 0.05). The scores were significantly higher for the MS in realism [max=80] (58.33±2.18 vs. 42.28±2.70, p<0.05) and usefulness as instructional tool/general applicability in ERCP training [max=60] (49.5±1.23 vs. 37.17±2.05, p<0.05). When the results were stratified according to the level of ERCP experience (<100 versus > 100), the difference in pre and post understanding, confidence, and credibility scores were significantly higher for the less experienced endoscopists than that for the experienced endoscopists regardless of the type of simulator (Table). The scores for realism, usefulness as an instructional tool, and applicability were higher among the less experienced endoscopists for both types of simulators, but were only statistically significant for the CS when compared to the experienced. There was no statistical difference in the scores for the MS between the two groups. Conclusion: Endoscopists at varying levels of experience evaluated the MS as superior to CS for ERCP practice, which was more significant among less experienced endoscopists. TableDifference in scores based on ERCP experience Computer simulator Mechanical simulator Survey question <100 ERCP experience >100 ERCP experience <100 ERCP experience >100 ERCP experience Understanding(difference between pre and post) 3.07 ± 0.84† -0.75 ± 0.75† 5.23 ± 0.99 1.25±1.70 Confidence(difference between pre and post) 3.07 ± 0.90 0.75 ± 0.75 6.15 ± 1.12 3.0 ± 2.12 Credibility(difference between pre and post) 1.71 ± 1.92 -6.0 ± 5.73 7.54 ± 2.17 3.75 ± 2.59 Realism compared to human ERCP 45.29 ± 2.04† 31.75 ± 8.64† 59.57 ± 2.29 54.0 ± 5.80 Usefulness as an instructional tool & applicability 39.79 ± 1.59† 28.0 ± 5.67† 50.5 ± 1.26 46.0 ± 3.11 Data expressed as mean ± SEM (standard error of mean). For endoscopists with <100 ERCP experience, N=14 except for mechanical understanding/confidence/credibility scores where N=13. For endoscopists with >100 ERCP experience, N=4 for computer and mechanical. † p value significant. Open table in a new tab Data expressed as mean ± SEM (standard error of mean). For endoscopists with <100 ERCP experience, N=14 except for mechanical understanding/confidence/credibility scores where N=13. For endoscopists with >100 ERCP experience, N=4 for computer and mechanical. † p value significant.

The Usefulness of Multiple Double Pigtail Stents and Oral Ursodeoxycholic Acid in the Treatment of Difficult Bile Duct Stones

Background: Large common bile duct (CBD) stones accompanied with risk factors can be difficult to extract by conventional techniques. When the extraction techniques have failed, temporary stenting is a technically easy and feasible method. Aim: Our study was to investigate the efficacy of combination therapy with multiple double pigtail stents and ursodeoxycholic acid (UDCA) as a prospective clinical trial. Materials and Methods: From September 2005 to September 2008, a total of 895 patients underwent attempted removal of CBD stones at our hospital. ERCP was performed using a video duodenoscope (TJF 240; Olympus, Japan). Difficult CBD stones were defined as those which could not be removed after sphincterotomy and/or balloon plasty by basket or balloon extraction, because of multiple or large stone (> 20 mm in diameter) accompanying with/without risk factors. Two or three double pigtail stents (7 or 10 Fr) were inserted into the bile duct over a guidewire with the proximal end above the stone and the distal end in the duodenum. The stents were left in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during follow-up. Follow-up was performed every one or two months. Results: In 21 patients (2.34%), complete clearance was not achieved by the conventional method. There were 9 men and 12 women with a mean age of 73.8 years (range 38-88). Large (size > 20 mm, n=11) and multiple (n>3 and size > 10mm; n=16) stones, the presence of periampullary diverticulum limiting sphincterotomy (5), narrowing or stricture of distal CBD (3), and severe cardiopulmonary diseases (8) were found as limiting factors for stone removal in this study. Two stents were inserted in 13 patients and 3 stents in 8 patients. Complete endoscopic clearance was achieved in 12 patients (57.1%) and there was a statistically significant reduction in stone size (17.65 ± 4.20 mm vs. 13.04 ± 3.16 mm; p = 0.002). The mean duration (±SD) of stenting and medication was 73.9 (± 35.3) days. The outcomes for the remaining 9 patients were spontaneous migration of the stent with the stone (1), surgical operation (2), exchange of occluded stents (3), and remaining well with stents (3). There was no immediate complication related to the insertion of biliary stents. Conclusion: Our results suggest that combination therapy with multiple pigtail stenting and UDCA is an easy and effective method for difficult CBD stones and may not necessitate long-term care. However, this study was conducted using a limited number of patients and further prospective randomized controlled trials should be conducted.

Peroral cholangioscopy-guided stricture therapy in living donor liver transplantation

Anastomotic biliary strictures are common in patients that undergo living donor liver transplantation (LDLT).1-5 Most anastomotic strictures are effectively treated by the endoscopic insertion of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic treatment of biliary strictures requires passage of a guidewire through the stricture.1 The wire is then used to guide instruments for subsequent stricture dilatation and stent placement. In severe cases, when endoscopic placement of a guidewire cannot be accomplished, more invasive procedures such as transhepatic access or surgery may become necessary. In this report, we describe a new technique for successful guidewire placement in severe anastomotic strictures after failed placement by conventional means. ERCP, endoscopic retrograde cholangiopancreatography; LDLT, living donor liver transplantation. A 65-year-old woman who had undergone a right-lobe LDLT with duct-to-duct anastomosis 3 months earlier presented for an ERCP because of rising alkaline phosphatase and gamma-glutamyl transferase levels. The cholangiogram obtained during the ERCP showed a high-grade stricture at the anastomotic site (Fig. 1). The stricture could not be traversed with a guidewire (Jagwire, Boston Scientific, Natick, MA). An extraction balloon that was already in place was inflated and centered in the bile duct. The stricture was probed with the guidewire while the orientation and degree of inflation of the balloon were changed. The stricture still could not be passed. The balloon was then positioned close to the stricture, inflated, and slightly pulled down toward the ampulla to straighten and stretch the bile duct while probing with the guidewire was continued.6 However, this technique also failed to provide access to the donor ducts. The balloon was then exchanged with a rotatable sphincterotome (Autotome Rx, Boston Scientific). This sphincterotome has a rotating handle that is designed to change its tip orientation to facilitate cannulation. Probing with the guidewire through the sphincterotome at different tip orientations also failed. The guidewire was then exchanged for an angled tip hydrophilic guidewire (Hydra Jagwire, Boston Scientific), and the aforementioned sequence was repeated without success. We have good experience with passing severe strictures by spinning an angled tip hydrophilic wire while simultaneously exerting mild longitudinal force on the guidewire pushing it toward the stricture. This technique proved futile as well. After failure to traverse the stricture with conventional means, a cholangioscope (SpyGlass Direct Visualization System, Boston Scientific) was introduced into the bile duct, and a very small slit-like opening was visualized at the anastomotic site (see Supplementary Video 1). Under direct cholangioscopic guidance, a guidewire (Jagwire) was passed through the opening and placed in the donor duct, traversing the stricture (see Supplementary Video 1 and Fig. 2). The stricture was then dilated and stented with excellent bile and contrast drainage (Fig. 3). After a few days, repeat laboratory work-up showed normalization of the liver enzymes. A severe anastomotic stricture prevents the passage of a guidewire (arrow). An inflated balloon (arrowhead) is placed in the recipient duct for injection of contrast under pressure in order to visualize the donor ducts. The stricture is traversed with a guidewire under direct visual guidance by a cholangioscope. Appropriate positioning of the guidewire is confirmed by fluoroscopy. A stent is placed in the bile duct crossing the stricture with excellent drainage of contrast. Various refinements in surgical techniques and postoperative and immunosuppressive management have reduced the incidence of complications after liver transplantation. Biliary complications, however, continue to be a significant cause of morbidity after LDLT.5, 7 Nonsurgical techniques such as ERCP have in recent years attained a primary role in the treatment of posttransplant biliary strictures. The success of ERCP in these cases, however, depends on the ability to traverse the stricture with a guidewire. In the vast majority of cases, this is accomplished easily. In severe strictures, however, it can represent a time-consuming challenge and, in some reports, a failure rate as high as 20%.2 In these cases, a more invasive procedure such as transhepatic access or surgery may become necessary.2 The SpyGlass Direct Visualization System is a peroral cholangioscope with 4-way tip deflection that recently became commercially available. In contrast to traditional dual-operator cholangioscopes, the SpyGlass system allows a single endoscopist to operate both “mother and baby scopes.” In this case, we used this system to pass a guidewire under direct visualization through a severe stricture after failure to do so during ERCP. This technique can prove useful and time-sparing in selected cases when the severity of the stricture prevents guidewire placement by conventional methods. Supplementary material for this article can be found on the Liver Transplantation Web site ( http://www.mrw.interscience.wiley.com/suppmat/1527-6465/suppmat/ ). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Primary Sclerosing Cholangitis: Role of Extrahepatic Biliary Resection

Most centers advocate orthotopic liver transplantation (OLT) for patients with primary sclerosing cholangitis (PSC) and cirrhosis. Management of PSC patients without cirrhosis remains controversial. We examined the results of extrahepatic biliary resection (EHBR) for PSC. Between 1981 and 2006, 126 patients with PSC underwent EHBR (n = 77) or OLT (n = 49). Data on biliary drainage procedures, perioperative morbidity, and longterm survival were collected and analyzed. Of 77 patients undergoing EHBR, mean preoperative bilirubin level was 5.6 mg/dL. Nine (11.7%) patients had cirrhosis. Most patients had preoperative biliary drainage (ERCP, 61.0%; PTC, 67.5%). At operation, 73 (94.8%) patients underwent EHBR, including hepatic duct bifurcation. Most patients also had insertion of bilateral transhepatic silicone elastomer biliary stents; 4 (5.2%) underwent EHBR with stent insertion plus hepatectomy. For EHBR patients, perioperative complication rate was 38.7% and 30-day mortality was 3.9%. Bilirubin levels significantly decreased postoperatively (mean drop 3.8 mg/dL; p < 0.01). At 3 years, 57.1% of patients had no PSC-related readmissions, and 16.2% had more than 3. At a median followup of 10.5 years, 5- and 10-year survival was 76.4% and 52.7%, respectively. Cholangiocarcinoma did not develop in any patients, and only seven required OLT. Factors associated with worse survival included postoperative bilirubin >or= 2 mg/dL and history of cirrhosis (both p < 0.001). In patients undergoing EHBR, noncirrhotic patients had significantly better longterm outcomes versus cirrhotic patients (10-year survival, 60.2% versus 12.0%; p < 0.001). In contrast, 10-year survival of OLT patients with cirrhosis was 57.0%. Noncirrhotic patients with PSC can be successfully managed with EHBR. EHBR for noncirrhotic patients is associated with low perioperative morbidity, few readmissions, no new cholangiocarcinomas, and 10-year survival > 60%. OLT should be reserved for patients with PSC and associated hepatic cirrhosis.

An obstructive, proximally migrated plastic biliary stent extracted with a “modified” Seldinger technique and a polypectomy snare

Endoscopic retrieval of proximally migrated, plastic biliary stents may be technically challenging and sometimes unsuccessful [1]. Data from the literature report a retrieval success rate of 85%, with the remaining 15% requiring surgical removal [2]. The choice of retrieval technique is dependent on several factors, including biliary ductal dilatation, depth of stent migration, distal stent impaction, and biliary stricture distal to the migrated stent. The placement of an additional stent alongside an irretrievable stent has been reported as an alternative technique to retrieval, but the risk of cholangitis associated with this technique is not yet widely known by practitioners [3]. Despite the widespread use of such stents, there are few reports on the technique and the different accessories available for retrieval of migrated stents. Furthermore, there are no reports in the literature on proximally migrated, biliary stent removal using a polypectomy snare. A 53-year-old man with a history of chronic pancreatitis underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent insertion in September 2006, for distal common bile duct benign stenosis. On Nov ember 2006 he was referred to our center after developing cholangitis. An ERCP was carried out, and the abdominal pre-procedural radiograph showed a proximal migration of the biliary stent. Different techniques were utilized to retrieve the stent (Dormia basket, forceps, balloon, Sohendra extractor), but all of them failed. It was not possible to insert a guide wire into the distal orifice of the stent because the angulated distal part of the stent was too close to the biliary wall. With a sphincterotome, which allowed us to address the direction, a wire was inserted through the distal flap-hole, and into the stent ( l

Successful Treatment of Intractable Bronchobiliary Fistula Using Long-term Biliary Stenting

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

Endoscopic Drainage of Pyogenic Liver Abscesses With Suspected Biliary Origin

Pyogenic liver abscesses remain an important and life-threatening clinical problem but their causes and management have changed over the last two decades. The aim of this study was to assess the feasibility and the impact of an endoscopic approach in the management of liver abscesses with suspected biliary origin. We reviewed the records of 16 patients suffering from pyogenic liver abscess, who underwent endoscopic retrograde cholangiopancreatography (ERCP) in the setting of biliary diseases between January 1995 and December 2004. Nine patients had an underlying neoplastic disease; 13 had a history of biliary endoscopic maneuvers. When the collections were communicating with the biliary tree, an endoscopic drainage of the abscess was performed either by sphincterotomy, dilation, insertion of a nasobiliary catheter, or stenting. In noncommunicating liver abscesses associated with bile duct abnormalities, biliary decompression was obtained by insertion or replacement of biliary stents. Fourteen patients had liver abscesses communicating with the biliary system and underwent an endoscopic drainage of the cavity. Ten of these patients had an exclusive endoscopic drainage of the abscess, while four cases required additional percutaneous drainage. The two noncommunicating abscesses were associated with previous insertion of biliary stents; these were cured percutaneously after endoscopic stent replacement. Among the 16 patients, 13 had a rapid resolution of symptoms (81%). This initial clinical experience suggests that ERCP can demonstrate communications between the biliary tract and liver abscesses, and that an internal drainage of the cavity is feasible and safe.

Complications and treatment of migrated biliary endoprostheses: A review of the literature

Endoscopic biliary stent insertion is a well-established procedure. It is especially successful in treating postoperative biliary leaks, and may prevent surgical intervention. A routine change of endoprostheses after 3 mo is a common practice but this can be prolonged to 6 mo. We reported a colonic perforation due to biliary stent dislocation and migration to the rectosigmoid colon, and reviewed the literature.

Mirizzi's syndrome – results from a large western experience

Background. This paper reports a series of patients with Mirizzi's syndrome (MS) who were managed at our institution over an 11-year (1994–2005) period. Methods. Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospital's radiology computer coding system. Results. 33 patients were identified with a median age of diagnosis of 70 (35–90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1–7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2). Conclusion. Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.

Prior Experience and Use of Short Wire Technology Predicts Faster ERCP Procedure Time

Purpose: Therapeutic ERCP requires advanced training beyond regular endoscopy. ERCP utilizes side-viewing scopes and different accessories, in addition to fluoroscopy. Close coordination is required between endoscopist and assistant in manipulating accessories. Traditional teaching involves use of conventional long accessories. The short wire Fusion system minimizes exchanges, allows better control by the endoscopist and less reliance on the assistant, thus shortening the ERCP procedure. Aim: Using a mechanical simulator, we determine 1. if use of short accessories will shorten procedure time compared to long accessories, and 2. determine the possible correlation between procedure time and actual ERCP skill (total experience). Methods: 13 advanced GI fellows from the Western United States participated in a hands-on practice ERCP course. An anonymous survey documents the pre-practice endoscopy experience, and post-practice evaluation of simulator practice in ERCP training. ERCP was performed using a mechanical simulator and an artificial bile duct with a built-in stricture. A pin-hole camera is used in place of fluoroscopy to monitor events within the bile duct. Time taken (minutes) to negotiate the stricture with a guide wire, perform balloon dilation and brushing cytology, and insertion of a plastic biliary stent using the conventional method or Fusion system were determined. The total procedure time (TT) and fluoroscopy time (FT) were taken. Each fellow was paired with an experienced assistant and each set of tasks was repeated two times. Five experienced biliary attendings also performed the same tasks. T-tests were used for statistical analysis. Results: The mean TT and FT taken by fellows (n = 13) was 15.1 min and 4.31 min for long accessories and 12.6 min and 4.88 min for the Fusion system respectively. The difference for TT between long and short accessories (p < 0.05) was significant, but not FT (p = 0.14). The mean TT for attendings using long accessories was 7.87 min and 6.43 minutes for the Fusion system (p = 0.02). The differences in both time taken for long and short accessories between fellows and attendings were significant (p < 0.005 for both). Conclusions: The mechanical simulator allows comparison of objective data for ERCP practice with different accessories. The procedure time is inversely related to the total ERCP experience. Short wire and accessories may shorten procedure time compared to long accessories.

Mechanical Simulator for ERCP Training

Purpose: Diagnostic and therapeutic ERCP requires special technical skills and thus specific training. With a higher expectation set for competency, many training programs may not be offer GI fellows sufficient experience in advanced therapeutic procedures especially ERCP-related. There are no accepted alternatives to clinical teaching. Currently available computer simulators are unrealistic and lack tactile sensation. Animal models or ex-vivo tissue require special training settings. An economical, portable and reproducible simulator will help with training and assessing fellows' progress in ERCP without jeopardizing patient care. Aim: To evaluate the use of a mechanical simulator for training and teaching new ERCP techniques to GI fellows. Methods: 13 advanced GI fellows from Western United States participated in a hands-on ERCP practice course. All completed an anonymous pre-practice and post-practice survey on their endoscopy experience. ERCP was performed using a mechanical simulator and an artificial bile duct with a built-in stricture. A pin-hole camera is used (in place of fluoroscopy) to monitor events within the bile duct. Time taken (minutes) to negotiate the stricture with a guide wire, perform balloon dilation and brushing cytology, and insertion of a plastic biliary stent using the conventional method or the Fusion system were measured including total procedure time (TT) for stent placement and fluoroscopy time (FT) to monitor the process. Each fellow worked with an experienced assistant and performed each task two times. Results: All participants performed more than 400 upper endoscopies and the mean number of ERCPs was 140. All participants were able to complete the four ERCP tasks using conventional accessories and the Fusion system. The mean TT and FT was 15.1 min and 12.6 min respectively. The survey revealed only 6/13 participants would have done > 200 ERCPs at graduation yet all intended to perform ERCP, 9/13 fellows were trained with long ERCP accessories but 10/13 fellows planned to use short wire accessories in future practice. 10/13 participants planned to enter a community practice. Conclusions: The mechanical simulator provides a risk-free setting for GI fellows to learn and practice ERCP techniques. All fellows regardless of their prior training experience with different accessories were able to complete the tasks. Although the mechanical simulator does not substitute clinical ERCP experience, it serves as an adjunct to allow fellows to practice and familiarize themselves with new techniques or accessories.

Endoscopic treatment of chronic pancreatitis

Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.

Infuence of Biliary Stenting (BS) on Endoscopic Ultrasonography (EUS) Detection and Staging Accuracy of Pancreaticobiliary Neoplasms (PN)

Background: EUS has been shown to be an highly accurate test for PN imaging which has a fundamental influence on patients management. However, the timing when to perform EUS in the diagnostic algorithm of PN is less defined. In clinical practice EUS is often requested in patients whose diagnosis and staging are still uncertain after endoscopic retrograde cholangiopancreatography (ERCP) with stent positioning in the bile duct. Aim of this study was to assess the influence of biliary stenting on EUS detection and staging accuracy rates in pts with PN. Material and Methods: Our records were reviewed for patients who underwent EUS for staging of PN and had a prior stent positioning in the bile duct. Time period: July 2002-July 2004. EUS examinations were performed either with a radial mechanical scanning or with a sector electronic scanning Olympus echoendoscope. The influence of a biliary stent at the time of EUS on the diagnosis and staging was evaluated. EUS results could be controlled by comparison with surgical pathological staging when available or, alternatively, by follow up data including EUS-fine needle aspiration results. Results: Twenty-one patients were identified (13M/8F; mean age 61.2 yrs, 34-80 yrs) who had a transpapillary biliary stent at the time of EUS (19 plastic and 2 metallic stents). Reason for stent positioning at the time of ERCP was obstructive jaundice suspicious for malignancy. Biliary stenting compromised to some extent all EUS examinations because of intervening air in the duodenum and material artifacts in the bile duct. EUS results were as follows: compatible with PN in 14/21; negative for PN in 4/21; ampullary neoplasm in 2/21; and chronic pancreatitis in 1/21. In 13/14 cases with EUS compatible with PN who underwent subsequent surgical operation, EUS vs. surgical pathology T staging results were: T1 = 0 vs. 1 pt; T2 = 1 vs. 1 pts; T3 = 7 vs. 2 pts; T4 = 5 vs. 9 pts. T staging was underestimated by EUS in 4/13 pts. and overestimated in only 1/13 pt. (EUS T3 vs surgical T1). Three/4 pts. with EUS negative for PN were subsequently found to have PN (2 adenocarcinoma and 1 cholangiocarcinoma). Overall EUS detection rate for PN was 84%. Conclusion: Our data confirm that impact of EUS on PN diagnosis is substantial. Biliary stent insertion adversely influenced EUS detection rate and T stage accuracy of PN. Understaging was more likely to occur than overstaging. Every effort should be taken to perform EUS prior to biliary stent insertion.

Endoscopic Ultrasound (EUS) in the Evaluation of Patients with Suspected Choledocholithiasis but Negative Cross-Sectional Imaging (Transabdominal Ultrasonography or Abdominal CT Scan)

Aim: To evaluate the usefulness of EUS in the evaluation of patients with a clinical suspicion of choledocholithiasis in whom cross-sectional imaging with either transabdominal ultrasound (US) or abdominal CT does not detect any common bile duct (CBD) stones. Method: This was a prospective study conducted on patients presenting with symptoms referable to the biliary system (biliary colic, cholangitis, jaundice) who had a transabdominal ultrasound or abdominal CT scan that was negative for stones or sludge in the CBD. These patients subsequently underwent EUS examination which was performed using a radial scanning echoendoscope (Olympus GF-UM160). Patients in whom choledocholithiasis or sludge in the CBD was noted underwent therapeutic ERCP and were offered laparoscopic cholecystectomy. Those in whom EUS did not provide a positive diagnosis were followed up clinically. Results: 50 patients (26M/24F) were included in the study. Of these, 14 had a dilated CBD noted on transabdominal US but the cause of the dilatation could not be determined. The remaining 36 patients had a non-dilated CBD on transabdominal US. In 30 out of the 50 patients (60%), choledocholithiasis was diagnosed by EUS. Another 8 patients (16%) had sludge noted in the CBD by EUS. The EUS diagnosis of choledocholithiasis or sludge in the common bile duct was verified in all 38 patients by therapeutic ERCP with resolution of symptoms soon after stone extraction or biliary stent insertion. Of the remaining patients, 10 were diagnosed with cholelithiasis but no lesion could be identified in the common bile duct. In all 10 patients, clinical signs and liver biochemical abnormalities resolved soon after hospital admission, suggestive of passage of a stone through the CBD. These patients were offered cholecytectomy. 2 patients did not have a positive EUS diagnosis. Both of these patients presented with a mixed picture on liver function tests and declined liver biopsy. At 3-month follow-up, their symptoms and/or signs had resolved. Conclusions: EUS is a useful imaging method for the evaluation of patients with suspected choledocholithiasis but in whom cross-sectional abdominal imaging (US or CT) is negative for CBD stones. When EUS is negative for choledocholithiasis or microlithiasis, ERCP along its accompanying risks can be avoided.

Clinical Outcome of Consecutive Non-Operative Management for Palliation of Malignant Biliary and Duodenal Obstruction

Background: Malignancies of the gastrointestinal tract sometimes cause symptomatic biliary and duodenal obstruction, which occur one after another. However, most of them are frequently unresectable to be cured and receive palliative care only. Non-operative management has offered less invasive alternatives to surgical palliation of the symptomatic duodenal and biliary obstruction. Methods: The consecutive 23 patients with unresectable malignant biliary and duodenal obstruction, in whom non-operative managements were performed between February 1998 and March 2004, were retrospectively analyzed. Self-expanding metal stents were endoscopically inserted for the palliation of the duodenal obstruction, while the self-expanding biliary metal stent insertion or percutaneous biliary drainage was performed for the palliation of the biliary obstruction. Results: The total 23 patients had the following underlying diseases: pancreatic cancer 11, gallbladder cancer 3, common bile duct cancer 3, ampullary cancer 3, and gastric cancer 3. Self-expanding metal stents were endoscopically inserted for the palliation of duodenal obstruction in all the patients without immediated complications. Seventeen patients had previous biliary obstructions before duodenal obstructions. Ten of them were treated with an endoscopic placement of a biliary stent and the remaining 7 patients were treated with a percutaneous biliary drainage for biliary obstruction. Symptomatic duodenal obstructions were developed with a mean of 121 days after the biliary obstruction. During the follow-up, 1 patient had recurrent jaundice due to biliary stent occlusion and was managed with a percutaneous biliary drainage. Six patients had previous duodenal obstructions before biliary obstructions. One of them was treated with an endoscopic placement of a biliary stent and the remaining 5 patients were treated with a percutaneous biliary drainage due to biliary obstruction. Symptomatic biliary obstructions were developed with a mean of 28 days after the duodenal obstruction. During the follow-up, 1 patient with a percutaneous biliary drainage had recurrent jaundice and was managed with a percutaneous biliary stent. Conclusion: Non-operative management of the malignant biliary and the duodenal obstruction may provide a safe and less invasive alternative to surgical palliation with an acceptable clinical outcome.

Endoscopic insertion of biliary stents in 18 patients with metallic duodenal stents who developed secondary malignant obstructive jaundice

The aim of this work was to evaluate the feasibility of endoscopic insertion of biliary stents in patients with duodenal stents who develop secondary malignant obstructive jaundice. The study population included 133 patients with unresectable malignant duodenal obstruction. In 106 patients a biliary stent was inserted before or at the same time as the duodenal stent. Malignant biliary obstruction appeared secondarily in 18 patients; fifteen of these patients already had a biliary stent. We present our experience of biliary stent insertion in these 18 patients with metallic duodenal stents. Biliary obstruction was successfully alleviated in 17 out of 18 patients (94%) without complication. Insertion of a new biliary stent failed in one patient because the mesh of the duodenal stent passed over the metallic biliary stent already in place. Mean duration of endoscopic insertion was 95 minutes (range: 60 - 180). All patients remained free of biliary complications to death (57 days, range: 30 - 120). Our report shows that endoscopic insertion of a biliary stent is feasible in patients who have metallic duodenal stents. Technical difficulties exist especially if the mesh of the duodenal stent passes over the papilla.