Repeat ERCP Research Articles

A Unique Case of Radiation-Induced Cardiac, Biliary, and Duodenal Strictures in a Patient With Prior Hodgkin’s Lymphoma

Introduction: A 48-year-old man with a history significant for mantle radiation and chemotherapy completed in 1989 for Hodgkin’s lymphoma and a more recent history of cardiac stenting secondary to radiationinduced cardiac stenosis presented to Albany Medical Center with a 1.5-week history of jaundice. MRI showed a diffusely dilated bile duct to the level of the ampulla with intrahepatic biliary dilation. He underwent EUS/ERCP, which showed the upper third of the main bile duct to contain a single high-grade localized stenosis 30 mm in length with markedly dilated left and right hepatic ducts and dilation of all intrahepatic branches. An area of duodenal stenosis was also noted at the time of the endoscopy, requiring balloon dilation prior to completion of the ERCP. Cytologic brushings of the stricture were negative. In subsequent months, the patient had multiple repeat ERCPs with metal stent placement and exchanges. The patient also continued to have a persistent duodenal stenosis requiring balloon dilation prior to each ERCP. Eventually placement of bilateral plastic biliary stents was performed due to recurrent episodes of cholangitis and failure after repeated metal stenting. Repeat duct brushings continued to return negative. General surgery was consulted for surgical evaluation of a hepaticojejunostomy for treatment of his recurrent high-grade biliary stricture. In the operating room the patient was found to have a significant amount of inflammation and scarring secondary to radiation, involving the right upper quadrant with the duodenum stuck against the porta hepatis along with omentum and colon overlying this. This created a mass-like effect in the porta hepatis and made the possibility of a safe and complete dissection too high risk. A percutaneous transhepatic cholecystostomy tube was placed for long-term management of his biliary stricture. Mantle radiation has long been known to cause delayed complications in the form of cardiac disease and secondary cancers. Our case demonstrates a unique presentation of cardiac, biliary, and GI tract stricturing. This patient presented not only with the common presence of cardiac stenosis and requisite coronary stenting, but was quite distinctive in terms of the resultant involvement of both the biliary system and GI tract, with recurrent biliary stricturing requiring repeated metal stenting and the development of duodenal stenosis requiring repeated balloon dilation. Although radiation-induced biliary and duodenal stenosis has been reported, such a latent presentation from prior mantle radiation is rare in the literature.

PTH-008 Safety And Efficacy Of Balloon Sphincteroplasty Using Controlled Radial Expansion (cre) Balloon During Endoscopic Retrograde Cholangio Pancreatography In The Management Of Large Common Bile Duct (cbd) Stones: A District General Hospital Experience

IntroductionExtraction of large (>1 cm) CBD stones at ERCP is often difficult despite adequate sphincterotomy. Failure of extraction of stones warrants repeat ERCPs and also referral to advanced techniques such...

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Endoscopic Ampullectomy to Gain Access in CBD in a Patient with RNY Gastric Bypass Surgery

Figure: No Caption available.Purpose: A 55-year-old white female with RNY gastric bypass presented with complaints of puritus for 3 months. Liver test was noted grossly abnormal with predominant choestatic pattern. MRI/MRCP showed grossly dilated intra- as well as extra-hepatic biliary channels. CBD dilated to 14 mm with smooth distal narrowing suggestive of stricture. No filling defects in CBD or any ampullary or pancreatic mass seen. ERCP was performed with pediatric colonoscope, ampulla was reached via afferent limb. A large ampullary mass was found. Attempt to cannulate CBD failed, mass was partially resected with snare, tissue collected and histology showed adenoma with no high-grade dysplasia. Once ampullary carcinoma was ruled out, a few weeks later repeat ERCP was performed successfully and the following key steps are demonstrated in the video: 1.) successful CBD cannulation, stent deployment; 2.) needle knife papillotomy; 3.) ampullectomy with hot snare in piecemeal fashion; 4.) stent removal; 5.) balloon dilation of the stricture and sphincteroplasty; and 6.) balloon sweep. Complete procedure was recorded and later edited to include only key elements of the procedure. No attempt was made to cannulate pancreatic duct. Post ERCP, patient was observed overnight in the hospital. No post-ERCP pancreatitis occurred. Patient was followed in clinic regularly, pruritus completely resolved, and liver test slowly normalized. Endoscopic ampullectomy in RNY gastric bypass patient is technically challenging; however, this can be performed by experienced therapeutic endoscopists working at high-volume pancreatic-biliary centers.

Pancreatico-peritoneal Fistula: A Rare Cause of Recurrent Ascites and a Novel Treatment

Introduction: Pancreatico-peritoneal fistula is a rare and clinically challenging cause of recurrent ascites. We report a patient with recurrent ascites secondary to a pancreatic duct leak, and its successful treatment using Coseal® surgical sealant delivered endoscopically. Case Report: A 42-year-old male with a history of alcoholism and presumed alcoholic cirrhosis, presented with worsening ascites, abdominal pain, weight loss, and anorexia. One month prior, the patient underwent outpatient paracentesis, and was started on a diuretic regimen of spironolactone 100 mg and furosemide 40 mg daily. On physical exam, he was febrile and cachectic, with abdominal protuberance and tenderness. Laboratory tests revealed WBC 17.8 K/uL, albumin 2.8 g/dL, total bilirubin 0.9 mg/dL, direct bilirubin 0.4 mg/dL, alkaline phosphatase 161 U/L, AST 75 U/L, and ALT 40 U/L. Paracentesis indicated bacterial peritonitis (5,167 WBC/uL, 99% PMNs), and intravenous cefotaxime was initiated. Despite antibiotics, the leukocytosis and symptoms persisted. CT scan revealed three pancreatic pseudocysts, scattered pancreatic calcifications, and a 5-mm pancreatic duct in the tail, along with large ascites but no evidence of cirrhosis. Subsequent large volume paracentesis revealed elevated ascitic fluid amylase (43,869 U/L), and cultures isolated Pseudomonas aeruginosa. Given the CT findings and the high ascitic fluid amylase, the diagnosis of a pancreatico-peritoneal fistula was suspected. ERCP revealed a moderate pancreatic duct stenosis in the body with a small stone proximal to the stricture, as well as a pancreatic duct leak originating from the tail. A 7 Fr x 11 cm straight pancreatic stent was successfully placed and antibiotic coverage with imipenem was maintained, yet the patient's symptoms and ascites with high amylase content persisted. Repeat ERCP re-demonstrated extravasation of contrast from the pancreatic tail. Coseal® surgical sealant was then injected through a catheter into the tail of the pancreatic duct for closure, and an 8.5 Fr x 14-cm pancreatic stent was placed. Within days, the patient's symptoms improved, and he remains stable at 3 months after fistula closure. Conclusion: Ascites from a pancreatic-peritoneal fistula is rare, and it poses a significant diagnostic and therapeutic challenge. Given the patient's alcohol history, the true etiology of his ascites and peritonitis was initially misdiagnosed. Once properly recognized, the pancreatico-peritoneal fistula was successfully closed by applying a surgical sealant delivered endoscopically.

Single-operator Peroral Cholangioscopy (SpyGlassTM) for Extraction of a Cystic Duct Stone in the Setting of Mirizziʼs Syndrome Post-remote Cholecystectomy

Introduction: Cystic duct and gallbladder neck stones are seen as a cause of biliary obstruction due to extrahepatic bile duct compression: “Mirizzi's Syndrome.” Management of symptomatic cystic duct stones after cholecystectomy can be challenging often requiring surgical extraction. The SpyGlassTM Direct Visualization System provides an attractive option for endoscopic management of cystic duct stones. Summary of Case: A 27-year-old female with history of remote cholecystectomy for symptomatic cholelithiasis presented with epigastric pain radiating to the right upper quadrant and back. Laboratory evaluation was consistent with cholestasis. MRCP showed a 9-mm stone at the confluence of the cystic and common hepatic ducts resulting in biliary and cystic ductal dilatation with surrounding inflammation (Figure 1).Figure: MRCP.Description of Intervention: ERCP was performed with biliary sphincterotomy and biliary stent placement after failed cannulation of the cystic duct. On repeat ERCP the cystic duct was successfully cannulated. There was a filling defect consistent with a 9-mm stone with proximal cystic duct dilatation and extravasation of contrast suggestive of a contained cystic duct leak. Following failed attempts of stone extraction using a balloon, cholangioscopy was performed using SpyGlassTM. The stone was visualized and fragmented using electrohydrolic lithotripsy (EHL; Figure 2). Balloon sweeps of the cystic duct successfully cleared the cystic duct of stone fragments.Figure. SpyGlass: TM cystic duct stone.Conclusion: Our case highlights the merits of using SpyGlassTM cholangioscopy for endoscopic removal of an obstructing cystic duct stone causing Mirizzi's Syndrome. This non-surgical, safe, and effective modality should be considered when conventional ERCP has failed in managing complex ductular stones.

EUS-guided drainage of liver abscess by using a lumen-apposing metal stent (with video)

A 92-year-old man with cholangitis underwent ERCP complicated by incomplete removal of all visualized bile duct stones. Two plastic biliary stents were inserted, and another attempt at stone extraction was planned at a later date. Two months later, the patient was admitted with recurrent cholangitis. CT demonstrated a 10-cm abscess in the left lobe of the liver (A). Intravenous antibiotics were initiated, and the patient underwent repeat ERCP. During the procedure, an obvious bulge was observed in the stomach (B).

PTU-038 Should a Plastic or a fully Covered Metal Stent be Placed at Index ERCP when a Patient Presents with Jaundice Due to a Malignant Distal Biliary Stricture?

IntroductionTraditionally plastic stents (PS) are inserted at the index ERCP to treat obstructive jaundice from malignant distal biliary strictures. However, with the development of fully covered metal stents (C-SEMS), this...

Sp706 Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction

Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction Se Jeong Park*, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim After failed ERCP, other alternative biliary accesses such as PTBD, repeated ERCP, or surgical bypass could be considered. PTBD has a complication rate of 10% to 30% such as bile leak, bleeding, and peritonitis. Repeat ERCP could be as an alternative if immediate biliary drainage is not required. Surgical bypass is effective, but is associated with considerable mortality and morbidity. EUSguided transgastric imaging of dilated left intrahepatic duct is a useful technique to drain the left biliary system and an effective alternative for percutaneous transhepatic biliary drainage after failed ERCP. To date, EUS-guided biliary drainage in isolated right hepatic duct obstruction has not been attempted. In our center, 4 consecutive patients were candidates for EUS-guided right hepatic duct approach within recent year with last case in October 2012. We performed three kinds of approaches to the right hepatic duct using EUS; (1) using a cholangiogram obtained by EUS-guided transduodenal puncture of the right hepatic duct as a “roadmap” to assist retrograde cannulation, (2) EUS-guided transduodenal puncture of the right hepatic duct and an antegrade balloon dilatation and stenting for bilioenteric anastomotic strictures in a patient with hepaticojejunostomy, and (3) transluminal stenting as an antegrade bypass stenting between the right hepatic duct and the duodenal wall under EUSguidance. EUS-guided hepaticoduodenostomry (EUS-HD) of right hepatic duct by expert hands may be a relatively safe and feasible alternatives after failed ERCP. Moreover, an availability in the same session without dicontinuation of sedation after failed ERCP is another great advantage. In contrast, the other alternative accesses such as PTBD, repeated ERCP, and surgery almost need another session for further procedure on a different day. Further, large multicentered study may help enhance our results.

Su1343 Outcome of Repeat ERCP After Biliary Cannulation Failure Following Needle Knife Sphincterotomy

Needle knife sphincterotomy (NKS) is often used to gain biliary access in failed standard cannulation techniques. If selective biliary cannulation is unsuccessful, the next step may include either percutaneous or EUS-guided biliary drainage. ERCP is sometimes repeatedly performed in clinically stable patients. However, there are few reports about the outcome. The aim of this study was to assess the outcome of repeat ERCP after failure with NKS for selective biliary access.

Evaluation of Repeat ERCP: Analysis of a Four-Year Experience

In this trial, a total of 1010 ERCP procedures performed in 410 patients at the endoscopy department of our hospital between 2006 and 2010, were retrospectively evaluated. The age, gender, complaints, pre-procedure diagnosis, the radiologic and clinical results, number of procedure repetitions and the final diagnosis were assessed. The local Ethics Committee approved this retrospective study protocol. All of the procedures were performed by the same team of endoscopists with compatible levels of ERCP experience (Mean 5 years). At our department, pethidine HCl (0.3-0.5 mg/kg), midazolam (0.03-0.07 mg/kg) and hyoscine-N-butylbromide (0.3-0.6 mg/kg) are used in the ERCP procedures for premedication and additionally, cefazolin 1 gram intravenous is routinely administered for prophyllaxis one hour before the examination. During the procedure, oxygen saturation and heart rate are monitored by pulse-oximeter. The patients were those admitted to our hospital or referred from other healthcare centers. Statistical assessment was performed by evaluating the first ERCP procedures and the repeat procedure records. Chi-square test was used to statistically analyze the results. The level of significance was set at p<0.05.

Safety and Efficacy of Endoscopic Radiofrequency Ablation in Non-Resectable Cholangiocarcinoma: A Case Series

Purpose: Surgery remains the only curative treatment for cholangiocarcinomas. Less than 20% of tumors are resectable at the time of diagnosis. Median survival without surgery is about 3 months. Multiple studies have shown that photodynamic therapy plus biliary stenting improve jaundice, prolong survival and enhance quality of life. Endoscopic radiofrequency ablation (RFA) followed by self-expandable metal stenting has been shown to be safe and effective in small trials. Methods: Three patients with non-resectable hilar cholangiocarcinoma underwent ERCP and focal ablation therapy using an endoscopic bipolar radiofrequency probe, ENDOHPB (EMcizion Ltd, UK) at either 7 or 10 W for 90 seconds. Following the RFA, two patients had a non-covered self-expandable metal stent placed and the third had two bilateral plastic stents. All had a repeat ERCP following treatment. Results: Mean age was 68; two were females. There were no procedure-related complications. There was a significant reduction in total bilirubin (Table 1). At a mean of 89 days after initial treatment patients had repeat ERCP. Because of severe stricture, patient #3 received 10 W rather than 7 W at initial treatment and bilateral plastic stents were placed after ablation, in anticipation of possible retreatment at follow-up. At the time of repeat ERCP, the cholangiogram showed marked improvement of the malignant stricture diameter from <3 mm to 6 mm. A 12 mm extraction balloon was pulled through the stricture with minimal resistance. Further ablation was therefore withheld. Plastic stents were then replaced by an uncovered metal stent.Table: No Caption available.Conclusion: Endobiliary RFA is safe, well tolerated and may prove to be an effective palliative intervention that helps maintain biliary patency in patients with unresectable cholangiocarcinoma. It is possible that 10 W for 90 seconds may be as safe but more effective compared 7 W treatments for the same duration. Large randomized studies are needed to evaluate the safety and efficacy of this intervention.

PTU-076 Factors at first ERCP which influence the decision to proceed to subsequent surgery or repeat ERCP for complex biliary problems

IntroductionERCP is a safe and highly effective solution to many pancreaticobiliary problems. However, surgical options also exist. After a challenging first ERCP, it can be unclear whether surgery or repeat...

PWE-207 Bile duct leaks from an aberrant duct of Luschka

IntroductionThe Duct of Luschka is an accessory biliary radicle first described by the German anatomist Hubert von Luschka in the 19th century. If this aberrant duct goes unnoticed at the...

Su1403 The Quality of Bowel Preparation for Screening Colonoscopy in an Inner City Health Care Center

excluded. PEP was diagnosed by typical pancreatic-type abdominal pain and elevation of amylase/lipase 3X ULN following ERCP. Severity of PEP was defined by established criteria4. Results: 549 OLTs with duct-to-duct anastomosis were performed during the study period. Of the OLT recipients, 100 patients (63% male; 89% Caucasian; mean age 51 13) underwent ERCP (122 total ERCPs). ERCP was performed at a median of 96 days (IQ range, 30-387) following OLT. Findings at ERCP included: anastomotic stricture in 29% (35/122), bile leak in 16% (19/122), stones/sludge in 9% (11/122), and papillary stenosis in 6% (7/122). Difficult cannulation was noted in 22% (27/122) and biliary sphincterotomy was performed during 66% (81/122) of the ERCPs. Prophylactic pancreatic stents were placed during 12 procedures (10%). PEP occurred following 5 cases (4 male, 1 female). Of the PEP cases, ERCP finding of anastomotic stricture was observed in 4 of 5 cases. Four cases of PEP occurred after documented difficult cannulation and 2 cases occurred despite pancreatic stent placement. Two patients developed PEP during a repeat ERCP after a post-transplant ERCP had been performed previously without sphincterotomy. There were no episodes of severe acute pancreatitis; three were moderate in severity, and 2 were mild. Conclusions: The rate of PEP in patients following liver transplant is comparable to that previously documented in the general population1,2. However, ERCP evidence of an anastomotic stricture and difficult bile duct cannulation appear to be risk factors for development of PEP in the OLT population.

Sp813 Pancreatic Necrosis Treated With Direct Endoscopic Debridement by Transpapillary Approach

The patient is a 33 year-old male with a recent history of severe alcohol-induced acute necrotizing pancreatitis who was transferred with dyspnea and abdominal pain. Chest x-ray showed a high amylase right-sided pleural effusion suggesting a pancreatico-pleural fistula. Adbominal CT showed multiple pancreatic fluid collections in addition to changes of severe necrotizing pancreatitis, with total loss of parenchyma in the head. Initial ERCP confirms a complete pancreatic duct disruption, and a pancreatic duct stent is placed. The patient does not improve, and he is scheduled for repeat ERCP.

Sp811 Mucin Producing Intrahepatic Biliary Papillomatosis in a Young Female Patient

A 29 year old female with ulcerative colitis presented with pain, obstructive jaundice, weight loss, after ERCP attempt. Exam demonstrated a thin jaundiced female with mild tenderness to palpation of the right upper quadrant. Laboratory data demonstrated abnormal liver enzymes with marked hyperbilirubinemia. CT and MRCP demonstrated dilation and irregularity of the extra and left intrahepatic ductal system. These ductal irregularities brought up concern for possible PSC. She was taken for a repeat ERCP and cholangioscopy as described below. She underwent PTC drainage, but because of symptoms and biopsy concerns of high grade dysplasia it was elected to evaluate for liver transplantation which she received 14 months after initial presentation. Examination of the explanted liver demonstrated an 18cm cystic mass containing abundant amounts of tan mucoid material. Large mucin pools containing cancer glands were noted with focal areas of invasion. Currently she is 18 months post-transplant.

Su1363 Selective Avoidance of Pancreatic Duct Manipulation Decreases the Need for Repeat ERCP and Lowers the Risk in Patients With Unexplained Upper Abdominal Pain: a Single-Center Long-Term Study

Su1363 Selective Avoidance of Pancreatic Duct Manipulation Decreases the Need for Repeat ERCP and Lowers the Risk in Patients With Unexplained Upper Abdominal Pain: a Single-Center Long-Term Study

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking. To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes. Cross-sectional study, retrospective chart review. Virginia Mason Medical Center, Seattle, Washington. This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire. P-ESWL and ERCP, outcomes survey. Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery. A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071). Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales. P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Proximal Gastrojejunal Reconstruction after Pancreaticoduodenal Resection

Introduction. Reconstruction by proximal gastrojejunostomy, and distal biliary and pancreatic anastomoses is infrequently used after resection of the head of the pancreas because of fear of fistulas and cholangitis. Pancreaticoduodenectomy is being performed more frequently for cystic malignant and premalignant lesions. Because of this there is a need for endoscopic visualization and biopsy of the residual pancreatic duct, since multi-centricity is characteristic of some of these malignancies. Since endoscopic access of the bile duct and pancreatic duct is difficult and unsuccessful in 50–70% after B II or Roux Y reconstruction, we prospectively studied the merit and complications (early and late) of proximal gastrojejunal (PGJ) reconstruction after pancreaticoduodenal resection. Material and Methods. Thirty nine consecutive, non-radomized patients underwent pancreaticoduodenectomy and PGJ reconstruction over 14 mos. There were 21 males and 18 females. Results. 7 patients with IPMN have undergone repeat CT scanning for surveillance, with 3 requiring repeat EUS and ERCP. There were no technical difficulties accessing the pancreas or the pancreatic duct, supporting the PGJ reconstruction. Conclusion. Proximal gastrojejunal reconstruction following pancreaticoduodenal resection may be safely done with similar morbidity to traditional pancreaticojejunal reconstructions. PGJ reconstruction may be of greater value when direct visual access to the bile duct or pancreatic duct is necessary, and should be considered when doing resection for mucinous cysts or IPMN of the head of the pancreas.