Single Endoscopic Retrograde Cholangiopancreatography Research Articles

Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures.

Endoscopic management is the first-line therapy for post-liver-transplant anastomotic strictures. Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months, data on safety and duration for metal stents in this setting is scarce. Due to limited access to endoscopic retrograde cholangiopancreatography (ERCP) during the coronavirus disease 2019 pandemic in our centre, there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy. This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents. To compare the safety and efficacy profile of different stenting durations using Kaffes stents. Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query. Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records. The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months. Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for ≤ 120 d or > 120 d. During the study period, a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course. In 33 ERCPs, the stent was removed or exchanged on a 3-month interval. No pancreatitis, perforations or deaths occurred. Minor post-ERCP complications were similar between the 3-month (abdominal pain and intraductal migration) and 6-month (abdominal pain, septic shower and embedded stent) groups - 6.1% vs 9.1% respectively, P = 0.40. All strictures resolved at the end of the stenting course, but the stenting course was variable from 3 to 22 months. The recurrence rate for stenting courses lasting for up to 120 d was 71.4% and 21.4% for stenting courses of 121 d or over (P = 0.03). There were 28 patients that were treated with a single ERCP with Kaffes, 21 with removal after 120 d and 7 within 120 d. There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course (71.0% vs 10.0%, P = 0.01). Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

Safety of endoscopic retrograde cholangiopancreatography practice in a district hospital

An audit was undertaken to provide accurate success and complication rates to patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Consecutive procedures from a single ERCP endoscopist’s practice were included. Data on indications, results and early complications were collected prospectively. 101 procedures from a 6-month period were studied. In 73 …

Safety and Efficacy of ERCP in Patients With Periampullary Diverticulum at a General Hospital in Singapore

Introduction: It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) in the presence of a periampullary diverticulum (PAD) may be associated with more difficulty, morbidity and complications. The safety and efficacy of ERCP in the setting of a periampullary diverticulum in Singapore is not known. The aim of the study is to investigate and compare the success rate, procedure difficulty (ERCP grade, cannulation difficulty, procedure time) and complication rate between patients with and without PAD undergoing ERCP at a single center in Singapore. Methods: This is a retrospective, single center cross-sectional study. A total of 548 ERCP procedures were performed at our endoscopy center from January 2015 to December 2016. Patients with previous ERCP intervention (i.e., sphincterotomy, stent insertion) or an abandoned procedure were excluded. Clinical and endoscopic data were collected from the electronic medical record. A total of 357 procedures in 351 patients were included in the analysis. Results: Of 357 procedures, 116 (32.5%) were found to have PAD. The ampulla was located within the diverticulum in 10 (8.9%), on the edge of the diverticulum in 44 (38.9%), and near the diverticulum in 59 (52.2%) cases. Patients with PAD were significantly older (69 vs. 60 years, p<0.001) and more likely to undergo ERCP for choledocholithiasis as the procedure indication (93.9% vs 83.8%, p<0.007). There was no statistically significant difference in the success and complication rates between the two patient groups. On multivariate logistic regression analysis, younger age was associated with higher cannulation success (p=0.023); older age and indication other than choledocholithiasis were associated with higher cannulation difficulty (p=0.01 and p=0.04 respectively). Patients with PAD were 3.3 times more likely to have common bile duct stones compared to patients without PAD (p=0.006). Conclusion: At a single ERCP center in Singapore, the frequency of PAD in patients undergoing ERCP is 33%. Choledocholithiasis is more prevalent in the PAD group of patients undergoing ERCP. Success and safety of ERCP in patients with and without PAD is comparable. In patients with PAD, older age and procedure indication other than choledocholithiasis are associated with higher ERCP difficulty.

Efficacy and Optimal Duration of Metallic Stent in the Management of Refractory Anastomotic Stricture After Liver Transplantation

Anastomotic bile duct stricture (ABS) remains as one of the most common complications in liver transplant patients. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with insertion of plastic stent often requires multiple procedures before achieving stricture resolution. To date, studies using covered self-expandable metallic stent (cSEMS) in ABS management reported varying degrees of efficacy. The aim of this study was to analyze long-term efficacy of cSEMS in patients with ABS and identify factor(s) influencing the probability of stricture resolution. Liver transplant patients with ABS who received cSEMS were identified by query of our endoscopic database. The rate of stricture resolution, duration of stricture-free interval, factors associated with stricture resolution, and adverse outcomes were analyzed. Among 44 liver transplant patients with refractory ABS who underwent ERCP-cSEMS, stricture resolution was observed in 33 patients (75%). Longer duration of cSEMS insertion was the only variable associated with increasing probability of stricture resolution. There was 20% increase in odds of stricture resolution for every additional week cSEMS was in place. Among 33 patients with initial stricture resolution, 26 patients (78.8%) maintained bile duct patency throughout the follow-up period. The most common adverse outcome was internal migration of cSEMS, which occurred in 11 patients (25%). The rate of ABS resolution observed with cSEMS placement in a single ERCP session appears to be comparable with that of multiple ERCPs with plastic stent placement reported previously. Longer stent insertion period is associated with higher likelihood of ABS resolution.

Multiple Preoperative Endoscopic Retrograde Cholangiopancreatography and Large Common Bile Duct Diameter Predict the Need for Complex Surgery

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used to clear the common bile duct (CBD) in patients with choledocholithiasis. While a single ERCP is usually effective, many patients undergo multiple ERCP attempts before cholecystectomy. Here we sought to identify preoperative factors predictive of surgical complexity beyond routine laparoscopic cholecystectomy after ERCP. Data were prospectively collected for all ERCPs between September 2010 and February 2012 at a public academic medical center including demographics, indication, stone presence, CBD diameter, sphincterotomy, stent placement, and ERCP number. A total of 124 ERCPs were attempted in 73 patients with choledocholithiasis, 10 per cent of whom presented with cholangitis. Fifty-six per cent of patients underwent one ERCP, whereas 16 per cent required ≥ 3 procedures. Laparoscopic cholecystectomy was performed in 58 (79%) patients whereas 15 (21%) patients required more complex operations including eight open CBD explorations and two hepaticojejunostomies. The likelihood of requiring more complex surgery correlated with increasing number of ERCPs with an adjusted odds ratio of 5.75 (95% confidence interval: 2.31-14.3, P ≤ 0.001). Increased CBD diameter also correlated with complex surgery with adjusted odds ratio of 1.5 (95% confidence interval: 1.10-2.06, P = 0.012) for each millimeter. The number of preoperative ERCPs and CBD diameter in choledocholithiasis patients are strong predictors of the need for open surgery and CBD exploration and should be considered in surgical planning and consent for patients requiring more than one ERCP procedure.

How do we manage post-OLT redundant bile duct?

To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a "redundant bile duct" (RBD). Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stones-sludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention. One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twenty-one out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%) non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review. Although surgical biliary reconstruction techniques have improved, RBD represents a post-OLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.

Combined brush cytology and stent placement in a single session for presumed malignant biliary stricture

Biliary stricture may be benign or malignant and causes obstructive jaundice. Brush cytology is a simple technique for diagnosing the cause of biliary stricture; however, its sensitivity has been reported to be low. A technique that comprises diagnosing the cause of stricture with a satisfactory sensitivity and relieving jaundice is required. This study was designed to evaluate the diagnostic performance of brush cytology and the feasibility of the subsequent stent placement in a single endoscopic retrograde cholangiopancreatography (ERCP) session performed for presumed malignant biliary strictures. Data were collected by reviewing the medical records of 100 consecutive patients with suspected malignant biliary stricture who underwent brush cytology followed by stent placement at our center. Diagnostic performance of brush cytology, completion rate of the whole procedures comprising brush cytology and stent placement, and complications were evaluated. Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of brush cytology were 83%, 100%, 100%, 33% and 84%, respectively. Biliary stent was successfully inserted for all patients (100%) subsequent to brush cytology in a single ERCP session. Eight patients (8%) had complications. Brush cytology was performed with much higher sensitivity of 83% than those of previous reports and the subsequent stent placement was successfully completed in all cases. For presumed malignant biliary stricture, brush cytology should be selected as an initial attempt because this technique is simple and enables subsequent stent placement in a single ERCP session.

Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones

Endoscopic sphincterotomy (EST) for the removal of bileduct stones is associated with acute complications and a permanent loss of biliary-sphincter function. Endoscopic balloon dilation (EBD) causes less trauma to the biliary sphincter, but may be less effective in allowing stone removal. 218 consecutive patients with bileduct stones on endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. 202 who met all eligibility criteria were randomly assigned EST or EBD. The patients were observed in hospital for at least 24 h and followed up at 1 month and 6 months. Complications were classified by an expert panel unaware of treatment allocation and outcome. Analysis was done by intention to treat. After a single ERCP, all stones were removed from 92 (91%) of 101 patients assigned EST and 90 (89%) of 101 assigned EBD (p = 0.81); in nine of the latter, successful removal required additional EST. Mechanical lithotripsy was used to fragment stones in 31 EBD procedures and 13 EST procedures (p < 0.005). Early complications (before 15 days) occurred in 24 EST patients and 17 EBD patients (p = 0.29). One patient died of retroperitoneal perforation after EBD. Four patients had bleeding after EST. Seven patients in each group had pancreatitis. Complications during follow-up occurred in 23 EST patients and 18 EBD patients (p = 0.48). Acute cholecystitis was observed in seven EST patients and one EBD patient (p < 0.05). The success rate of EBD was similar to that of EST. We found there is no evidence of the previously suggested higher risk of pancreatitis with EBD and suggest that EBD is preferred in patients at risk of bleeding after EST. Preservation of biliary-sphincter function after EBD may prevent long-term complications and reduce the risk of acute cholecystitis during follow-up. This procedure is a valuable alternative to EST in patients with bileduct stones.