Successful Biliary Drainage Research Articles

Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction

A 6F endoscopic biliary self-expanding metal stent (SEMS) has been newly introduced for intended simultaneous side-by-side bilateral deployment in hilar malignant obstruction. To report our initial experience with the Zilver 635 biliary SEMS. Retrospective chart review. Tertiary referral medical center. Sixteen consecutive malignant hilar biliary obstruction patients. Endoscopic palliative treatment of malignant biliary obstruction with the Zilver 635 SEMS from December 2008 to January 2010. Technical/functional success rates, early complications (within 30 days of stent placement), early/late stent occlusion, and biliary reintervention rates. A total of 49 Zilver SEMSs were placed in 16 patients (mean age 61 years, 6 men) for Bismuth type II (n = 4), III (n = 5), and IV (n = 7) lesions. Twelve had cholangiocarcinoma, 2 had metastatic colon cancer, 1 had lung cancer, and 1 had pancreatic cancer. The technical success rate was 100%. Side-by-side simultaneous bilateral stent deployment was required and was achieved successfully in 10 cases. Additional transpapillary stents were placed for potential future biliary access. The 30-day mortality rate was 0%. There were 1 early (6%) and 3 late (19%) stent occlusions. Successful overall biliary drainage was 75%. Small sample size, uncontrolled retrospective study. Malignant hilar biliary obstruction endoscopic palliation with the Zilver 635 SEMS offers acceptable initial feasibility, safety, and efficacy profiles. The current design facilitates smaller bile duct negotiation and more precise intrahepatic placement. Expanding available lengths would allow transpapillary bridged bilateral SEMS placement for future reobstructed biliary access. Further long-term studies are required for comparative outcomes with other current SEMS technology.

S1251 Short-Term Antibiotic Therapy for Acute Cholangitis After Successful Endoscopic Biliary Drainage

S1251 Short-Term Antibiotic Therapy for Acute Cholangitis After Successful Endoscopic Biliary Drainage

Symptomatic portal biliopathy: a single centre experience from the UK

Biliary obstruction as a consequence of portal biliopathy, because of extrahepatic portal vein occlusion is an uncommon cause of biliary disease in the western world. We reviewed all patients presenting to the Regional Liver Transplant Unit in Birmingham, UK with symptomatic portal biliopathy between 1992 and 2005 and report the presentation, investigation, management and outcome of these complex patients. Thirteen patients with symptomatic portal biliopathy were followed up for a median of 2 years (range 1-18 years). Jaundice was the presenting feature in all cases and was associated with bile duct stones or debris in 77% (10 of 13) of cases. Successful treatment of biliary problems was achieved by biliary decompression in six cases (metallic stent=three, plastic stent=one, combined procedure=one and sphincterectomy=one) and portal decompression in three cases (transjugular intrahepatic portosystemic shunt=two, meso-caval shunt=one). Successful biliary drainage could not be achieved endoscopically or by portal decompression in one case that was accepted for combined liver and small bowel transplantation. Three patients had spontaneous resolution without recurrence over the follow-up period. Ten patients (77%) experienced gastrointestinal bleeding. Two deaths over the follow-up period occurred; both were associated with portal hypertensive bleeding. Endoscopic management (sphincterectomy and stone extraction or stent insertion) is effective initial therapy for patients with symptomatic portal biliopathy. In the case of persistent biliary obstruction porto-systemic shunting (transjugular intrahepatic portosystemic shunt or surgical) should be considered, however, the extent of vascular thrombosis precludes this in most cases.

Extrahepatic Cholestasis Increases Liver Stiffness (Fibroscan®) Irrespective of Fibrosis

Aims: Transient elastography [Fibroscan (FS)] is a novel non-invasive tool to assess liver fibrosis/cirrhosis. However, it remains to be determined if other liver diseases such as extrahepatic cholestasis interfere with fibrosis assessment since liver stiffness is indirectly measured by the propagation velocity of an ultrasound wave within the liver. Methods and Results: In this study we measured liver stiffness immediately before ERCP and 3 to 12 days after successful biliary drainage in patients with extrahepatic cholestasis due to benign or malignant bile duct obstruction. Initially elevated liver stiffness decreased in 13 of 15 patients after intervention, in 10 of them markedly. In 3 patients, liver stiffness was elevated to a degree that suggested advanced liver cirrhosis (mean 15.2 kPa). Successful drainage led to a drop of bilirubin by 2.8 to 9.8mg/dL while liver stiffness almost normalized (mean 7.1 kPa). In all patients with successful biliary drainage, the decrease of liver stiffness highly correlated with decreasing bilirubin (Spearman’ rho=0.67, P<0.05) with a mean decrease of liver stiffness of 1.2±0.56 kPa per 1g/dl bilirubin. Two patients, in whom liver stiffness did not decrease despite successful biliary drainage, had advanced liver cirrhosis and multiple liver metastases, respectively. The relationship between bile duct obstruction and liver stiffness was reproduced in an animal model of bile duct ligation in landrace pigs where liver stiffness increased from 4.6 kPa to 8.8 kPa during 120 min of bile duct ligation and decreased to 6.1 kPa within 30 min after decompression. Conclusion: Extrahepatic cholestasis increases liver stiffness irrespective of fibrosis. Once extrahepatic cholestasis is excluded e.g. by liver imaging and laboratory parameters, transient elastography is a valuable tool to assess liver fibrosis in chronic liver diseases.

Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of fibrosis

Transient elastography (FibroScan [FS]) is a novel non-invasive tool to assess liver fibrosis/cirrhosis. However, it remains to be determined if other liver diseases such as extrahepatic cholestasis interfere with fibrosis assessment because liver stiffness is indirectly measured by the propagation velocity of an ultrasound wave within the liver. In this study, we measured liver stiffness immediately before endoscopic retrograde cholangiopancreatography and 3 to 12 days after successful biliary drainage in patients with extrahepatic cholestasis mostly due to neoplastic invasion of the biliary tree. Initially elevated liver stiffness decreased in 13 of 15 patients after intervention, in 10 of them markedly. In three patients, liver stiffness was elevated to a degree that suggested advanced liver cirrhosis (mean, 15.2 kPa). Successful drainage led to a drop of bilirubin by 2.8 to 9.8 mg/dL whereas liver stiffness almost normalized (mean, 7.1 kPa). In all patients with successful biliary drainage, the decrease of liver stiffness highly correlated with decreasing bilirubin (Spearman's rho = 0.67, P < 0.05) with a mean decrease of liver stiffness of 1.2 +/- 0.56 kPa per 1 g/dL bilirubin. Two patients, in whom liver stiffness did not decrease despite successful biliary drainage, had advanced liver cirrhosis and multiple liver metastases, respectively. The relationship between extrahepatic cholestasis and liver stiffness was reproduced in an animal model of bile duct ligation in landrace pigs where liver stiffness increased from 4.6 kPa to 8.8 kPa during 120 minutes of bile duct ligation and decreased to 6.1 kPa within 30 minutes after decompression. Extrahepatic cholestasis increases liver stiffness irrespective of fibrosis. Once extrahepatic cholestasis is excluded (e.g., by liver imaging and laboratory parameters) transient elastography is a valuable tool to assess liver fibrosis in chronic liver diseases.

17 Extrahepatic Cholestasis Increases Liver Stiffness (Fibroscan ®) Irrespective of Fibrosis

Transient elastography (FibroScan [FS]) is a novel non-invasive tool to assess liver fibrosis/ cirrhosis. However, it remains to be determined if other liver diseases such as extrahepatic cholestasis interfere with fibrosis assessment because liver stiffness is indirectly measured by the propagation velocity of an ultrasound wave within the liver. In this study, we measured liver stiffness immediately before endoscopic retrograde cholangiopancreatography and 3 to 12 days after successful biliary drainage in patients with extrahepatic cholestasis mostly due to neoplastic invasion of the biliary tree. Initially elevated liver stiffness decreased in 13 of 15 patients after intervention, in 10 of them markedly. In three patients, liver stiffness was elevated to a degree that suggested advanced liver cirrhosis (mean, 15.2 kPa). Successful drainage led to a drop of bilirubin by 2.8 to 9.8 mg/dL whereas liver stiffness almost normalized (mean, 7.1 kPa). In all patients with successful biliary drainage, the decrease of liver stiffness highly correlated with decreasing bilirubin (Spearman’s 0.67, P < 0.05) with a mean decrease of liver stiffness of 1.2 0.56 kPa per 1 g/dL bilirubin. Two patients, in whom liver stiffness did not decrease despite successful biliary drainage, had advanced liver cirrhosis and multiple liver metastases, respectively. The relationship between extrahepatic cholestasis and liver stiffness was reproduced in an animal model of bile duct ligation in landrace pigs where liver stiffness increased from 4.6 kPa to 8.8 kPa during 120 minutes of bile duct ligation and decreased to 6.1 kPa within 30 minutes after decompression. Conclusion: Extrahepatic cholestasis increases liver stiffness irrespective of fibrosis. Once extrahepatic cholestasis is excluded (e.g., by liver imaging and laboratory parameters) transient elastography is a valuable tool to assess liver fibrosis in chronic liver diseases. (HEPATOLOGY 2008;48:1718-1723.)

Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica

Background and objective: endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. A large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. Patients and methods: a retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. Results: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). Conclusions: the geriatric population showed similar success and morbidity & mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.

Endoscopic management of acute cholangitis in elderly patients

To evaluate clinical presentation, etiology, complications and response to treatment in elderly patients with acute cholangitis. Demographics, etiology of biliary obstruction, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. Of 175 patients, 52 aged >or=60 years (group I, age<60 years; group II, age>or=60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in group I. High fever (fever >or=38.0 degrees C) was more common in group I (118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n=34) and benign diseases in group I (n=120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of >or=38.0 degrees C (n=136), hypotension (n=18), peritonism (n=36), altered sensorium (n=22), and failure to improve within 72 h of conservative management (n=22). High grade fever was more common indication of biliary drainage in group I and hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 group I, 24 group II, stent: 64 group I, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in group I (2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in group I compared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n=3, CBD stones n=2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4+/-5.6, 7-30 d) than in group I patients (8.2+/-2.4, 7-20 d). Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.

Complications infectieuses précoces au cours des drainages biliaires percutanés transhépatiques

Purpose To evaluate the prevalence, severity and outcome of cholangitis within two months after percutaneous transhepatic biliary drainage. Materials and methods One hundred and nineteen patients with obstructive jaundice but no septic symptoms underwent biliary drainage for biliary decompression. Biliary obstruction was malignant in 87 patients and benign in 32 patients. Clinical and biological criteria were developed to confirm and grade the cholangitis. Based on these, the prevalence, severity and outcome of cholangitis was determined and analysed through review of clinical records. Results All patients had successful biliary drainage and internal drainage. Nine patients (7.5%) developed cholangitis after biliary drainage, three (2.5%) being of the severe type. Of these, 8 had malignant obstruction. All three patients with severe cholangitis had malignant obstruction. All patients with cholangitis except one (0.8%) responded to antibiotic and supportive therapy. Conclusion Severe cholangitis occurring within two months following PBD for obstructive jaundice was uncommon. It tended to occur in patients with malignant obstruction. Although most responded favorably to medical treatment, post procedural sepsis must be handled with great care since it is life-threatning.

Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis.

In selected patients with chronic pancreatitis in whom conventional plastic stenting fails and in whom surgery is contraindicated or declined, insertion of a biliary self-expanding metal stent (SEMS) may be a valuable treatment option. Between 1994 and 1999, 13 patients with chronic pancreatitis received SEMS for benign biliary strictures (four women and nine men; mean age 56). The indications for SEMS placement were: contraindication to surgery (n = 10), presumed inoperable pancreatic carcinoma (n = 1), concomitant unresectable lung cancer (n = 1), and declined surgery (n = 1). The success of treatment was defined as adequate biliary drainage due to SEMS therapy. The mean follow-up period was 50 months (range 6 days - 86 months). Nine patients (69 %) were successfully treated with SEMS therapy: a patent first SEMS (n = 5); a patent second SEMS inserted through the first SEMS (n = 3); and one patent SEMS after balloon cleaning. SEMS treatment was not successful in four patients (due to stent migration in one case and occlusion in three ). The mean patency period of the SEMS was 60 months (95 % CI, 43 months - 77 months). At 33 months, the probability of adequate biliary drainage with SEMS therapy was 75 %. SEMS therapy was safe and provided successful and prolonged biliary drainage in a selected group of patients with benign biliary strictures due to chronic pancreatitis in whom surgical intervention was not possible or desirable.

Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life.

Endoscopic decompression is used for palliation of patients with malignant biliary obstruction. Little is known of its effect on quality of life. The aims of this study were to determine clinical characteristics that have the greatest adverse impact on quality of life in patients with malignant biliary obstruction, and to quantify changes in the quality of life of patients with malignant biliary obstruction after successful decompression with a plastic stent. Patients with malignant biliary obstruction without liver metastases considered nonsurgical candidates and referred to a tertiary university medical center for palliative endoscopic decompression were sequentially enrolled in this prospective cohort study. The SF-36 Health Survey questionnaire at baseline and 1 month after stent insertion was used to quantify quality of life. Results were correlated to clinical and laboratory parameters. Multivariate analyses were carried out to determine independent predictors of baseline quality of life and improvement after stent insertion. Fifty patients (20 men, 30 women; mean [SD] age 72.6 [10.6] years) with a mean weight of 62.4 (12.9) kg and mean body mass index of 23.4 (4.3) kg/m(2) were enrolled. Two thirds had a distal malignant lesion, 12.5% had mid bile duct obstruction, and the rest either hilar or intrahepatic cholangiocarcinoma. At baseline, 70% complained of pruritus and 98% were jaundiced (mean total bilirubin 15 [7] mg/dL). Mean duration of symptoms before decompression was 23 (25) days. Weight loss, and elevated bilirubin level had the greatest impact on baseline quality of life domains in both univariate and multivariate analysis. After biliary drainage, complete follow-up information was available for 51% of the initial cohort. Among these 26 patients, a 33% improvement in bilirubin level was documented in 84% of patients and was associated with significant improvements in social function (relative risk = 0.11; 95% CI [0.03, 0.19]) and mental health (relative risk = 0.036; 95% CI [0.011, 0.08]). A baseline bilirubin of greater than 14 mg/dL was associated with lack of improvement in social function at 1-month follow-up (p = 0.03). Weight loss and hyperbilirubinemia are strongly predictive of poor quality of life before endoscopic decompression. Successful biliary drainage after stent insertion is associated with improvements in quality of life, although this is less true among patients with a baseline bilirubin over 13 mg/dL. These results may lead to better selection of patients for palliative biliary decompression and require prospective validation.

Palliation of malignant biliary obstruction: A prospective trial examining impact on quality of life

Background: Endoscopic decompression is used for palliation of patients with malignant biliary obstruction. Little is known of its effect on quality of life. The aims of this study were to determine clinical characteristics that have the greatest adverse impact on quality of life in patients with malignant biliary obstruction, and to quantify changes in the quality of life of patients with malignant biliary obstruction after successful decompression with a plastic stent. Methods: Patients with malignant biliary obstruction without liver metastases considered nonsurgical candidates and referred to a tertiary university medical center for palliative endoscopic decompression were sequentially enrolled in this prospective cohort study. The SF-36 Health Survey questionnaire at baseline and 1 month after stent insertion was used to quantify quality of life. Results were correlated to clinical and laboratory parameters. Multivariate analyses were carried out to determine independent predictors of baseline quality of life and improvement after stent insertion. Results: Fifty patients (20 men, 30 women; mean [SD] age 72.6 [10.6] years) with a mean weight of 62.4 (12.9) kg and mean body mass index of 23.4 (4.3) kg/m 2 were enrolled. Two thirds had a distal malignant lesion, 12.5% had mid bile duct obstruction, and the rest either hilar or intrahepatic cholangiocarcinoma. At baseline, 70% complained of pruritus and 98% were jaundiced (mean total bilirubin 15 [7] mg/dL). Mean duration of symptoms before decompression was 23 (25) days. Weight loss, and elevated bilirubin level had the greatest impact on baseline quality of life domains in both univariate and multivariate analysis. After biliary drainage, complete follow-up information was available for 51% of the initial cohort. Among these 26 patients, a 33% improvement in bilirubin level was documented in 84% of patients and was associated with significant improvements in social function (relative risk = 0.11; 95% CI [0.03, 0.19]) and mental health (relative risk = 0.036; 95% CI [0.011, 0.08]). A baseline bilirubin of greater than 14 mg/dL was associated with lack of improvement in social function at 1-month follow-up ( p = 0.03). Conclusions: Weight loss and hyperbilirubinemia are strongly predictive of poor quality of life before endoscopic decompression. Successful biliary drainage after stent insertion is associated with improvements in quality of life, although this is less true among patients with a baseline bilirubin over 13 mg/dL. These results may lead to better selection of patients for palliative biliary decompression and require prospective validation. (Gastrointest Endosc 2002;56:835-41.)

Duration of Antibiotic Therapy for Cholangitis After Successful Endoscopic Biliary Drainage

The mainstay of therapy for patients with acute cholangitis is drainage of an obstructed biliary tree. Antibiotic administration is a complementary

Biliary guidewire facilitates bile duct biopsy and endoscopic drainage.

The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage. Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively. The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure. A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

Background: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. Methods: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. Results: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 ± 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period ( P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. Conclusions: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Urgent endoscopic nasobiliary drainage without fluoroscopic guidance: A useful treatment for critically ill patients with biliary obstruction

Background: Endoscopic nasobiliary drainage (ENBD) is routinely performed under fluoroscopic control. This is a report of our experience with urgent ENBD without fluoroscopic guidance in critically ill patients. Methods: Twenty-six critically ill patients who underwent urgent ENBD for biliary obstruction were analyzed. ENBD was performed without fluoroscopic control because of high risk of transportation or inaccessibility of the x-ray facilities. A pig-tailed nasobiliary catheter was inserted into the bile duct with the help of a guidewire under endoscopic control to bypass the site of obstruction. Successful placement was confirmed by free flow of bile on aspiration via the nasobiliary catheter. Results: A nasobiliary catheter was successfully placed in 23 patients (88%). Adequate bile drainage was achieved in 20 patients with an overall success rate of 77%. There were no procedure-related complications. The mortality rate for patients with successful biliary drainage was 10% (2 of 20), in contrast to 83% (5 of 6) for the group in which drainage was unsuccessful. Conclusions: Urgent ENBD is effective for patients with biliary obstruction. With experience, this procedure may be successfully performed in critically ill patients without fluoroscopic guidance at primary care hospitals or intensive care units where fluoroscopic facilities are not readily available. (Gastrointest Endosc 2000;52:741-4.)

3395 Clinical usefulness of primary endoscopic choledochoduodenal fistulotomy in patients with ampullary cancer.

Background: In patients with ampullary cancer, the use of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) between the bulged suprapapillary intraduodenal part of the bile duct and the duodenum by needle-knife sphincterotome (NKS) has been reported sporadically as an alternative to failed bile duct cannulation and subsequent endocopic biliary drainage such as biliary stenting or endoscopic sphincterotomy (EST). However, endoscopic fistulotomy can be performed primarily, for both successful biliary drainage and avoidance of recurrent symptoms by possible stent dysfunction or fatal bleeding by EST, in patients especially with suprapapillary bulged, distorted, or friable to bleeding papilla causing failed endoscopic biliary drainage procedures. Aim: To evaluate safety and clinical usefulness of primary endoscopic fistulotomy in patients with ampullary cancer. Methods: Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients(44.8%) with suprapapillary bulged papilla underwent fistulotomy using NKS (HPC-2, Wilson-Cook Medical Co, NC) alone or followed by upward extension of the fistulous orifice using standard sphincterotome (fistulotomy group). The remaining 16 patients underwent transpapillary stenting with standard techniques (transpapillary stenting group). In both groups, the success rate of bile duct cannulation and effective biliary drainage was assessed and compared. Results: Bile duct cannulation was successful in 12 patients (92.3%) of the fistulotomy group and 13 patients (81.3%) of the transpapillary stenting group (p>0.05), and complication was mild bleeding in 1 patient (7.7%) and cholangitis by stent occlusion in 1 patient (6.3%), respectively (p>0.05). The success rate of initial biliary drainage by endoscopic fistulotomy and transpapillary stenting was 100% and 84.6% (p>0.05), respectively. In 13 patients, biliary drainage was used as a definite treatment and the symptom-free duration was 3.2 months in 7 patients (52.8%)of the fistulotomy group and 3.9 months in 6 patients (37.5%) of the transpapillary stenting group (p>0.05). Conclusions: Endoscopic fistulotomy is as effective as transpapillary stenting in preoperative or palliative decompression of the obstructed bile duct due to the ampullary cancer. Without the need of biliary stenting, this can be employed primarily with safety in selective patitients when bulged suprapapillary intraduodenal part of the bile duct is observed definitely.

7243 Endoscopic retrograde cholangiopancreatography (ercp) in roux-en-y anastomosis or whipple surgery patients: eight-year experience from a large tertiary care center.

Reaching major papilla and performing cannulation of the pancreatic and bile duct in the setting of Roux-en-Y anastomosis or Whipple surgery is considered one of the most technically challenging anatomic variants in patients (pts) with symptomatic pancreaticobiliary disease. AIM: To describe eight-year ERCP experience in Roux-en-Y anastomosis or Whipple surgery pts from a large tertiary care center. METHODS: Nineteen consecutive pts (10-male, 9-female, age range 38-79) with Rouxen-Y anastomosis or Whipple surgery presented over a eight-year period had an attempted ERCP. Thirteen (70%) of pts had Roux-en-Y anastomosis while 6 pts had undergone Whipple surgery. Indications for ERCP were obstructive jaundice (n=5), cholangitis (n=3), suspected choledocholithiasis (n=5), abdominal pain (n=3), dilated pancreatic duct (n=2), and chronic pancreatitis (n=1). RESULTS: Successful bile duct cannulation could be achieved in only 8 (47%) of the 17 pts. Six out of 13 (46%) Roux-en-Y anastomosis pts had successful ERCP (5 of 6 with the use of diagnostic duodenoscope),while only 2 out of 6 (33%) Whipple surgery pts had successful ERCP. Major papilla could not be reached in 8 pts (88%) in whom ERCP was unsuccessful. In one patient with Whipple surgery a pancreatogram could not be obtained because of inability to locate enteropancreatic anastomosis. Two Roux-en-Y anastomosis pts who had successful cannulation, common bile duct stones were removed, one patient with Whipple surgery had a plastic stent placed across a choledochojejunostomy stricture, one patient with a Roux-en-Y anastomosis underwent sphincter of Oddi manometry and in one Roux-en-Y anastomosis patient a plastic stent was placed in an occluded wallstent. Diagnostic duodenoscope was the most commonly used instrument (n=11), followed by pediatric colonoscope (n=7). One patient had a small intestinal perforation requiring surgery. All pts with obstructive jaundice and cholangitis (n=5) who had unsuccessful ERCP underwent subsequent successful percutaneous transhepatic biliary drainage. Conclusions: Success rate in performing ERCP in Roux-en-Y anastomosis or Whipple surgery pts is low despite a high level of endoscopic expertise. Both side viewing duodenoscopes and forward viewing colonoscopes can be used in an attempt to reach the major papilla in pts with Roux-en-Y anastomosis, although the instrument of choice remains the former.

Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures

BACKGROUNDMagnetic resonance cholangiography (MRC) is currently under investigation for non-invasive biliary tract imaging.AIMTo compare MRC with endoscopic retrograde cholangiography (ERC) for pretreatment evaluation of malignant hilar obstruction.METHODSTwenty patients (11 men,...

Stenting or surgery for treatment of irretrievable common bile duct calculi in elderly patients?

Background: The value of endoprostheses for long-term management of bile duct stones has not been formally established. We retrospectively compared the results of this method versus surgical approach in elderly patients (>70 years) with endoscopically irretrievable bile duct stones. Methods: From January 1990 to September 1998, 68 patients over 70 years old underwent endoscopic biliary stenting (group A: 31 patients) or surgery (group B: 37 patients) for endoscopically irretrievable bile duct stones. The groups were similar with regard to gender, age, clinical presentation, ASA score, and number and size of the stones. Results: Successful biliary drainage was achieved in 31 of 31 patients of group A and 37 of 37 patients of group B. Early complications occurred in 12.9% of group A versus 29.7% of group B ( P <0.005) and early mortality was 0% in group A versus 2.7% of group B ( P = NS). Over the long-term follow-up, late complications occurred in 35.5% of group A versus 8.1% of group B ( P <0.001). Three cases of biliary-related death occurred in group A versus 0 in group B (9.6% versus 0%: P <0.005). Conclusions: For immediate bile duct drainage endoprostheses proved a safe and effective alternative to surgery in elderly patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, their use as a definitive treatment should be restricted to highly selected cases.