Use Of Endoscopic Sphincterotomy Research Articles

Su1575 DISTAL BILIARY STENT MIGRATION IN PATIENTS WITH IRRETRIEVABLE COMMON BILE DUCT STONES: A RETROSPECTIVE COMPARISON BETWEEN STRAIGHT AND DOUBLE-PIGTAIL STENTS

Migration of biliary stents is a well-documented problem. Different types of plastic stents (straight or double-pigtail) are used for biliary drainage in patients with irretrievable common bile duct stones (ICBDS). Due to their physical characteristics, double-pigtail stents are expected to migrate less frequently; however, comparisons remain scarce. We aimed to compare the distal migration rate between patients who received either straight or double-pigtail stents in the biliary drainage of ICBDS. Consecutive patients with ICBDS who received plastic biliary stents at the Venizeleio General Hospital between 2009 and 2019 were retrospectively reviewed. Distal migration was confirmed on follow-up endoscopy when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Among 4524 ERCPs, a total of 618 biliary plastic stent placement procedures (410 patients) were performed for ICBDS: 289 (46.8%) with a straight stent (Group A) and 329 (53.2%) with a double-pigtail stent (Group B). No significant differences were observed between the two groups concerning age, gender, bile duct diameter, placement of single vs multiple biliary stents, as well as use of endoscopic sphincterotomy and balloon sphincteroplasty. The median time period of repeated endoscopy was 7 months (IQR 4-12 months). The rate of distal stent migration was 17.3% (50/289) in group A and 27.4% (90/329) in group B (p=0.003). By Kaplan-Meier analysis (Figure), freedom from distal stent migration was 91.6% and 82.7% at 6 months, 78.6% and 72.3% at 12 months, and 73% and 55% at 18 months, for groups A and B respectively (P=0.004, log-rank). Contrary to common perception, pigtail stents are more likely to migrate distally compared with straight stents in patients with ICBDS.

Early adverse events and long-term outcomes of endoscopic sphincterotomy in a pediatric population: a single-center experience.

Background and aims: The use of endoscopic sphincterotomy (EST) in the management of pancreaticobiliary disease in children is increasing. However, studies of long-term outcomes are limited in pediatric patients. Therefore, this study evaluated the early adverse events and long-term outcomes following EST in pediatric patients. Patients and methods: We retrospectively analyzed data from 198 pediatric patients who underwent ESTs at Asan Medical Center Children's Hospital between 1994 and 2013. The median age was 8.7 years (range 18 months to17 years). We evaluated the indications, success rates, early adverse events, and long-term outcomes. Results: Long-term information was available in 198 patients with a median follow-up duration of 42 months (range, 1.8 - 232.1 months). Early adverse events (< 30 days) following 294 ESTs among 198 patients included pancreatitis in 17 (5.7 %), hemorrhages in 6 (2.0 %), sepsis in 3 (1.0 %), and perforations in 2 (0.7 %). Long-term complications ( > 30 days) developed in 12 patients (6.1 %), including cholangitis with or without bile duct stone (n = 7), and minor papilla restenosis (n = 5). The cumulative incidence rates of long-term complications were 3.1 %, 6.1 %, 9.3 %, and 9.3 %, at 1, 5, 10, and 15 years. There were no procedure-related pancreaticobiliary malignancies or deaths. All adverse events and long-term complications improved with appropriate management. Conclusions: In pediatric patients with pancreaticobiliary disease, EST has a high level of technical success. In addition, pediatric EST showed low rates of early adverse events and long-term complications, which could be managed safely. Our results suggest that EST is a safe method for treating pancreaticobiliary disease, even in the pediatric population.

Sa1661 Long Term Outcome of Endoscopic Sphincterotomy for Pancreaticobiliary Diseases in Pediatric Patients: a Single-Center Experience

The use of endoscopic sphincterotomy (ES) is increasing in the treatment of pancreaticobiliary disease in children. However, long-term results of ES are limited in pediatric patients. The aim of this study was to assess demographic characteristics, indications, long-term outcome of ES for pancreaticobiliary diseases in pediatric patients.

Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases. In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated. SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups. ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

Acute pancreatitis caused by impaction of hydatid membranes in the papilla of Vater: a case report.

Acute pancreatitis is a rare complication of hydatidosis and the successful use of endoscopic sphincterotomy associated with extraction of hydatid membranes has been rarely reported. We describe a young man who developed acute pancreatitis after rupture of an echinococcus cyst, located at the left hepatic lobe, into the biliary tract. The cause of pancreatitis was confirmed by endoscopic retrograde cholangiopancreatography, which revealed the presence of a daughter cyst impacted in the major papilla. After sphincterotomy and removal of hydatid membranes from the biliary tract, the patient presented rapid resolution of pancreatitis and made an uneventful recovery.

Endoscopic sphincterotomy in young patients with choledochal dilatation and a long common channel: a preliminary report.

An anomalous elongated pancreaticobiliary common channel encourages reflux up both the biliary tree and the pancreatic ductal system, resulting in progressive choledochal dilatation, cholangitis with ductal calculi, relapsing pancreatitis and malignant change. Transduodenal sphincteroplasty has been used to improve drainage from the abnormal channel. The use of endoscopic sphincterotomy (ES) to establish drainage and minimize the surgical risks is reported in six symptomatic patients with mild choledochal dilatation (common bile duct diameter less than 15 mm), a common channel less than 15 mm in length and a distal stenosis. This was successful in five patients, who have no further symptoms. ES failed in the only patient with an undilated common channel and this patient went on to have open surgery. We believe ES to be safe and effective in the treatment of selected cases of long common channel.

Acute pancreatitis complicating intrabiliary rupture of liver hydatid cyst

Acute pancreatitis is a rare complication of hydatidosis, and the successful use of endoscopic sphincterotomy in the treatment of pancreatitis complicating ruptured hydatid cyst has been very rarely reported.We report here a case of a 50-year-old man, known to have hydatid cyst of the liver, who presented with upper abdominal pain. Amylase and lipase were elevated and echinococcus serology was positive. Abdominal CT scan showed a cystic lesion in the right lobe of the liver and a diffusely swollen pancreas with indurations around it. At endoscopic retrograde cholangiopancreatography (ERCP) the common bile duct was dilated. A sphincterotomy was performed and a mucoid structure was extracted, after which the patient made an uneventful recovery.

Biliary sphincterotomy: less benign than once thought?

Twenty-five years ago, Classen and Kawai, working independently, reported the first use of endoscopic sphincterotomy. Since that time, thousands of patients have undergone this procedure. The immediate risks of sphincterotomy, including pancreatitis, bleeding, perforation, and infection, are well documented. However, the long-term complications of ablating the sphincter of Oddi are poorly understood. It is becoming clear that exposing the biliary tree to duodenal contents is far from benign. Recently reported long-term complications of sphincterotomy include stone formation, cholecystitis, sphincterotomy site stenosis (with recurring cholangitis), and, possibly, an increased risk of cholangiocarcinoma. Balloon dilation of the duodenal papilla (balloon sphincterplasty) has been shown to carry unacceptable risk of serious and even fatal pancreatitis. Medical dilation of the papilla is rarely helpful. Consequently, endoscopists must reevaluate their use of endoscopic sphincterotomy in light of long-term complications in the data.

Are complications of endoscopic sphincterotomy age related?

Editor,—Deans et al ( Gut 1997; 41 :545–8) have supported the use of endoscopic sphincterotomy for bile duct stones in young people in preference to laparoscopic bile duct exploration. They do this because sphincterotomy causes no more complications in young than in old people. Any comparison between the two methods must also take into account the complications, particularly pancreatitis, that occurred in the remaining two-thirds of the patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) without sphincterotomy. Laparoscopic duct exploration is still a relatively new technique. Rhodes et al reported 129 explorations with one case of postoperative pancreatitis.1 We have had no pancreatitis in 53 explorations. Until larger series are reported judgement is impossible. For the treatment of bile duct stones a comparison of therapeutic success and the manoeuvres required to achieve it are required on an intention-to-treat basis. The consequences of sphincterotomy and reflux in the very long term are not known. Most bile duct stones are predominantly composed of pigment, thought to be … Mr Deans.

Complications of Endoscopic Sphincterotomy

The four most frequent complications of endoscopic sphincterotomy—bleeding, pancreatitis, perforation, and infection—are presented according to their frequency of occurrence. Prevention of complications (if possible), recognition, and management are discussed in detail and appropriate tables are presented to aid in the treatment of these complications. Despite the widespread use of endoscopic sphincterotomy, the complication rate has not increased.