Endoscopic Management of Postoperative Bile Duct Injuries: A Single Center Experience

Background/Aim:

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI.

Patients and Methods:

Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared.

Results:

The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%).

Conclusions:

Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.     

Comparative Study on Presentation of Biliary Ascariasis with Dead and Living Worms

Background/Aim:

Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms.

Materials and Methods:

We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests.

Results:

The age (mean ± SD) of the patients was 36.8 ± 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms.

Conclusion:

Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.     

Increased liver stiffness in extrahepatic cholestasis caused by choledocholithiasis

Background

Extrahepatic cholestasis that is caused by benign and malignant diseases has been reported to increase liver stiffness (LS), as measured by transient elastography (TE).

Objectives

The aim of this study was to evaluate LS in patients with extrahepatic cholestasis due to choledocholithiasis before and after endoscopic sphincterotomy and stone removal.

Patients and Methods

LS was measured by TE (Fibroscan) in patients with extrahepatic cholestasis that was caused by choledocholithiasis before and 1 month after endoscopic sphincterotomy and successful stone removal.

Results

We studied 12 patients (7 females, 5 males), aged 36 to 76 years (mean age 57.1 ± 11.6 years), with extrahepatic cholestasis that was caused by choledocholithiasis. LS was increased in all patients (range: 6.2-18.4 kPa; mean: 8.9 ± 3.5 kPa) before endoscopic therapy. Successful biliary drainage was effected by sphincterotomy and stone removal in all patients, which led to a significant decline in LS to 3.9-8.1 kPa (Mean: 5.6 ± 1.2 kPa; p < 0.001) within a mean observation time of 29 days. The decrease in LS values correlated significantly with a decline in serum total bilirubin levels (r = 0.691; p < 0.0001).

Conclusions

Extrahepatic cholestasis due to choledocholithiasis increases LS and should be excluded before assesing liver fibrosis by transient elastography.     

Sequential Double-Guidewire Technique and Transpancreatic Precut Sphincterotomy for Difficult Biliary Cannulation

Background/Aims:

The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK).

Patients and Methods:

Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed.

Results:

DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).

Conclusions:

Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.     

Outcome of Laparoscopic Cholecystectomy at a Secondary Level of Care in Saudi Arabia

Background/Aim:

The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care.

Patients and Methods:

Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m²), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

Results:

Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients).

Conclusion:

Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.     

Endoscopic treatment of persistent thoracobiliary fistulae after penetrating liver trauma

Background:

This study evaluated the outcomes of patients with complex or persistent thoracobiliary fistulae following penetrating liver trauma, who underwent endoscopic biliary intervention at a tertiary referral centre.

Methods:

All patients who underwent endoscopic retrograde cholangiography (ERC) and endoscopic biliary intervention for traumatic thoracobiliary fistulae between 1992 and 2008 were evaluated. Bile duct injuries were classified according to their biliary anatomic location on cholangiography and type of pulmonary communication.

Results:

Twenty-two patients had thoracobiliary (pleurobiliary, n = 19; bronchobiliary, n = 3) fistulae. The site of the bile duct injury was identified in 20 patients on cholangiography. These 20 patients underwent either sphincterotomy and biliary stenting (n = 18) or sphincterotomy alone (n = 2). In 17 patients the fistulae resolved after the initial endoscopic intervention. Three patients required secondary stenting with replacement of the initial stent. Three patients developed mild pancreatitis after stenting and one stent migrated and was replaced. All fistulae healed after endoscopic treatment. In 18 patients the stents were removed 4 weeks after bile drainage ceased. Three of the 22 patients required a thoracotomy for infected loculated pleural collections after initial catheter drainage.

Conclusions:

Endoscopic retrograde cholangiography is an accurate and reliable method of demonstrating post-traumatic thoracobiliary fistulae and endoscopic biliary intervention with sphincterotomy and stenting in this situation is safe and effective. Surgery in patients with thoracobiliary fistulae should be reserved for fistulae which do not heal after endoscopic biliary stenting or for patients who have unresolved pulmonary or intra-abdominal sepsis as a result of bile leak.     

Bile Duct Injuries Following Laparoscopic Cholecystectomy: A Clinical Study

Background/Aim:

This study aimed at assessing the outcome of laparoscopic cholecystectomy (LC) by determining the frequency of complications, especially of bile duct injuries.

Materials and Methods:

The case files of all patients undergoing laparoscopic cholecystectomy between 2002 and 2006 (inclusive) at King Hussein Medical Center (KHMC) were retrospectively analyzed. We evaluated the data according to outcome measures, such as bile duct injury, morbidity, mortality and numbers of patients whose resections had to be converted from laparoscopic to open.

Results:

During the four years (January 2002 and December 2006), 336 patients underwent LC for chronic cholecystitis (CC), of whom 22 (6.5%) developed complications. Among those who developed complications, two patients had major bile duct injuries (0.4%); 43 other patients (12.8%) had planned laparoscopic operations converted to open cholecystectomy intra-operatively. None of the patients in this study died as a result of LC.

Conclusion:

Bile duct injury is a major complication of LC. Anatomical anomalies, local pathology, and poor surgical techniques are the main factors responsible. The two patients who had severe common bile duct injury in this study had major anatomical anomalies that were only recognized during surgery.     

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/Aims

Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.

Methods

Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.

Results

Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.

Conclusions

Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.     

“Post-cut”: An endoscopic technique for managing impacted biliary stone within an entrapped extraction basket

Background and study aims

Ampullary impaction of an entrapped stone-basket complex is not an infrequent yet challenging event during endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study is to evaluate the feasibility, safety, and efficacy of “post-cut” for the management of such scenarios.

Necessity of a repeat cholangiogram during biliary stent removal after postcholecystectomy bile leak

PURPOSE:

To assess the need for repeat endoscopic retrograde cholangiography (ERC) in patients undergoing biliary stent removal after management of postcholecystectomy bile leak.

METHODS:

A retrospective analysis of the Clinical Outcomes Research Initiative endoscopy database at PennState Milton S Hershey Medical Center (Hershey, Pennsylvania, USA) identified all patients referred for ERC with an indication of postcholecystectomy bile leak from January 2001 to June 2010. Baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC were analyzed.

RESULTS:

A total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One patient was excluded due to a complete transection of the common bile duct necessitating immediate surgical intervention. Fourteen (17.5%) patients underwent open cholecystectomy, 46 (57.5%) underwent laparoscopic procedures and 10 (12.5%) procedures were converted from a laparoscopic to an open approach intraoperatively. Of the 80 patients, 47 (58.7 %) had a cystic duct leak, 11 (13.7 %) had a right hepatic duct leak, 11 (13.7%) had a common bile duct leak, five (6.2%) had a gallbladder fossa leak, four (5%) had a common hepatic duct leak and the remaining two (2.5%) had a left hepatic duct leak. All 80 patients underwent biliary stenting as part of management for their bile leak. Fifty-seven of the 80 patients (71.2%) had a 10 Fr stent placed, with the remainder undergoing placement of a 7 Fr stent. Seventy-five (93.7%) patients underwent biliary sphincterotomy during the initial ERC. Sixty-nine patients underwent repeat ERC after a mean duration of 8.2 weeks (range 0.4 to 18.5 weeks). Eleven patients had no reviewable records regarding a repeat procedure performed for stent removal. Three patients required an early repeat ERC due to suspicion of cholangitis and, hence, were excluded from the final analysis. Of the 66 patients included in the final analysis, 61 (92.4%) had resolution of their bile leak on repeat ERC. All patients had resolution of their bile leak by the third ERC. Fifteen patients (22.7%) had an abnormality on repeat cholangiography (persistent leak in four, stones in three, sludge in seven, and a combination of leak and stone in one) that required further endoscopic intervention including balloon sweep or additional stenting.

CONCLUSION:

Although the majority of postcholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage (22.7%) of patients had abnormalities on subsequent cholangiograms that required further intervention. These findings suggest the need for a repeat ERC at the time of biliary stent removal in the management of postcholecystectomy bile leaks.     

Experience of Laparoscopic Cholecystectomy Under Spinal Anesthesia with Low-pressure Pneumoperitoneum - Prospective Study of 300 Cases

Introduction:

Having long experience of open upper abdominal surgery under spinal anesthesia and laparoscopic cholecystectomy under general anesthesia, we performed this study of laparoscopic cholecystectomy with low-pressure pneumoperitoneum under spinal anesthesia to assess its safety and feasibility.

Materials and Methods:

In a private rural health set-up, 300 patients were selected prospectively for laparoscopic cholecystectomy under low-pressure (8 mm) pneumoperitoneum under spinal anesthesia in a span of three years. Only 3.5 ml of 0.5% bupivacaine was used for spinal anesthesia. Fourth port positioned at lower than usual at the level of umbilicus, change of position of the table with different stages of operation, massaging of right shoulder in cases of shoulder pain, removal of smoke if formed during dissection to diminish shoulder pain and holding the body of the gallbladder by the fourth port grasper at the level of lower margin of the liver in cases of long gallbladder were some modifications of standard laparoscopic cholecystectomy made in this study.

Results:

We successfully performed the operations in 291 patients without major complications. Four patients denied operation under spinal anesthesia. Spinal anesthesia was converted to general anesthesia in two patients due to severe shoulder pain. The operation was converted to open cholecystectomy in three patients. Mean age was 34.6 years (range 21-82 years). Mean BMI was –23.1 (range 20.8-28.3). Mean duration of operation was 39.6 min (range 18-78 min). Mean O₂ saturation was 97.6%. Mean peak respiratory rate was 23.4 (range 16-38). 90.08% patients complained of right shoulder pain – most of them managed by shoulder massage alone. All patients were satisfied on follow up.

Conclusion:

Laparoscopic cholecystectomy under spinal anesthesia with low-pressure pneumoperitoneum can be performed safely and satisfactorily without major complications by experienced surgeons.     

Risk Factors for Development of Biliary Stricture in Patients Presenting with Bile Leak after Cholecystectomy

Background/Aims

This study was aimed at determining the factors associated with the development of benign biliary stricture (BBS) in patients who had sustained a bile duct injury (BDI) at cholecystectomy and developed bile leaks.

Methods

A retrospective analysis of 214 patients with BDI who were referred to our center between January 1989 and December 2009 was done.

Results

One hundred fifty-three (71%) patients developed BBS (group I), and 61 (29%) were normal (group II). By univariate analysis, female gender (p=0.02), open cholecystectomy as the index operation (p=0.0001), delay in the referral from identification of injury (p=0.04), persistence of an external biliary fistula (EBF) beyond 4 weeks (p=0.0001), EBF output >400 mL (p=0.01), presence of jaundice (p=0.0001), raised serum total bilirubin level (p=0.0001), raised serum alkaline phosphatase level (p=0.0001), and complete BDI (p=0.0001) were associated with the development of BBS. Furthermore, open cholecystectomy as the index operation (p=0.04), delayed referral (p=0.02), persistent EBF (p=0.03), and complete BDI (p=0.001) were found to predict patient outcome in the multivariate analysis.

Conclusions

For the majority of patients with BDI, the risk of developing BBS could have been predicted at the initial presentation.     

Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Acute Coronary Syndrome

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is considered a high-risk procedure in patients with previous acute coronary syndrome (ACS); however, clinical studies are rare in the literature. The aim of this study was to investigate the safety and efficacy of ERCP in patients with previous ACS.

Methods

We retrospectively reviewed the medical records of patients with previous ACS who underwent ERCP between January 2007 and August 2012. The clinical characteristics, ERCP diagnoses, treatment results, and complications were analyzed.

Results

Fifty patients underwent ERCP an average of 41.6 months after ACS. The most common indication for ERCP was calculous cholangitis. After deep biliary cannulation, endoscopic sphincterotomy, biliary stone removal and endoscopic biliary drainage were successfully performed. Immediate postsphincterotomy bleeding occurred in seven patients, which was successfully controlled using endoscopic therapy. Elevation of cardiac troponin I levels were observed in three patients (6%) before ERCP, and all of these patients were diagnosed with pancreatobiliary disease combined with recurrent ACS, which was treated with coronary artery stent insertion (n=2) and balloon angioplasty (n=1).

Conclusions

Therapeutic ERCP is effective and safe in patients with previous ACS. Cardiac troponin I elevation should be considered a warning sign for recurrent ACS in patients who undergo ERCP.     

Endoscopic Papillary Large Balloon Dilation for the Retrieval of Bile Duct Stones After Prior Billroth II Gastrectomy

Background/Aims:

Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.

Materials and Methods:

From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.

Results:

Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.

Conclusions:

EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.     

Nintinol self-expandable metallic stenting in management of malignant obstructive jaundice: a case series

Background and Aims

Palliation therapy is the only available therapeutic method for most patients with tumor-induced obstructive jaundice. Metallic stents are now performed percutaneously as an alternative route to the endoscopic approach. It is widely accepted because of its safety, good patency rate, and minimal invasiveness. This study was designed to evaluate the long-term results of metallic self-expandable stent insertion in patients with malignant stenosis of the biliary tree.

Methods

It is a longitudinal study of patients with percutaneously biliary stenting from September 2005 to March 2009. The patients had unresectable malignant biliary obstruction with unsuccessful endoscopic stenting and access. Percutaneous transhepatic cholangiogram performed after adequate local anesthesia, under sonographic or fluoroscopic guidance. Stenting or balloon dilation was performed through the hydrophilic guide wire. Among 50 patients, 45 stents were placed in biliary tree stenosis sites. Patients’ follow-up was during the first, second, third, and then the sixth month after insertion of biliary stents. Stent patency was considered successful in our patients, when there were no lab results or sonographic appearance of biliary tree obstruction.

Results

10(20%) patients’ stent placement treatment failed because of unsuccessful technical procedure. The stenosis of biliary tract was complete and passage of guide wire was not possible through the tumor growth. 6 (15 %) patients with successful stent placements died within one month (mean, 22 days). Total serum bilirubin resolved to below 1.5 mg/dl within 30 days for 36 (90%) patients with successful stent placements. Early complications not leading to death occurred in 28% of cases. The mean survival time for all patients who underwent stent placement was 140 days (16-420days). The mean patency rate for all stents was 147 days.

Conclusions

Percutaneous biliary stenting is a safe procedure with few technical complications and a high success rate of palliation for patients with malignant biliary jaundice. Early complications are mostly managed conservatively and death is mainly due to systemic effects of the malignant disease.     

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

Background:

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

Methods:

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

Results:

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

Conclusions:

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.     

Ascaridiose biliaire traitée par voie c?lioscopique

Background

Bilio-pancreatic ascariasis is the most frequent extra-intestinal localization of digestive ascariasis. Its diagnosis is generally made with ultrasonography and the therapeutic management is controlled by endoscopy.

Aim of study

We present a 24-year-old woman, with biliary ascariasis, operated by laparoscopy after failure of endoscopic treatment.

Observation

A 24-year-old woman was hospitalized for abdominal pain and fever. Abdominal ultrasound showed a common bile duct (VBP) dilated to 11 mm seat of a mobile serpiginous structure measuring 20 mm suggestive of an ascariasis. After failure of the extraction of the worm by endoscopic, treatment was laparoscopic surgery.

Conclusion

This case illustrates that the diagnosis of biliary ascariasis should be considered even in non-endemic countries. Endoscopic treatment was the reference. Surgery was indicated for failures of endoscopic treatment and association of ascariasis and common bile duct stones.     

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.     

Superiority of 10-mm-wide Balloon over 8-mm-wide Balloon in Papillary Dilation for Bile Duct Stones: A Matched Cohort Study

Background/Aims:

Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy (EST) for common bile duct (CBD) stones. To date, 10- and 8-mm EPBD have not been fully compared.

Patients and Methods:

Patients who underwent EPBD for CBD stones at two Japanese tertiary care centers between May 1994 and January 2014 were identified. Matched pairs with 10- and 8-mm EPBD were generated. Short- and long-term outcomes were compared between the two groups.

Results:

A total of 869 patients were identified (61 and 808 patients for 10- and 8-mm EPBD, respectively), and 61 well-balanced pairs were generated. The rate of complete stone removal within a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%, P < 0.001), and use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%, P < 0.001). The rates of post-ERCP pancreatitis were similar between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% [95% confidence interval (CI): 79–97%] and 94% (95% CI: 88–100%) at 1 year and 69% (95% CI: 56–85%) and 80% (95% CI: 69–93%) at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not observed, and pneumobilia was found in 5% of cases during the follow-up period.

Conclusions:

EPBD using a 10-mm balloon for CBD stones is safe and more effective than 8-mm EPBD. The sphincter function is highly preserved after 10-mm EPBD.     

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography

Background

Endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis.

Methods

The study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES).

Results

The PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79–9.91)] and more complex [higher than 6 points, on a 0–10 scale, OR 3.12 (95% CI 1.43–6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different.

Discussion

A laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.