Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis

AIM: To compare the efficacy of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) in therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y entero-enteric anastomosis.METHODS: Retrospective analysis of our patient cohort revealed 4 patients with enterobiliary anastomosis and Roux-en-Y entero-enteric anastomosis who underwent repeated ERC with DBE and SBE because of recurrent cholangitis.RESULTS: A total of 38 endoscopic retrograde cholangiopancreatography procedures were performed in 25 patients with Roux-en-Y entero-enteric anastomosis. DBE was used in 29 procedures and SBE in 9. The 4 patients who underwent repeated ERC with DBE and SBE suffered from recurrent cholangitis due to stenosis of the enterobiliary anastomosis. ERC was performed repeatedly to achieve balloon dilation with/without biliary stone extraction and multiple stent placement at the level of the enterobiliary anastomosis. In all 4 patients DBE and SBE were equally successful. Compared to DBE, SBE was equally effective in passing the Roux-en-Y entero-enteric anastomosis, reaching the enterobiliary anastomosis and performing therapeutic ERC.CONCLUSION: This retrospective comparison shows that DBE and SBE are equally successful in the performance of therapeutic ERC at the level of the enterobiliary anastomosis after Roux-en-Y entero-enteric anastomosis.     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy

Endoscopic retrograde cholangiography (ERC) after Roux-en-Y reconstruction and modified BII surgery or duodenopancreatectomy is considerably more difficult than ERC under normal anatomic conditions. If the common bile in the afferent loop cannot be reached by a common lateral-viewing duodenoscope because of excessive intestinal length, it has recently become possible to use double balloon enteroscopy (DBE) for ERC to reach the common bile duct. Cannulating the bile duct via DBE in these postoperative settings remains one of the most difficult ERCP manipulations because of the lack of an Albarran lever and the use of extra long ERCP accessories. Here, we report on a facilitated method for endoscopic interventions at the bile duct in postoperative settings with a long afferent loop using DBE. For facilitation of interventions the enteroscope can be exchanged for a 110-cm-long conventional gastroscope after incision of the overtube in three quarters of its circumference. Care has to be taken that the pressure line for the balloon remains intact. The huge benefit of this facilitated method is the use of standard endoscopic material like guides, catheters and papillotomes.     

Biliary leakage after urgent cholecystectomy: Optimization of endoscopic treatment

AIM: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.METHODS: This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography(ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded. RESULTS: During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d(interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23(77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy(median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed andthe biliary stent was removed on gastroscopy. In seven(23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d(interquartile range, 28-43 d). Among the patients included in the follow-up(median 30.5 mo, range 7-59 mo), four patients(14.8%) died of severe underlying comorbid illnesses.CONCLUSION: Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.     

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy.METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations.RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.     

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.     

Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy

AIM： TO introduce a new method： small endoscopic sphincterotomy （ES） combined with endoscopic papillary large balloon dilation （SES ＋ EPLBD） to treat patients with large biliary stones.
METHODS： Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 ± 3 mm and mean number of stones was 2.5 ± 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket.
RESULTS： Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 ± 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis （1%） occurred.
CONCLUSION： SES ＋ EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.     

Passive-bending,short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients

AIM:To evaluate short-type-single-balloon enteroscope(SBE) with passive-bending,high-force transmission functions for endoscopic retrograde cholangiopancreatography(ERCP) in patients with Roux-en-Y anastomosis.METHODS:Short-type SBE with this technology(SIF-Y0004-V01; working length,1520 mm; channel diameter,3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis.The rate of reaching the blind end,time required to reach the blind end,diagnostic and therapeutic success rates,and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology(SIF-Y0004; working length,1520 mm; channel diameter,3.2 mm) in 25 patients.RESULTS:The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004(P = 0.59).The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004(16 min vs 24 min,P = 0.04).The diagnostic success rate was 93% with SIFY0004-V01 and 84% with SIF-Y0004(P = 0.17).The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004(P = 0.68).The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004(P = 0.50).The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group(P = 0.723).The incidence of pancreatitis was 0% in the SIFY0004-V01 group and 5.9% in the SIF-Y0004 group(P > 0.999).The incidence of gastrointestinal perforation was 2.0%(1/50) in the SIF-Y0004-V01 group and 2.9%(1/34) in the SIF-Y0004 group(P > 0.999).CONCLUSION:SIF-Y0004-V01 is useful for ERCP inpatients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.     

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.     

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.     

Use of a double balloon enteroscope facilitates caecal intubation after incomplete colonoscopy with a standard colonoscope

BACKGROUND: Caecal intubation is a necessary step in the complete endoscopic evaluation of the colon. Studies have estimated that experienced colonoscopists may fail to reach the caecum in up to 10% of cases. AIMS: To evaluate the utility of the double balloon enteroscope used for complete examination of the colon in patients with incomplete standard colonoscopy. PATIENTS: Twenty consecutive patients with incomplete colonoscopies within the Veterans Affairs Palo Alto Health Care System. Mean age of 66 years (S.D.+/-12 years, range 46-84), 16 men. METHODS: Prospective single-centre case series on the caecal intubation rate using standard double balloon enteroscope technique in patients with previous incomplete conventional colonoscopy. RESULTS: Use of the standard double balloon enteroscope technique permitted complete colonoscopy to be achieved in 95% of the patients (19/20). Seven patients (35%) had significant pathology beyond the extent of the prior incomplete colonoscopy. We performed endoscopic mucosal resection, polypectomy or biopsy. The mean time to reach the caecum was 28 min (S.D.+/-20 min, range 6-90 min). The sedation was similar to conventional colonoscopy. No complications occurred. CONCLUSIONS: The double balloon enteroscope technology and technique can be used to complete examination of the colon in patients who were referred because of incomplete standard colonoscopy.     

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis

Objective. Roux-en-Y reconstructions can be divided into intact papilla of Vater and bilioenteric anastomosis (BEA) with respect to endoscopic retrograde cholangiography (ERC). Double-balloon enteroscopy-assisted ERC (DBE-ERC) may produce different results between the two populations but lacks studies. Material and methods. Forty-seven patients with Roux-en-Y anastomosis undergoing 73 procedures of DBE-ERC were enrolled between July 2007 and August 2013. There were 14 patients with intact papilla of Vater (group A) and 33 patients with BEA (group B). The effectiveness of DBE-ERC, including data of reaching the blind end, performance of ERC, results of endoscopic therapies, and follow-up were retrospectively analyzed and compared between the two groups. Results. For reaching the blind end, the success rate was not different between the groups (85.7% vs. 81.8%, p = 0.7), but the mean procedure time was significantly shorter for group A (28 min vs. 52 min, p = 0.01). For ERC, the success rate was not different between the groups (91.7% vs. 96.3%, p = 0.53), but the mean procedure time was significantly longer for group A (28.4 min vs. 4 min, p < 0.001). All endoscopic therapies could be successfully performed in both groups. No group A patients and five (23.8%) group B patients developed recurrent biliary stricture/stones requiring interventions during a mean follow-up period of 26.1 months. Conclusions. DBE-ERC was effective for both populations with biliary disorders. Reaching the blind end was more difficult but ERC was easier for patients with BEA in terms of procedure time rather than success rates.     

Tips for double balloon enteroscopy in patients with Roux‐en‐Y reconstruction and modified Child surgery

Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)‐related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP‐related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB‐ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB‐ERCP and provide several tips for insuring a successful procedure.     

Endoscopic Retrograde Cholangiopancreatography with Single-Balloon Enteroscopy Is Feasible in Patients with a Prior Roux-en-Y Anastomosis

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65–91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.     

Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy. METHODS: Patients who developed biliary complications were analysed in detail for the clinical information,laboratory tests,treatment offered,response to it,follow up and outcomes. The profile of liver enzymes was determined. The safety,efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed. RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L,P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L,P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients. CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early,non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.     

Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis: Long-Term Outcome and Its Related Factors after Endoscopic Treatment

Background/Aims

Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome.

Methods

Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Mary''s Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed.

Results

Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016).

Conclusions

Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.     

税制改革背景下会计学专业税法教学存在的问题及对策

税制改革背景下,会计学专业税法教学存在忽视道德素养教育、教学内容重知识轻理论、教学方法单一、实践教学环节弱化等问题。因此,会计学专业税法教学改革应重新定位会计学专业税法教学目标,转变观念,重视税法理论教学,更新教学内容,改进教学方法,加强实践教学环节,让学生真正参与企业实践。     

Endoscopic papillary large balloon dilation after limited sphincterotomy for difficult biliary stones

AIM:To assess the efficacy and safety of endoscopic papillary large balloon dilation after biliary sphincterotomy for difficult bile duct stones retrieval.METHODS:Retrospective review of consecutive patients submitted to the technique during 18 mo.The main outcomes considered were:efficacy of the procedure(complete stone clearance;number of sessions;need of lithotripsy) and complications.RESULTS:A total of 30 patients with a mean age of 68 ± 10 years,23 female(77%) and 7 male(23%) were enrolled.In 10 patients,a single stone was found in the common bile duct(33%) and in 20 patients multiple stones(67%) were found.The median diameter of the stones was 17 mm(12-30 mm).Dilations were performed with progressive diameter Through-TheScope balloons(up to 12,15) or 18 mm.Complete retrieval of stones was achieved in a single session in 25 patients(84%) and in two sessions in 4 patients(13%).Failure occurred in 1 case(6%).Mechanical lithotripsywas performed in 6 cases(20%).No severe complications occurred.One patient(3%) had mild-grade post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.CONCLUSION:Endoscopic balloon dilatation with a large balloon after endoscopic sphincterotomy is a safe and effective technique that could be considered an alternative choice in therapeutic ERCP.