Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study

OBJECTIVES: The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. METHODS: Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. RESULTS: Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). CONCLUSION: Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting.     

Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents

OBJECTIVES: The goal of this study was to evaluate our medium-term results on common bile duct stenting with increasing numbers of stents on strictures due to chronic calcifying pancreatitis. BACKGROUND: Common bile duct strictures frequently complicate the course of chronic calcifying pancreatitis. The effectiveness of endoscopic stenting to resolve definitely these strictures is still debated. STUDY: Twenty-nine patients with common bile duct stricture due to chronic calcifying pancreatitis were stented and followed up. Biliary sphincterotomy, dilation of the stricture, and insertion of plastic biliary stents (7.5-10 F) were performed. Patients were scheduled for elective stent changing/restenting at 3-month intervals or any time when it was urgently indicated. Our basic intention was to insert the maximum possible number of stents to reach as large diameter as the stricture allowed. All stents were removed after the disappearance of common bile duct dilatation or left in place in cases of persisting strictures. RESULTS: Eighteen patients (60%) had complete radiologic and serologic recovery after a mean of 21.1 months overall stenting time and had a stent free follow-up period for a mean of 12.1 months without recurrence of stricture. Five patients (16%) still have stents in place after 26 months. Three patients (13%) required surgery. There were 3 deaths (10%): 1 for unrelated cause and 2 with septic shock of biliary origin. CONCLUSIONS: Most chronic calcifying pancreatitis patients with common bile duct strictures respond to the increasing numbers of endoscopic stents, and remain stent free for medium term periods. Less patients (30%) does not benefit of biliary stenting, who are candidates for surgery.     

Long-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis

OBJECTIVES: Endoscopic stent therapy is an established treatment modality for postoperative biliary strictures. At present, biliary stenting is also widely applied in chronic pancreatitis (CP), but results regarding long-term outcome are scarce. METHODS: All CP patients who underwent endoscopic biliary drainage of a benign stricture in our hospital between 1987 and 2000 were included in this retrospective study. RESULTS: Fifty-eight CP patients underwent biliary stenting (median age, 54 years; 44 male). The procedure-related mortality rate was 2% and the complication rate 4%. Median follow-up was 45 months (range, 0-182 months). Endoscopic treatment was successful in 22 patients (38%). Concomitant acute pancreatitis was the only factor identified as predictive of a successful outcome by multivariate analyses. Subanalysis of these 12 patients revealed a success rate of 92%, as opposed to 24% in cases without acute inflammation. In this latter group, continued stenting beyond a 1-year period almost never resulted in additional stricture resolvement. If stricture resolution was accomplished, however, no recurrences were observed. CONCLUSIONS: For biliary strictures due to CP, without evidence of concomitant acute pancreatitis, the long-term success rate of endoscopic therapy is poor and only one out of four strictures is treated successfully. When a biliary stricture has not resolved after 1 year of endoscopic stenting, surgery should be considered.     

Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas

BACKGROUND: Life expectancy in patients with unresectable pancreatic cancer has improved by using new chemotherapeutic regimens. Biliary and digestive stenoses can be endoscopically treated in most cases. However, long-term efficacy of these stenting procedures remains unknown. AIM: To evaluate the incidence of biliary and duodenal stenoses as well as technical success and short- and long-term patency of endoscopically deployed stents in patients with unresectable pancreatic cancer. PATIENTS AND METHODS: All consecutive patients with unresectable cancer of the pancreatic head seen between January 1999 and September 2003 in our center were retrospectively studied. Patients with biliary and/or duodenal stenoses underwent endoscopic stent insertion as first intention therapy. Outcomes included technical and clinical success, stent patency, and survival. RESULTS: One hundred patients, median age 65 yr (32-85), with locally advanced (62%) or metastatic (38%) pancreatic cancer were studied. Eighty-three percent received at least one line of chemotherapy. The actuarial median survival was 11 months (0.7-29.3). Biliary and duodenal stenoses occurred in 81 and 25 patients, respectively. A biliary stent was successfully placed in 74 patients (91%). When a self-expandable metallic stent was first introduced (N = 59), a single stent was sufficient in 41 patients (69%) (median duration of stent patency 7 months (0.4-21.1)). Duodenal stenting was successful in 24 patients (96%); among them, 96% required a single stent (median duration of stent patency 6 months [0.5-15.7]). In the 23 patients who developed both biliary and duodenal stenoses, combined stenting was successful in 91% of cases. No major complication or death occurred related to endoscopic treatment. CONCLUSION: Endoscopic palliative treatment of both biliary and duodenal stenoses is safe and effective in the long term, including in patients with combined obstructions. Use of such palliative management is justified as repeat procedures are rarely required even in patients who have a long survival.     

Outcome following endoscopic stenting of pancreatic duct strictures in chronic pancreatitis

GOALS: To assess outcomes following 6 months of endoscopic stenting for dominant pancreatic duct strictures in painful chronic pancreatitis. BACKGROUND: Pancreatic stent placement may improve pain in chronic pancreatitis. Long-term outcomes after a 6-month period of stenting are unknown. STUDY: We identified all patients with chronic pancreatitis who underwent stenting of a dominant pancreatic duct stricture at one hospital. Stents were left in place for 6 months. Changes in weight, hospital visits, and narcotic use were analyzed. RESULTS: Mean follow-up for the 15 subjects was 36 months; 87% improved following stent placement, and 11 (73%) completed 6 months of stent therapy. Hospital visits per subject decreased from 3.6 in the year prior to stent placement to 0.1 in the year after stent removal (P < 0.01). Oral narcotic use decreased from 33 mg MSO4/day in the month prior to stenting to 2 mg MSO4/day in the 12 months after stent removal (P = 0.01). Mean weight change was -5 kg in the year prior to stenting and +3.2 kg in the year after stent insertion (P < 0.01); 36% required endoscopic reintervention during the follow-up period. CONCLUSIONS: Six months of stenting resulted in sustained clinical improvement in most patients with chronic pancreatitis and a dominant pancreatic duct stricture. Stenting was associated with subsequent weight gain, fewer hospital visits, and less narcotic use.     

Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes,clinical response,and stent patency

OBJECTIVE: Pancreatic duct stenting is now recognized as a treatment option for a number of pancreatic disorders. Although stent-induced ductal changes may result, there is little information regarding the frequency of these stent-induced changes in chronic pancreatitis and their relationship to stent occlusion and clinical response. Our objectives were to evaluate pancreatic ductal changes after endoscopic stenting in patients with preexisting radiographic evidence of chronic pancreatitis and to evaluate the relationships between ductal changes, pain response, and stent patency. METHODS: Twenty-five consecutive patients had 40 stent placement episodes. Main pancreatic duct diameter, pancreatitis grade, preexisting obstructive lesions, and stent-induced strictures were recorded. Pain response and stent patency were correlated with main pancreatic duct caliber change using chi(2) analysis. RESULTS: In 28 (70%) of 40 episodes, main pancreatic duct caliber increased or was unchanged after stenting; pain improved in 20 (71%) of 28. Pain improved in six (50%) of 12 patients with smaller ducts after stenting. Stent patency was documented upon retrieval in 34 episodes; most stents were occluded. Stent-induced strictures developed in 18% of 40 stent episodes. CONCLUSIONS: Main pancreatic duct caliber after endoscopic stenting was not a good indicator of pain response or stent patency; main pancreatic duct was often larger, and even with stent occlusion, patients' symptoms were frequently improved. Stent-induced strictures were infrequent, compared with values previously reported in the literature.     

Biliary stenting alone versus biliary stenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy biliary leaks: a prospective randomized study

OBJECTIVE: Although various endoscopic techniques have been proved effective in treating post-cholecystectomy biliary leaks, the choice of the best method remains controversial. The aim of this prospective study was to compare the efficacy and safety of biliary stenting alone with biliary stenting plus sphincterotomy for the treatment of post-cholecystectomy biliary leaks. METHODS: Patients with post-laparoscopic cholecystectomy leaks were randomized into two groups. The first group included 24 patients who were treated with a 7 Fr biliary stent alone, and the second group included 28 patients who underwent an endoscopic sphincterotomy followed by insertion of a 10 Fr biliary stent. RESULTS: Endoscopic therapy was successful in all patients (100%). Clinical improvement was observed after 2-6 days. Patients remained hospitalized for 4-12 days. Stents were removed after 6.7 (6-8) weeks. The overall complication rate was 4.16% for the first group and 10.71% for the second (P=0.615). No complications were recorded during the follow-up period. CONCLUSIONS: Endoscopic therapy of biliary leaks with a small-diameter biliary stent alone is as effective and safe as endoscopic sphincterotomy followed by insertion of a large-diameter stent.     

Four years experience with short term stenting in primary sclerosing cholangitis

OBJECTIVE: Symptomatic dominant strictures in primary sclerosing cholangitis are often treated with endoscopic stent therapy, but the optimal treatment duration is not well established. After a promising pilot study, we now report our 4 yr experience with short term endoscopic stent therapy for relief of dominant strictures. METHODS: Between January 1994 and October 1997, 32 patients with symptomatic primary sclerosing cholangitis with a dominant stricture at endoscopic retrograde cholangiopancreatography were treated with insertion of a 7- or 10-Fr polyethylene endoprosthesis, which was extracted after a mean of 11 days (range 1-23 days). Primary end points were changes in complaints and cholestasis after 2 months, and time interval until a repeat endoscopic treatment was deemed necessary. A secondary end point was the occurrence of treatment-related complications. RESULTS: Cholestatic complaints improved after 2 months in 83% of patients. Mean scores for pruritus, fatigue, and right upper quadrant pain decreased from 0.94, 1.0, and 0.87 to 0.26, 0.39, and 0.26, respectively. All improvements were significant. Of 14 patients presenting with jaundice, 12 regained normal serum bilirubin levels 2 months after short term endoscopic stenting. The mean levels of conjugated bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase dropped significantly from 36 micromol/L, 309 U/L, and 426 U/L to 7 micromol/L, 205 U/L, and 258 U/L, respectively. The reintervention-free proportions after 1 and 3 yr were 80% and 60%. Seven transient procedure-related complications occurred in 45 therapeutic endoscopic retrograde cholangiopancreatographies. CONCLUSIONS: Short term endoscopic stenting for symptomatic dominant strictures in primary sclerosing cholangitis is effective and safe, and the beneficial effect is sustained for several years.     

ENDOSCOPIC TREATMENT FOR THE BENIGN BILIARY STRICTURE IN THE PATIENT WITH CHRONIC PANCREATITIS

In some patients with chronic pancreatitis (CP), strictures are observed in the intrapancreatic bile ducts due to fibrosis and inflammation in the pancreas. Normally, even when biliary strictures exist, obstructive jaundice is rarely observed. It seemed that obstructive jaundice was brought about by temporary pancreatitis due to immoderate alcohol ingestion, followed by the aggravation of the intrapancreatic biliary stricture. When immoderate alcohol ingestion is incriminated for the pancreatic disorder, the patient should be strictly instructed to abstain from alcohol, but failure to observe this instruction seems to render endoscopic biliary stenting ineffective. When CP is complicated with pancreatolithiasis, stone fragmentation using extracorporeal shock wave lithotripsy (ESWL) is effective, and combination with endoscopic lithotomy makes it possible to remove pancreatic stones in the main pancreatic duct (MPD). To treat the beside dilating stricture of the MPD, balloon dilation and pancreatic duct stenting are performed. We obtained good results with 10 Fr pancreatic duct stents, but biliary strictures are better treated with a combination of these methods. When 10 Fr or larger straight biliary stents are used, they may be dislodged or stray if the bile duct is sharply curved. To prevent this accident we have used 10 Fr double layer stents and obtained good results. In patients with benign biliary strictures, stents are temporarily placed and should be removable. Some cases have been reported where Wallstent gave good results in a short period, but the stents were occluded due to hyperplastic proliferation of the biliary epithelium. Metal stents are not considered desirable for benign biliary strictures. Our results seem to support the assumption that benign biliary strictures are improved with 10 Fr or larger biliary stents while exercizing care to keep the patient abstinent from alcohol and performing ESWL and endoscopic treatment for CP.     

Long-term ciprofloxacin treatment for the prevention of biliary stent blockage: a prospective randomized study

OBJECTIVE: In vitro experimental and animal studies have shown that quinolones reduce the adherence of bacteria on a polyethylene tube and prevent stent blockage. Our aim was to see whether ciprofloxacin prevents stent blockage in patients with malignant stricture of the biliary tract. METHODS: Patients with inoperable biliary or pancreatic tumor not involving the bifurcation of the common hepatic duct were recruited. They were randomized to receive either endoscopic stenting alone or stenting with prophylactic treatment of ciprofloxacin (200 mg i.v. before stenting, followed by 250 mg orally twice per day). In each follow-up visit, clinical symptoms of cholangitis were documented and blood samples taken for blood counts, serum levels of bilirubin, and alkaline phosphatase. Stent blockage was defined as clinical symptom(s) of cholangitis with biochemical or radiological evidence of stent dysfunction. RESULTS: Fifty-eight patients were recruited into the study. Three patients in the stenting group and three in the ciprofloxacin group were excluded after randomization. Eleven patients received stenting alone and five patients receiving ciprofloxacin had previous endoscopic stenting. Thirteen patients (50%) in the ciprofloxacin group and eight patients (31%) in the stenting group died before stent blockage. Ten patients (38%) in each group had stent blockage during the follow-up at 20 wk. The median stent patency was 11.6 wk and 11.9 wk in the ciprofloxacin group and the stenting group, respectively. Kaplan-Meier analysis of stent patency showed no difference between the two groups. Among patients who received endoscopic stenting for the first time, there was a trend favoring ciprofloxacin treatment, but the difference was not significant. The 30-day and 20-wk mortality between the groups were comparable. CONCLUSION: Long-term use of ciprofloxacin does not prevent blockage of polyethylene biliary stents.     

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.     

Endoscopic double-metallic stenting for malignant biliary and duodenal obstructions

Background

Endoscopic metallic stenting is a safe, effective treatment for malignant biliary obstructions, but can be technically difficult when combined malignant biliary and duodenal obstructions exist. Available duodenal metallic stents feature a tight mesh unsuitable for transpapillary biliary stenting. We evaluated the feasibility and usefulness of new endoscopic procedures for endoscopic double-stent placement in managing such obstructions.

Methods

The through-the-scope duodenal metallic stent has a central cross-wired, unfixed structure that allows insertion of the biliary stent through the mesh wall of a duodenal stent. Transpapillary endoscopic placement of a biliary stent was performed through the lumen of this duodenal stent. Endoscopic ultrasound (EUS)-guided biliary drainage was performed successfully through the duodenal bulb after puncturing with a 19G needle. Biliary metallic stenting through the choledochoduodenal tract and effective drainage were achieved.

Conclusions

Use of a combined endoscopic biliary and duodenal stent inserted through the mesh of the new duodenal metallic stent is feasible and effective in managing the aforementioned obstructions. EUS-guided biliary metal stenting is a therapeutic option for endoscopic management when a failed transpapillary approach through the lumen of the duodenal stent occurs. The continued development of endoscopic procedures and devices should resolve issues associated with complicated strictures.     

Endotherapy in chronic pancreatitis

Chronic pancreatitis(CP)is a progressive disease with irreversible changes in the pancreas.Patients commonly present with pain and with exocrine or endocrine insufficiency.All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications.Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi,strictures,ductal leaks,pseudocyst or associated biliary strictures.Endotherapy offers a high rate of success with low morbidity in properly selected patients.The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery.Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis.Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi.Long term follow up has shown pain relief in over 60%of patients.A transpapillary stent placed across the disruption provides relief in over 90%of patients with ductal leaks.Pancreatic ductal strictures are managed by single large bore stents.Multiple stents are placed for refractorystrictures.CP associated benign biliary strictures(BBS)are best treated with multiple plastic stents,as the response to a single plastic stent is poor.Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed.Pseudocysts are best drained endoscopically with a success rate of 80%-95%at most centers.Endosonography(EUS)has added to the therapeutic armamentarium in the management of patients with CP.Drainage of pseudcysts,cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS.Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.     

Results of endoscopic management of anastomotic biliary strictures after orthotopic liver transplantation.

BACKGROUND/AIMS: Anastomotic biliary strictures are common biliary complications after orthotopic liver transplantation. We assessed the success of endoscopic retrograde cholangio-pancreaticography (ERCP) in the treatment and outcome of post-liver transplantation anastomotic biliary strictures in a university hospital, retrospectively. METHODS: Thirty-three ERCPs were performed in 20 of 162 adult liver transplant recipients with duct to duct anastomosis. RESULTS: In five patients, ERCP failed because the stricture could not be passed with guidewire. Four patients were treated with balloon dilatation only; two of them are recurrence-free with a follow-up of 24 and 8 months. Eleven patients had balloon dilatation and plastic stent placement as their primary treatment modality. In six of them, the anastomosis remained patent for the rest of the follow-up (22+/-13 months). Five patients had stricture recurrence after first stenting which necessitated re-stenting; four of them required a third, and three had a fourth stenting. CONCLUSIONS: Endoscopic balloon dilatation and stenting are safe and effective means of treatment of anastomotic biliary strictures following liver transplantation.     

Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents

BACKGROUND: A rare, late complication of endoscopic biliary sphincterotomy is the occurrence of short strictures extending from the papillary orifice to the distal parts of the extraduodenal common bile duct. METHODS: We evaluated the efficacy of the sequential insertion of multiple stents in the treatment of endoscopic biliary sphincterotomy associated common bile duct strictures. The design of the study is a prospective, single-arm observational study at a university-affiliated teaching hospital of 20 patients with distal common bile duct strictures because of choledocholithiasis-related endoscopic biliary sphincterotomy. Endoscopic treatment consisted of the sequential insertion of an increasing number of plastic stents with ever-larger diameters in 3-month follow-up intervals until stricture resolution. The primary outcome of the study was the rate of resolution of the stricture. The parameters measured were the duration of placement of stents, the maximum diameter, the total number of stents, and the total number of endoscopic sessions required for dilation of the strictures. RESULTS: After a median of 9.0 months of stent placement (range 3-22 months) and a median of 20F maximum stent diameter (range 10F-30F), 18 patients (90%) remained stent-free for a median of 14.5 months (range 6-38 months). Two patients (10%) had stricture recurrences at 10 and 24 months. Multivariate regression analysis demonstrated that the time elapsed after endoscopic biliary sphincterotomy was significantly associated with the stent-placement time (however, significance was removed by correction for multiple testing) and the number of ERCPs required for dilation. The initial common bile duct size was significantly associated with the total stent number and diameter needed for stricture resolution (however, significance was removed by correction for multiple testing). Limitations are the low case number and the single-arm, noncontrolled study design. CONCLUSIONS: Sequential insertion of an increasing number of biliary stents affords effective treatment of the distal biliary strictures that develop as a late complication of endoscopic biliary sphincterotomy.     

Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures

We evaluated the efficacy of endoscopically placed biliary stents as treatment for 32 benign postoperative biliary strictures in 29 patients. Five patients also had bile fistulas. Stents were inserted for a mean of 162 days and then removed. ERCPs were obtained before stent insertion and again after removal. Responses were followed and categorized as excellent, good, or poor. Stent insertion was successful in 25 patients (86%), 23 of which have a mean follow-up of 19 months (range, 2 to 42 months) after stent removal. Seventy-four percent had an excellent (48%) or good (26%) response. Early postoperative strictures and fistulas responded favorably. We conclude that benign postoperative biliary strictures can be treated successfully by endoscopic prostheses.     

A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obstruction.

Effective palliation of malignant biliary obstruction with conventional 10 or 12 French gauge straight polyethylene endoprostheses is limited by stent occlusion, which typically occurs four to five months after insertion. Short term follow up studies of self expanding metal stents (Wallstent, Schneider, UK) in the treatment of patients with malignant biliary obstruction have shown that their use is associated with fewer episodes of stent occlusion compared with plastic stents. There are few data, however, on the longterm patency and durability of metal stents in malignant disease. Between May 1989 and May 1992, metal stents were inserted in 28 patients with malignant bile duct strictures secondary to ampullary tumour (n = 10), pancreatic carcinoma (n = 10), cholangiocarcinoma (n = 7), and porta hepatis nodes from colorectal carcinoma (n = 1). The follow up of these patients until May 1993 is reported with a median follow up of 14.6 months. Twenty two of 28 (78.6%) patients remained free of jaundice or cholangitis. The median period of stent patency was 8.2 months (range 1.0-32.5). Thirteen patients represented with jaundice or cholangitis and endoscopic retrograde cholangiopancreatography showed evidence of stent occlusion due to tumour ingrowth. Successful clearance of metal stents was achieved by balloon trawling, or insertion of a polyethylene stent. In conclusion, metal stents provide improved longterm palliation for patients with malignant biliary strictures with fewer episodes of occlusion compared with conventional stents.     

Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents

BACKGROUND: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. METHODS: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. RESULTS: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. CONCLUSIONS: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy.     

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy.METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared.RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed before complete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions).CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.