'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract

BACKGROUND:

Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a ‘short’ DBE in patients with surgically altered anatomy.

METHODS:

A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a ‘short’ DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed.

RESULTS:

A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple’s operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications.

CONCLUSION:

DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard ‘long’ DBEs have limitations of long working length and the need for modified ERCP accessories. ‘Short’ DBEs are equally as effective in reaching the target limb as standard ‘long’ DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.     

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy

Introduction

Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy.

Materials and methods

The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy.

Conclusion

Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments.     

Large dilating balloon to allow endoscope insertion for successful endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy (with video)

Background and purpose

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy can be present unique challenges. One of the major obstacles preventing successful ERCP is acute angulation and long afferent loops in patients with Billroth II gastrectomy or Roux-en-Y anastomosis. Here, we described a novel technique for successful endoscope insertion using a large dilating balloon.

Methods

The large dilating balloon (maximum diameter 20 mm) is used as an anchor for endoscope insertion (hooking method) in patients with Billroth II gastrectomy in whom no other endoscopes could be advanced into the end of the duodenum or the Roux-en-Y anastomosis.

Results

The hooking method allows the endoscope to be advanced into the proximal afferent loop, even in patients with sharp angulation of the Y limb.

Conclusions

To the best of our knowledge, this is the first report on the use of a large dilating balloon for endoscope insertion in patients with surgically altered anatomy, in particular Roux-en-Y anastomosis. We believe this technique may be effective for difficult cases like the present case.     

Double balloon enteroscopy for endoscopic retrograde cholangiopancreaticography after Roux-en-Y reconstruction: case series and review of the literature

BACKGROUND: Endoscopic access to the biliary system can be difficult in patients with surgically altered anatomy, such as a Roux-en-Y reconstruction. Double balloon enteroscopy (DBE) is a relatively new procedure that enables access to the small bowel. DBE has recently been advocated as a method for endoscopic retrograde cholangiopancreaticography (ERCP) in patients with surgical reconstructions, with the potential to perform diagnostic and therapeutic interventions. METHODS: In three patients with a hepaticojejunostomy and Roux-en-Y reconstruction, the experiences using DBE to perform ERCP are described. The literature on DB-ERCP in patients with a Roux-en-Y reconstruction was reviewed. RESULTS: In all patients, the Roux limb was entered and a diagnostic cholangiography was carried out. In one patient, endoscopic therapy could be performed, consisting of balloon dilation of a stenotic biliodigestive anastomosis, repeated balloon dilation of biliary strictures and removal of bile casts. CONCLUSION: This series confirms recent data emerging from the literature that double balloon enteroscopy is a safe and feasible technique to obtain biliary access in patients with surgically altered anatomical configurations, such as those with a Roux-en-Y reconstruction. The diagnostic and therapeutic potential of DB-ERCP is great, and the utility of the procedure could be further improved if customised accessories become more widely available.     

Spiral enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: actual technique and review of the literature

Background

Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with surgically altered anatomy. Recently, balloon enteroscopy (BE) has made it easier to perform ERCP in these patients. However, BE-assisted ERCP is often technically demanding and time consuming.

Methods

Spiral enteroscopy (SE), which has recently been developed, is a novel method of using a rotating overtube to pleat small bowel onto the enteroscope, thus advancing it through the lumen. We review the mechanism and efficacy of SE, especially in ERCP of patients with surgically altered anatomy, and report on the first patient to undergo ERCP using SE in Japan.

Results

Spiral enteroscopy-assisted ERCP seems to be feasible and safe in patients with surgically altered anatomy. Additionally, SE-assisted ERCP appears to be easier to perform than other methods previously described and allows stable positioning of the enteroscope in order to perform delicate therapeutic maneuvers.

Conclusions

SE for ERCP is expected to be at least as useful as balloon enteroscopy in patients with surgically altered anatomy.     

Usefulness of Intraductal Ultrasonography in Icteric Patients with Highly Suspected Choledocholithiasis Showing Normal Endoscopic Retrograde Cholangiopancreatography

Background

Choledocholithiasis is one of the causes of jaundice and may require urgent treatment. Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary management strategy for choledocholithiasis. However, small stones can be overlooked during ERCP.

Aim

The aim of this study was to evaluate the accuracy of intraductal ultrasonography (IDUS) for detecting choledocholithiasis in icteric patients with highly suspected common bile duct (CBD) stones without definite stone diagnosis on ERCP.

Methods

Ninety-five icteric (bilirubin ≥3 mg/dL) patients who underwent ERCP for highly suspected choledocholithiasis without definite filling defects on cholangiography were prospectively enrolled in the present study. We evaluated the bile duct using IDUS for the presence of stones or sludge. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge.

Result

Bile duct stones were detected with IDUS in 31 of 95 patients (32.6 %). IDUS findings were confirmed by endoscopic stone extraction in all patients. The mean diameter of CBD stones detected by IDUS was 2.9 mm (range 1–7 mm). IDUS revealed biliary sludge in 24 patients (25.2 %) which was confirmed by sludge extraction in 21 patients (87.5 %). In dilated CBD, detection rate of bile duct stone/sludge based on IDUS was significantly higher than in non-dilated CBD (p = 0.004).

Conclusion

IDUS is useful for the detection of occult CBD stone on ERCP in icteric patients with highly suspected CBD stones.     

Does Modified Braun Enteroenterostomy Improve Alkaline Reflux Gastritis and Marginal Ulcer After Pancreaticoduodenectomy?

Background

The safety of pancreaticoduodenectomy has improved significantly. However, alkaline reflux gastritis and marginal ulcer are two substantial problems after pancreaticoduodenectomy.

Aims

To identify whether Child reconstruction with a modified Braun enteroenterostomy decreases the incidence of alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy better than Roux-en-Y reconstruction.

Methods

Data on 57 consecutive patients who underwent standard pancreaticoduodenectomy between January 1, 2008 and January 31, 2012 were collected prospectively. Data on early and late complications of the Child reconstruction with a modified Braun enteroenterostomy and Roux-en-Y were gathered. The risk factors of alkaline reflux gastritis and marginal ulcer were also investigated by using univariate and multivariate analyses.

Results

Twenty-five patients received Roux-en-Y and 32 underwent Child reconstruction with a modified Braun enteroenterostomy. Early complications after the two reconstruction methods were insignificant. Significant differences in terms of later postoperative morbidity (P = 0.01) and change in body mass index (P = 0.03) were found 12 months after pancreaticoduodenectomy. No significant difference for alkaline reflux gastritis was observed between the two methods (14.8 vs. 28.6 %, P = 0.24). Marginal ulcer occurred significantly lower in patients with the modified reconstruction than in those with Roux-en-Y reconstruction (11.1 vs. 47.6 %, P = 0.01). Peptic ulcer history, diabetes mellitus, and reconstruction type had a significant effect on marginal ulcer formation.

Conclusions

Child reconstruction with a modified Braun enteroenterostomy offers an advantage with respect to marginal ulcer after standard pancreaticoduodenectomy, potentially decreasing the incidence of alkaline reflux gastritis as effectively as Roux-en-Y reconstruction.     

Single Balloon Enteroscopy (SBE) Assisted Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients with Roux-en-Y Anastomosis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches.

Aim

The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center.

Methods

This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined.

Results

Fourteen patients (nine women) with a median age of 63 years (range 35–83 years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n = 4), hepaticojejunostomy (n = 9) and partial gastrectomy (n = 1). Indications for SBE-ERCP were obstructive jaundice (n = 10), cholangitis (n = 7), post-PTC internalization (n = 3) and biliary stent extraction/exchange (n = 2). The hepaticojejunostomy site (HJS) was reached in 15 (68 %) procedures. Successful interventions were performed in 11 (73 %) of 15 cases, including balloon dilation of biliary strictures (n = 3), insertion of biliary stents (n = 7), retrieval of biliopancreatic stents (n = 4) and biliary stone extraction (n = 4). The mean procedural time for successful interventions was 97.6 min (range 73–147 min). No procedural complications occurred during the median follow-up of 501 days (range 22–1,242 days).

Conclusion

SBE-ERCP is safe and carries an acceptable success rate in experienced hands.     

Endoscopic biliary drainage for children with persistent or exacerbated symptoms of choledochal cysts

Background

Symptoms of choledochal cysts sometimes persist or become exacerbated. As preoperative management for patients with these cysts, we prospectively employed endoscopic drainage, based on the theory that protein plugs cause symptoms by obstructing the pancreatobiliary ducts.

Methods

Children with choledochal cysts underwent endoscopic retrograde cholangiopancreatography (ERCP). When ERCP showed compaction with filling defects in patients with persistent or worsening symptoms (study patients), the placement of a short biliary stent tube was attempted for drainage. The clinical and ERCP findings of the study patients were compared with those of patients who were asymptomatic at ERCP (asymptomatic patients).

Results

There were 13 study patients (median age 2.9 years) and 41 asymptomatic patients (4.7 years) enrolled in the study between August 2005 and February 2011. Study patients more frequently had jaundice and elevated transaminase levels. ERCP showed that all study patients had obstruction or compacted filling defects in the common channel or the narrow segment distal to the cyst. Insertion of a stent tube was successful in 11 patients. Symptoms were relieved soon after biliary drainage. Surgery revealed that the obstructing materials were protein plugs, except in one case, which involved fatty acid calcium stones.

Conclusions

These results support the protein plug theory. Endoscopic short-tube stenting is adequate and effective as preoperative management.     

Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?

Background

Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies.

Methods

The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement.

Results

The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC.

Conclusions

ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.     

Tips and tricks of double‐balloon endoscopic retrograde cholangiopancreatography (with video)

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double‐balloon endoscopy (DBE) allows endoscopic access to pancreato‐biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux‐en‐Y or Billroth‐II reconstruction, using DBE have been reported. However, two major technical parts are required for double‐balloon ERCP (DB‐ERCP). One is insertion of DBE and the other is an ERCP‐related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux‐en‐Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB‐ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB‐ERCP.     

One- and two-step self-expandable metal stent placement for distal malignant biliary obstruction: a propensity analysis

Background

Although self-expandable metal stents (SEMS) are widely used for distal malignant biliary obstruction, one-step SEMS (direct placement without a prior plastic stent) and two-step SEMS (placement at second endoscopic retrograde cholangiopancreatography [ERCP] following plastic stent placement) have not been fully compared.

Methods

In this multicenter retrospective study, patients were included who underwent first-time endoscopic SEMS placement between September 1994 and December 2010. We compared the one-step and two-step strategies using a propensity analysis.

Results

In total, 370 patients were identified and one-step SEMS was performed in 59 patients. After adjustment using propensity scores, the median times to dysfunction were 116 and 219?days, respectively, for one-step and two-step SEMS (P?=?0.058). Stent migration was more frequently observed in one-step SEMS as compared with two-step SEMS (25 vs. 11?%, P?=?0.031). In one-step SEMS, the number of days of hospitalization associated with first-time SEMS placement was shorter compared with that in two-step SEMS (21 vs. 30?days, P?=?0.001), and the total costs of SEMS-related interventions within 6?months were lower (6510 and 8100 USD, P?=?0.004). The pathological diagnosis rates for pancreatic and biliary tract cancer at initial ERCP were 52 and 61?%. After failed diagnosis at initial ERCP, pathological diagnosis rates for pancreatic cancer were 32 versus 76?% (P?=?0.005) by repeated ERCP versus endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA).

Conclusions

One-step SEMS was associated with increased stent migration, despite having potential cost-effectiveness. The additional yield of pathological diagnosis at repeated ERCP was low compared with that yielded by EUS-guided FNA.     

Clinical Characteristics of Small Bowel Tumors Diagnosed by Double-Balloon Endoscopy: KASID Multi-Center Study

Background

Small bowel tumors are relatively rare, and their confirmative diagnosis before surgery is not easy.

Aims

This study was performed to investigate the clinical characteristics of patients with small bowel tumors who received double-balloon enteroscopy (DBE). Secondary end points were to evaluate the usefulness and safety of DBE for the diagnosis of patients with suspected SB tumors derived from other previous procedures.

Methods

We retrospectively analyzed consecutive DBE examinations to explore the small intestine in eight university hospitals over a 5-year period.

Results

A total of 877 DBE examinations (per oral 487, per anal 390) were performed in 645 patients (405 males, mean age 48.2 years). Small bowel tumors were diagnosed in 112 patients (17.4%), of which 38 patients had benign polyps, 29 had gastrointestinal stromal tumors/leiomyomata, 18 had lymphomas, 14 had adenocarcinomas, five had metastatic or invasive cancers, five had lipomas, and three patients had cystic tumors. The main reasons for DBE among patients with small bowel tumors were obscure gastrointestinal bleeding (OGIB, 40.2%) followed by abnormal imaging study (25.2%). The concordance rate of diagnoses based on DBE with diagnoses based on small bowel follow-through, CT, and capsule endoscopy among patients with small bowel tumors was 68.9% (42/61), 75.3% (70/93), and 78.3% (18/23), respectively. Therapeutic plans were changed due to the DBE results in 64.2% of patients with small bowel tumors.

Conclusions

Approximately one-sixth of patients who received DBE had small bowel tumors, and the most common reason for DBE among patients with small bowel tumors was OGIB. DBE is a useful method for the confirmative diagnosis of small bowel tumors and has a good clinical impact on therapeutic plans and short-term clinical results.     

Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance

Purpose

This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact.

Methods

This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7 years. Procedural and patients' characteristics were precisely analyzed.

Results

Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P?<?0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245?±?65.3 vs. 218?±?62.6 and 355?±?101.9 vs. 319?±?91.2, respectively; P?<?0.001, each). By analyzing only recent years of enteroscopy (2008–2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40 min; anal: 55 vs. 46 min, P?<?0.001) and the usage of sedation was significantly less (propofol: P?<?0.001; pethidine: P?<?0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2 %; P?<?0.001). The rate of severe adverse events was close to zero.

Conclusion

Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.     

Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India

Background

Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures.

Methods

We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated.

Results

Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3 %) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4–60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40 %), asymptomatic elevation of liver enzymes in four (40 %) and jaundice in two patients (20 %). The median time from transplantation to the detection of the stricture was 12 months (2–42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2–5) endoscopic sessions and 3.4 (1–6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2–12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7–11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis.

Conclusions

Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.

     

Single-Operator Wire-Guided Cannulation Technique Enables Easier Cannulation of Endoscopic Retrograde Cholangiopancreatography

Background

The single-operator wire-guided cannulation technique in endoscopic retrograde cholangiopancreatography (ERCP) has been rarely reported.

Aims

This study was undertaken to determine the safety and efficiency of a single-operator wire-guided cannulation technique.

Methods

Four hundred sixty-five consecutive patients referred for ERCP were included in this prospective study and randomly divided into two groups. A new single-operator wire-guided cannulation technique was performed by the same experienced endoscopist, with experienced assistants (group A) and inexperienced ones (group B). The number of attempts at cannulation, cannulation time, success rate, and procedure-related complications were compared between the two groups.

Results

Successful cannulation was achieved in 460 out of the 465 patients (98.92?%). The incidences of post-ERCP pancreatitis, bleeding, infection, and perforation were 5.16, 0.64, 1.08, and 0?%, respectively. There were no severe complications or death. The cannulation time, number of attempts at cannulation and complications were not significantly different between the two groups (all P?>?0.05).

Conclusions

The single-operator wire-guided cannulation technique was feasible, safe and efficient. It doesn??t require an experienced assistant and precise coordination between the assistant and endoscopist during cannulation.     

Autoimmune pancreatitis mimicking pancreatic cancer

Background/purpose

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that can often be difficult to distinguish from pancreatic cancer. We describe the clinical and radiographic features of 23 patients with AIP whose presentations mimicked pancreatic cancer.

Methods

A review of clinic, radiology, and endoscopy records from a 6-year period identified patients with AIP initially suspected of having pancreatic cancer. Abdominal computed tomography (CT) with intravenous contrast, endoscopic ultrasonography (EUS), and/or ERCP was performed in each patient. The diagnosis of AIP was made histologically and/or cytologically for each patient.

Results

Nineteen of 23 patients (83%) presented with new-onset weight loss, jaundice, or both. Nineteen (83%) patients had CT findings worrisome for pancreatic cancer including: (1) pancreatic enlargement or focal mass, (2) regional lymphadenopathy, and/or (3) vascular invasion. Eighteen patients (78%) had common bile duct strictures on ERCP. EUS-guided fine-needle aspiration biopsies excluded pancreatic cancer in all 22 patients who had EUS (96%). Seven patients had surgery for continued suspicion of pancreatic cancer.

Conclusions

Although AIP commonly presents with features suggestive of pancreatic cancer, clinical recognition of AIP with appropriate diagnostic testing including EUS with fine-needle aspiration, ERCP, IgG4 levels, and pancreatic protocol CT expedites diagnosis and can spare patients unnecessary surgery.     

The timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography in cholelithiasis coexisting with choledocholithiasis

Background

An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreaticography (ERCP). Although early cholecystectomy is advised, there is no consensus about the time interval between LC and ERCP. The aim of this study is to evaluate the effects of the time interval between ERCP and ERCP on operation outcomes.

Methods

Patients with cholelithiasis and a risk of choledocholithiasis underwent ERCP. Patients were grouped as those operated on between 24 and 72 h after ERCP (group 1) and those operated on more than 72 h after ERCP (group 2). Patients’ age, gender, body mass index, American Society of Anesthesiologists Physical Status, abdominal ultrasonography findings, white blood cell count, total serum bilirubin, ALP, amylase, ALT, AST, GGT levels, ERCP findings, time interval between ERCP and LC, conversion rate, median postoperative hospital stay, median operation time, intraoperative complication and postoperative complication rates were collected.

Results

There was no significant difference between the demographics of the patients in both groups. The median operation time, median postoperative hospital stay and conversion rate in group 2 were significantly higher than those of group 1. More postoperative complications were seen in group 2.

Conclusion

Early cholecystectomy after ERCP, within 72 h, has better outcomes, probably due to the inflammatory processes.     

Complications of the treatment of endoscopic biliary strictures developing after liver transplantation

Background

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Endoscopic management by the conventional methods of biliary dilatation and/or stent placement has been successful, but sometimes severe complications occur, necessitating prolonged therapy. The aim of this study is to clarify the complications of the endoscopic approach for endoscopic dilatation and/or stent placement.

Method

Of 46 patients who underwent living-donor liver transplantation, 10 were diagnosed as having anatomic biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP). Two patients developing biliary strictures after deceased-donor liver transplantation were also enrolled in the study. For the purpose of comparison, 302 patients with a total of 550 consecutive ERCP cases (including 115 patients with 250 malignant bile duct strictures) were recruited in this study. Success rate, number of endoscopy sessions, the median procedure time for ERCP, and incidence of complications including post-ERCP pancreatitis were compared in the OLT cases and other cases.

Results

The following results were obtained in the OLT cases, malignant stricture cases, and all cases, respectively: mean number of endoscopy sessions was 3.62, 2.17, and 1.94 (P?=?0.0216, P?P?=?0.0327, P?=?0.0093); and severe pancreatitis occurred in 2 cases of OLT. In a univariate analysis for post-ERCP pancreatitis, OLT was extracted as the only significant risk factor.

Conclusions

Endoscopic maneuvering for biliary dilatation and/or stent placement following OLT was associated with a higher risk of post-ERCP pancreatitis than the use of the same technique for the treatment of malignant biliary stricture. Endoscopic treatment after OLT was a significant risk factor for post-ERCP pancreatitis.