Endoscopic papillotomy in the treatment of biliary tract disease

Endoscopic papillotomy has been successfully performed in 258 of 267 patients (96.6%) presenting with common duct stones, papillary stenosis, or ampullary adenocarcinoma. A low morbidity was experienced (5%) while mortality was 0.77% (2 deaths). Surgical intervention was necessary in 2 patients. The mean age of the group is 66.4 years (range 26–95 years), while the mean hospital stay remains low at 3 days (range 1–12) days. The procedure has proven to be safe and effective, creating a permanent biliary enteric fistula comparable to standard surgical procedures, but does not require a laparotomy/duodenotomy. Eliminating the latter reduces morbidity, immobility, and convalescence. Papillotomy is not a procedure to be performed by inexperienced endoscopists as it is the only endoscopic procedure with predictable morbidity and mortality. In order to maintain the progress achieved to date, papillotomy should be performed by those with extensive endoscopic experience in the diagnostic area before embarking onto the therapeutic procedure.     

Endoscopic interventions in the biliary tract

Opinion statement In patients with common bile duct stones, the endoscopic removal of such stones has become the standard therapy. The surgical approach is indicated only for stones that cannot be extracted endoscopically. In biliary obstruction due to pancreaticobiliary malignancy, endoscopic interventions represent the first-line therapy in the palliative situation. If endoscopic access is not possible, the percutanous approach often represents an alternative, followed by palliative surgical options. Biliary strictures or bile leaks after liver transplantation very often may be treated effectively by endoscopic dilatation or temporary stenting. In most cases, endoscopic therapy of such problems represents the first option before the percutaneous or surgical approach is indicated. In primary sclerosing cholangitis, dominant biliary strictures develop frequently and endoscopic treatment allows their opening in most cases. There is no real alternative to endoscopy in this situation. The situation is more complex in postoperative biliary strictures and chronic pancreatitis. In these conditions, advantages and disadvantages of the endoscopic versus the surgical approach have to be evaluated to find the most effective form of treatment in the individual situation. The surgical intervention often represents the better alternative.     

Endoscopic treatment of biliary tract disease prior to orthotopic liver transplantation

Opinion statement Endoscopic therapy for biliary tract disease in patients with end-stage liver disease (ESLD) before liver transplantation is safe and effective. Reported results in patients with choledocholithiasis, primary sclerosing cholangitis (PSC), and symptomatic gallbladder diseases are encouraging. Prompt recognition and appropriate treatment of symptomatic gallbladder and bile duct disease are important in reducing morbidity and mortality in these high-risk patients while they await liver transplantation. Confirmation of tissue diagnosis of cholangiocarcinoma in patients with sclerosing cholangitis is still difficult. Better screening tools and diagnostic methods are necessary for early detection. Because liver transplantation is the only definitive therapy for patients with advanced cirrhosis, maintenance of their candidacy with either endoscopic or radiologic therapeutic interventions is warranted until transplantation. Endoscopic therapy is the preferred method when feasible. If necessary, percutaneous transhepatic biliary drainage (PTBD) is a viable alternative because both avoid the attendant risks of surgery in a high-risk population with advanced liver disease.     

Endoscopic treatment of biliary tract strictures in sclerosing cholangitis: a larger series and recommendations for treatment

We report a group of 35 patients with primary sclerosing cholangitis who had long-term follow-up after endoscopic treatment of major ductal strictures in the primary or secondary biliary ducts. Our patients were all symptomatic with ascending cholangitis or jaundice. There was significant improvement as measured by clinical parameters of hospitalization rates and laboratory data and comparable radiography. Long-term follow-up averaged 24 (+/- 2.8 months). We believe endoscopic treatment of sclerosing cholangitis should be attempted in selected symptomatic cases with major ductal strictures before liver transplantation.     

内镜治疗术后胆漏和继发胆管狭窄

目的 探讨内镜治疗手术后并发胆漏和继发胆管狭窄的方法及效果。方法 胆漏患 者均先行内镜下十二指肠乳头切开,行鼻胆管引流术,继续保留原有胆道、腹腔引流。待胆道、腹腔引 流停止1-2周证实胆漏愈合后拔管,伴有胆道狭窄的患者在拔除鼻胆引流管后置入塑料内支架,持 续扩张2-3个月。结果 22例胆漏患者鼻胆引流3-4周后胆漏处均闭合,13例胆管狭窄置入内支 架者,10例支架取出后狭窄解除,2例合并肝总管狭窄者经重新置入双支架3个月后效果良好,1例 左肝管狭窄伴结石者,再置入单支架,术后仍有胆道感染症状反复出现。结论 内镜治疗可列为手术 后胆漏或继发胆管狭窄治疗的首选方法。     

Endoscopic and radiologic management of pancreatic and biliary tract diseases

Therapeutic biliary and pancreatic endoscopy has evolved over the last 30 years to a level where it represents the primarily mode of therapy for many frequently encountered diseases of the bile ducts liver and pancreas. The complication rates are expected to be low and the expectations of our colleagues are high. The endoscopist is expected to understand the origin and natural history of these diseases and the consequences of the various management options. The training of the endoscopist has taken on a very formal character, as has the emphasis on competency and quality improvement. The appearance of minimally invasive surgery and advanced imaging does not represent a threat to the biliary endoscopist but rather is complimentary and assists us so that unnecessary potentially morbid procedures are not done unnecessarily. The appearance of a new specialty: the minimally invasive biliary interventionalist, who would receive training by gastroenterologists, interventional radiologist and biliary-pancreatic surgeons, is the logical next step!     

Non-invasive endoprosthesis in treatment of biliary fistulas and pancreaticfistulas

AIM To search for a simple and safe method to avoid reoperation, reduce complications and mortality,shorten hospital stay and lower the medical cost.METHODS Based on the characteristic of pathology and anatomy of biliary fistula and pancreatic fistula,modified endoscopic nasobiliary drainage or endoscopic nasopancreas drainage with negative pressure wereused to drain the bile and pancreatic juice to the duodenum and in vitro to facilitate fistulous tract close.RESULTS In seven patients with biliary fistulas with conservative treatment who were not yet recoveredafter 6 - 110 days, the leakage was blocked after 6 - 17 days treatment, and in 6 patients with pancreaticfistulas with conservative treatment who were not recovered after 90 - 720 days, the leakage was blockedafter treatment for 12- 28 days.CONCLUSION The advantages of this modefied method are: retain the function of the Oddi sphincter; the anatomy of the pancreatic duct and bile duct and the position of fistulas can be seen clearly withcontrast examination; the drainage effect was defieate, safe and with less complications; the leakageblock can be promoted with the drainage of negative pressure; and hospital stay is shortened and medicalcost is reduced.     

Endoscopic removal of Ascaris lumbricoides from the biliary tract as emergency treatment for acute suppurative cholangitis

Ascariasis is the most common intestinal helminthiasis worldwide. Heavily infected individuals are prone to develop bowel obstruction or perforation as well as biliary disease. Nevertheless, the presence of roundworms in the biliary tree outside endemic areas is very uncommon. The migration of these worms to the biliary system can cause biliary colic, pancreatitis, or even acute suppurative cholangitis with hepatic abscesses and septicemia.We report here on 2 infants with 14 and 15 months and a 9-year-old boy who suffered from massive biliary ascariasis and who presented with acute suppurative cholangitis. All cases were successfully treated by endoscopic retrograde cholangiopancreatography with worm extraction and adjuvant medical therapy.Physicians should be aware of ascariasis in patients with pancreatobiliary symptoms who have traveled to endemic areas or in immigrants from these areas.     

Endoscopic treatment of biliary complications after liver transplantation

AIM： To evaluate the efficacy of endoscopic treatment in patients who undergo OLTx or LRLTx and develop biliary complications. METHODS： This is a prospective, observational study of patients who developed biliary complications, after OLTx and LRLTx, with duct-to-duct anastomosis performed between June 2003 and June 2007. Endoscopic Retrograde Cholangiopancreatography （ERCP） was considered unsuccessful when there was evidence of continuous bile leakage despite endoscopic stent placement, or persistence of stenosis after i year, despite multiple dilatation and stent placement. When the ERCP failed, a percutaneous trans-hepatic approach （PTC） or surgery was adopted. RESULTS： From June 2003 to June 2007, 261 adult patients were transplanted in our institute, 68 from living donors and 193 from cadaveric donors. In the OLTx group the rate of complications was 37.3%, while in the LRLTx group was 64.7%. The rate of ERCP failure was 19.4% in the OLTx group and 38.6% in LRLTx group. In OLTx group, i patient was retransplanted and 8 patients died. In the LRLTx group, 2 patients underwent OLTx and 8 patients died. The follow-up was 23.3±13.13 mo and 21.02± 14.10 mo, respectively.CONCLUSION： Albhough ERCP is quite an effective mode of managing post-transplant bile duct complications, a significant number of patients need other types of approach. Further prospective studies are necessary in order to establish whebher obher endoscopic protocols or new devices, could improve bhe current results.     

十二指肠乳头部微胆石的内镜诊治

目的探索十二指肠乳头部微胆石的内镜诊治方法和价值。方法对反复胆绞痛、术后再发胆绞痛、特别是发生急性胰腺炎者进行内镜乳头切开,观察乳头有无排石,收集胆汁进行显微镜检。结果在完成内镜检查治疗的319例患者中发现微胆石34例（10.7%,34/319）;依来源分：胆囊型（Ⅰ型）8例,胆管型（Ⅱ型）7例,胆囊胆管混合型（Ⅲ型）19例。单纯内镜治疗26例;内镜联合胆囊切除8例。结论微胆石临床发病率不高,但危害和风险大,内镜是最有效的诊断和治疗方法,Ⅰ型和Ⅲ型可联合切除胆囊。     

Endoscopic and surgical integration in the approach to biliary tract disease

Several techniques are available today to access the bile ducts, all equally safe and effective. Since 1990, we have studied three groups of patients treated with different methods: the sequential endoscopic sphincterotomy + laparoscopic cholecystectomy, the single-stage laparoscopic approach, and the single laparoscopic-endoscopic approach. The results obtained in 127 patients to date suggest that one single-stage treatment is more convenient for the patient, while the combination of endoscopic sphincterotomy with laparoscopic cholecystectomy is preferable in terms of efficacy and safety.     

Endoscopic management of esophagorespiratory fistulas

Esophagorespiratory fistulas (ERFs) are pathologic communications between the esophagus and respiratory tract. They are devastating conditions of malignant or benign (often iatrogenic) etiologies. Patients with ERF have significantly increased mortality and decreased quality of life. Multiple management options exist for the treatment of ERFs including surgical, endoscopic, and oncologic approaches. Surgical management, with fistula closure and removal of diseased esophageal or pulmonary tissue, is the time-honored treatment of ERF. However, these surgeries are major undertakings and many patients with ERF are poor surgical candidates. As such oncologic and endoscopic therapies are often employed. Many endoscopic therapies exist for the management of ERF and include: esophageal stenting, airway stenting, combined esophageal, and airway stenting, over-the-scope clip placement, cardiac septal occlusion devices, and other novel therapies (argon plasma coagulation, fibrin glue, endoscopic suturing, and polyglycolic acid sheets). These treatments can be employed alone or in combination. Each endoscopic management strategy has its own clinical success rate and adverse events. Although advances in endoscopic techniques have broadened the tools available to treat ERFs; little if any data are available comparing the various endoscopic management strategies. Despite this an experienced clinician may select the appropriate intervention to maximize the risks/benefits of the procedure based on the size, location, and etiology of the fistula.