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.     

A novel biodegradable biliary stent in the endoscopic treatment of cystic-duct leakage after cholecystectomy

BACKGROUND: A bile leak is a common complication after a cholecystectomy. OBJECTIVE: The use of a novel, self-expanding, radiopaque polylactide-barium sulphate biodegradable stent and a polyethylene stent was investigated in 12 pigs with cystic-duct leakage. DESIGN: Prospective animal study. SETTING: After cholecystectomy, the cystic duct was left without ligation, and then the foramen of Winslow was drained extra-abdominally. During the duodenoscopy, a biodegradable or a polyethylene biliary stent was inserted into the bile duct. MAIN OUTCOME MEASUREMENTS: The bile-drain output was measured daily, and when it was below 20 mL/d, the drain was removed. The animals were followed by repeated abdominal radiographs and serum determinations until they were euthanized at 6 months, when histologic evaluation of the bile duct and surrounding tissues was performed. RESULTS: In the biodegradable stent group, the total external output of bile was significantly smaller (median [range], 165 mL [100-1740 mL] vs 710 mL [355-1020 mL]; P<.01) and the drains could be removed earlier (5 days [4-5 days] vs 7 days [6-7 days] after surgery; P<.05) compared with the plastic stent group. In the abdominal radiograph, a biodegradable or polyethylene stent was seen to be in place in all animals at 3 months and in 0 of 6 (biodegradable biliary stent group) and 1 of 5 (polyethylene biliary stent group) animals at 6 months. One polyethylene stent was found to be clotted at the necropsy at 6 months. The rest of the stents had disappeared by 6 months, and there was no significant difference in the bile-duct inner diameter or the histology between the groups. CONCLUSIONS: This novel biodegradable stent is applicable, safe, and effective in the endoscopic treatment of postcholecystectomy cystic-duct leakage. In addition, the subsequent removal of the stent can be avoided. These encouraging experimental results warrant further clinical trials.     

Colonic diverticular perforation by a migrated biliary stent: A case report with literature review

Rationale:Plastic endobiliary stents, after endoscopic retrograde cholangiopancreatography, can get spontaneously dislocated from the common bile duct and migrate intothe distal bowel. Most migrated biliary stents are removed with the passing of stool. However, migrated biliary stents can cause bowel perforation, albeit rarely, and surgical intervention may be required. Recently, we observed a colonic diverticular perforation caused by a migrated biliary stent, and we have reported this case with a review of the literature.Patients concerns:A 74-year-old man presented with severe right lower quadrant pain after biliary stent insertion 1month ago.Diagnoses:Abdominal computed tomography revealed perforation of the proximal ascending colon by the migrated biliary stent, combined with localized peritonitis.Interventions:Emergency diagnostic laparoscopic examination revealed penetration of the proximal ascending colon by the plastic biliary stent, and right hemicolectomy was performed.Outcomes:On pathological examination, colonic diverticular perforation by the biliary stent was confirmed. The patient was discharged without any additional complications.Lessons:Endoscopic retrograde cholangiopancreatography endoscopists must always be cautious of the possibility of stent migration in patients with biliary stents in situ. In cases of biliary stent dislocation from the common bile duct in asymptomatic patients, follow-up with serial, plain abdominal radiographs, and physical examination is needed until confirmation of spontaneous passage through stool. In symptomatic cases suggesting peritonitis, abdominal computed tomography scan confirmation is needed, and early intervention should be considered.     

Endoscopic management of post-cholecystectomy biliary fistula

ObjectiveBile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries.MethodsA retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion.ResultsControlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen.ConclusionsThis review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.     

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.     

Morphological changes in bile ducts following preoperative biliary stenting.

OBJECTIVES: To analyze the morphological changes in bile ducts following endobiliary stent insertion, and consequent technical problems encountered at surgery. METHODS: Data on bile duct morphology--gross (luminal diameter and wall thickness) and microscopic (histological changes in bile duct wall graded semiquantitatively)--and operative parameters related to bile duct dissection (grade of difficulty in dissection) were collected prospectively in 31 consecutive patients undergoing pancreatico-duodenectomy. These data were compared between patients who had undergone preoperative endoscopic biliary stent placement (n=17) and those who had not (n=14). RESULTS: Mean duration of stenting before surgery was 34 (range 10-120) days. Stented ducts were significantly narrower (luminal diameter 9 [7-12] mm vs. 17.5 [8-23] mm; p=0.0001) and had thicker walls (2.3 [1.3-3.5] mm vs. 1.85 [0.8-2.2] mm; p=0.004) compared to non-stented ones. On microscopy, stented ducts had advanced grades of submucosal gland hypertrophy, fibrosis and inflammatory cell infiltrate. Difficulty in bile duct dissection was encountered more often in patients who had been stented than in those without stents, though the difference was not statistically significant. CONCLUSION: Endobiliary stent placement results in significant morphological and fibroproliferative inflammatory changes in bile ducts, making dissection difficult.     

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.     

Endoscopic placement of a new short-term biodegradable pancreatic and biliary stent in an animal model: a preliminary feasibility study (with videos)

Background and purpose

Recently, biodegradable pancreatic stents have been designed and placed in vivo and in vitro. The aim of this study is to investigate the feasibility of endoscopic stenting using the novel, braided, self-expandable, biodegradable, pancreatic and biliary stent in a pig model.

Methods

A braided, self-expandable, biodegradable stent was endoscopically placed into the pancreatic duct and bile duct in 4 pigs. Eventually, necropsy was performed to evaluate the stent placement after the procedure.

Results

Pancreatic and biliary stents were successfully inserted and easily deployed across the papilla into the main pancreatic duct and bile duct, respectively, in all the animals under endoscopic and fluoroscopic guidance. Necropsy performed immediate following stent placement, found that stents had been placed across the papilla and stent expansion had occurred in all cases.

Conclusions

Although this stent is not radiopaque and the number of cases was small in this experimental study, endoscopic stenting using this novel, braided, self-expandable, biodegradable, pancreatic and biliary stent was feasible in the pig model. Further animal studies to evaluate the short-term patency, tissue reactivity and degradability of the stents are warranted.     

CURRENT STATUS AND FUTURE EXPECTATIONS FOR ENDOSCOPIC BILIARY DRAINAGE IN 16 HOSPITALS

The authors examined the performance of endoscopic biliary drainage (EBD) in 16 hospitals. The examination was in the form of a questionnaire given between 1 June and 20 July 2005 to clarify the status of 369 patients who had undergone EBD. A total of 124 patients underwent endoscopic nasobiliary drainage (ENBD), 224 patients underwent endoscopic biliary drainage (EBS), and one patient underwent simultaneous ENBD and EBS. With regard to the underlying diseases, 227 patients had malignant disease and 142 had benign disease. A total of 244 patients underwent EBS. Plastic stent (PS) was used in 200 cases, and metal stent (MS) in 44 cases. One stent was used in 89% of cases, two stents in 10%, three or more stents in 1%. Metal stent was used in 44 patients (23 were covered and 21 uncovered) with unresectable biliary stenosis. One stent was used in 33 patients, two stents in 10 patients, and three stents in one patient. For treating middle and inferior common bile duct stenosis, PS having a caliber of 10 Fr is too soft; newer tubes should be developed utilizing materials that provide longer stent patency. Longer patency can be achieved now by applying EBS using a covered MS. Improving the materials will also improve stent flexibility and the smoothness of the coating film. When treating superior common bile duct and porta hepatic bile duct stenosis, the stent is placed in both lobes of the liver.     

A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model

AIM:To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for onestep endoscopic ultrasound(EUS)-guided biliary drainage(EUS-BD)in a new experimental biliary dilatation porcine model.METHODS:A novel dedicated device for one-step EUS-guided biliary drainage system(DEUS)introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation.A self-expandable metal stent,consisting of both uncovered and nitinol-covered portions,was preloaded into DEUS introducer.After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs,EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices.RESULTS:One-step EUS-BD was technically successful in seven pigs[7/9(77.8%)as intention to treat]without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic(n=2)or common hepatic(n=5)duct.Primary technical failure occurred in two cases that did not show adequate biliary dilatation.In seven pigs with a successful bile duct dilatation,the technical success rate was 100%(7/7 as per protocol).Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min(IQR;8.9-18.1).There were no immediate procedure-related complications.CONCLUSION:Modified tapered metal tip and low profile introducer may be technically feasible for onestep EUS-BD in experimental porcine model.     

Covered metallic stent for ischemic hilar biliary stricture

Compared with surgery, endoscopic treatment is safe and highly effective for a postoperative hilar benign bile duct stricture (BDS). However, the long-term outcome of conventional placement of a single biliary stent for hilar benign BDS is generally poor. Although the placement of multiple biliary stents is preferred, multiple stenting in a BDS is difficult. Alternatively, single or multiple stent placement above the papilla ('inside stent') or fully-covered self-expandable metallic stents (SEMS) are feasible approaches for benign BDS. Nevertheless, controversy remains regarding whether and how to perform endoscopic biliary drainage for a hilar benign BDS. In patients with hilar benign BDS, endoscopic biliary drainage can be performed by placing conventional plastic stents across the papilla, plastic stents above the papilla or fully-covered SEMS. Individualized treatment should be considered. We report the placement of a fully-covered SEMS for a hilar benign biliary stricture after extended left hepatectomy.     

Removal of a large stone growing around and encasing a plastic biliary stent: Respect the ductal axis

Plastic biliary stents are commonly used during Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The main indication for biliary stenting is benign or malignant obstruction. Plastic stents, among others, can be used as an escape route in patients with large common bile duct stones, or in cases of acute cholangitis with or without sphincterotomy to provide drainage until definitive treatment. Stent occlusion is the main disadvantage, limiting their patency to around 3 months, after which replacement is recommended. We present a case of a large, close to 2 cm, stone developing around and encasing the proximal end of a plastic biliary stent. The stent/stone complex was successfully removed en bloc. The stent was placed in the common bile duct without sphincterotomy, and remained in situ for 2 years. The presented case highlights the importance of definitive treatment for common bile duct stones, the need to respect the ductal axis especially when dealing with large stones and the significance of biliary sphincterotomy during endoscopic interventions in the bile duct.     

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.     

Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents

AIM: To determine the efficacy the value of self-expandable metal stents in patients with benign biliary strictures caused by chronic pancreatitis. METHOD: 61 patients with symptomatic common bile duct strictures caused by alcoholic chronic pancreatitis were treated by interventional endoscopy. RESULTS: Initial endoscopic drainage was successful in all cases, with complete resolution of obstructive jaundice. Of 45 patients who needed definitive therapy after a 12-months interval of interventional endoscopy, 12 patients were treated with repeated plastic stent insertion (19.7%) or by surgery (n = 30; 49.2%). In 3 patients a self-expandable metal stent was inserted into the common bile duct (4.9%). In patients treated with metal stents, no symptoms of biliary obstruction occurred during a mean follow-up period of 37 (range 18-53) months. The long-term success rate of treatment with metal stents was 100%. CONCLUSIONS: Endoscopic drainage of biliary obstruction by self-expandable metal stents provides excellent long-term results. To identify patients who benefit most from self-expandable metal stent insertion, further, prospective randomized studies are necessary.     

Do the benefits of metal stents justify the costs? A systematic review and meta-analysis of trials comparing endoscopic stents for malignant biliary obstruction

BACKGROUND: A variety of stent designs has been studied for endoscopic stenting of the bile duct in patients with malignant biliary obstruction. Although metal stents are associated with longer patency, their costs are significantly higher than plastic stents. AIMS: To compare clinical outcome and cost-effectiveness of endoscopic metal and plastic stents for malignant biliary obstruction by a systematic review and meta-analysis of all randomized controlled trials in this area. METHODS: We conducted searches to identify all randomized controlled trials in any language from 1966 to 2006 using electronic databases and hand-searching of conference abstracts. Meta-analysis was performed with RevMan software [Review Manager (RevMan) version 4.2 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003]. RESULTS: Seven randomized controlled trials were identified that met the inclusion criteria, and 724 participants were randomized to either metal or plastic endoscopic stents. No significant difference between the two stent types in terms of technical success, therapeutic success, 30-day mortality or complications was observed. Metal stents were associated with a significantly less relative risk (RR) of stent occlusion at 4 months than plastic stents [RR, 0.44; 95% confidence interval (CI) 0.3, 0.63; P<0.01]. The overall risk of recurrent biliary obstruction was also significantly lower in patients treated with metal stents (RR, 0.52; 95% confidence interval 0.39, 0.69; P<0.01). The median incremental cost-effectiveness ratio of metal stents was $1820 per endoscopic retrograde cholangiopancreatography prevented. CONCLUSION: Endoscopic metal stents for malignant biliary obstruction are associated with significantly higher patency rates than plastic stents as early as 4 months after insertion. Metal stents will be cost-effective if the unit cost of additional endoscopic retrograde cholangiopancreatographies per patient exceeds $1820.     

Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center

Background: Proximal migration of a biliary or pancreatic stent is an infrequent event but its management can be technically challenging. Methods: Review of all cases of proximally migrated biliary and pancreatic stents over a 10-year period at a referral pancreatic-biliary center. Data abstracted from patient records included indication for stenting, method of presentation, success of attempt, and method used. Successful methods were determined by reviewing procedure reports. Follow-up was attempted in all patients in whom stent retrieval had failed. Results: Thirty-three proximally migrated bile duct stents, and 26 proximally migrated pancreatic duct stents were identified. Most of the patients were without symptoms. Eighty-five percent of common bile duct stents and 80% of pancreatic duct stents were successfully extracted endoscopically. Seventy-one percent (34 of 48) were retrieved with a basket or balloon. Of the stents not retrieved, two patients did not return for repeat ERCP, three patients with malignant common bile duct strictures were managed with placement of a second stent, three patients with pancreatic duct stents have remained without symptoms with no further retrieval attempts, and three patients with proximally migrated pancreatic duct stents required surgery because of pain and failure of multiple endoscopic retrieval attempts. Conclusion: Over 80% of proximally migrated bile duct and pancreatic duct stents may be extracted endoscopically. Few patients will require surgery. (Gastrointest Endosc 1998;47:486-91.)     

塑料支架内引流在老年难取性胆管结石中的应用

目的:回顾性分析在老年性难取性胆总管结石患者中胆道塑料支架置入治疗的安全性和有效性.方法:先行常规逆行性胆胰管造影(ERCP)明确诊断,根据胆管扩张及结石大小情况,行十二指肠乳头括约肌切开后经导丝引导放置胆道塑料支架通畅引流.结果:103例取石困难患者在常规ERCP后置入塑料支架.3-6mo后复查ERCP显示有60例(58.2%)结石成为小结石,经内镜应用网篮取出;13例(12.6%)结石未变化,重新更换支架引流;11例(10.6%)最后行腹腔镜胆囊切除胆管探查取石治疗;16例(15.5%)患者因无特殊不适未复查ERCP,长期行内支架引流.结论:对于老年性难取性胆管结石患者,塑料支架内引流是一种十分有效和相对安全的手术方式.     

Cholangiopancreatography troubleshooting:the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents

BACKGROUND:Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting.Although there are some procedures to retrieve the migrated stent,including surgical,percutaneous,and endoscopic approaches,endoscopy should be attempted first because it is least invasive.This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.METHODS:Plastic stents that migrated in the bile duct(35 patien...     

Efficacy of Biodegradable Polydioxanone and Polylactic Acid Braided Biodegradable Biliary Stents for the Management of Benign Biliary Strictures

Background:Benign biliary strictures (BBS) are widely treated by endoscopic procedures involving temporary stent placement. Occasionally, stents are required to be removed, making the treatment process very painful as well as expensive. Until now, no effective biodegradable biliary stents (BDBS) have been available for clinical applications. This study aims to investigate the safety and efficacy of biodegradable polydioxanone (PDO) and polylactic acid (PLA) braided BDBS both in vitro and in vivo.Methods:Monofilaments of 3 different diameters, of PDO (0.30, 0.35, and 0.40 mm) and PLA (0.10, 0.15, and 0.20 mm) were braided to biliary stents and their mechanical properties were studied. The stents were placed in an ex vivo bile duct model perfused with porcine bile, taken out, and observed every week until they were completely degraded. After the bile duct stenosis model was established successfully in piglet, stents with appropriate mechanical properties were further examined under endoscopy; the changes in hematology, patency time, and pathology of the stents were observed for 8 months.Results:A total of 10 pigs were included (2 groups; 5 PDO, 5 PLA) in the study. The patency time of the stents in the PLA group was significantly longer than that in the PDO group (25.7 ± 5.6 weeks vs 11.3 ± 3.4 weeks, respectively).Conclusion:Our results project that biodegradable PLA and PDO braided biliary stents could be a better choice to treat BBS, with different rates of degradation.     

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM： To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography （ERCP） without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS： Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCI and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS： The mean age of the patients was 28 years （range, 21-33 years）. The mean gestational age for the fetus was 23 wk （range, 14-34 wk）. Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION： Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.