Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study

BACKGROUNDBiliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIMTo investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODSIn this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)]. RESULTSBiliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).CONCLUSIONBiliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.     

Endoscopic removal technique of migrated pancreatic plastic stents

Endoscopic pancreatic stenting (EPS) is used for various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been observed. Especially, proximal stent migration presents a more serious condition because of the possibility of pancreatic duct (PD) damage. However, the removal of proximally migrated stents is technically challenging because of the small PD diameter, the bended PD course, the presence of PD strictures, and the lack of suitable devices for stent removal. Thus, few cases of surgical intervention have been encountered. In this study, we review the endoscopic treatment of proximally migrated pancreatic plastic stents. We classify migrated stent conditions into four types according to stent and PD conditions. In Type A, the main pancreatic duct (MPD) has no stricture. In Type B, the stent is positioned across the stricture on the MPD. In Type C, the stent is positioned further away from the stricture on the MPD. The tip of the proximal stent is located in the MPD in types A thru C. In Type D, the tip of the proximal stent is located in a branch duct. We introduced the strategy of endoscopic removal technique of each type of migrated plastic stents.     

经内镜放置胆管金属支架联合鼻胆管引流治疗恶性胆管梗阻

目的探讨经内镜放置胆管金属支架联合鼻胆管引流对恶性胆管梗阻的治疗效果。方法 115例失去手术机会的恶性胆管梗阻患者行经内镜逆行胰胆管造影下放置胆管支架,其中48例行胆管塑料支架引流术,30例行胆管金属支架引流术,37例行胆管金属支架联合鼻胆管引流术;分析各组引流效果、成功率、早期并发症和胆管再堵塞发生情况。结果塑料支架组、金属支架组及金属支架联合鼻胆管组的谷丙转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)和碱性磷酸酶(AKP)在手术后均有明显降低(P0.05);手术后1周金属支架联合鼻胆管组的TBIL和DBIL明显低于塑料支架组、金属支架组(P0.05),塑料支架组和金属支架组相比,差异无统计学意义(P0.05);术后3个月内金属支架组和金属支架联合鼻胆管组再堵塞的发生率明显低于塑料支架组(P0.05),金属支架组和金属支架联合鼻胆管组相比,差异无统计学意义(P0.05);塑料支架组的手术成功率与金属支架组及金属支架联合鼻胆管组相比,差异无统计学意义(P0.05),塑料支架组的早期并发症发生率明显高于金属支架联合鼻胆管组,差异有统计学意义(P0.05)。结论经内镜逆行胰胆管造影下放置胆管金属支架联合鼻胆管对于恶性胆管梗阻有确切的引流效果。     

Biliary and pancreatic stenting: Devices and insertion techniques in therapeutic endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.     

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).METHODS: PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.RESULTS: Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).CONCLUSION: EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.     

Small bowel perforation from a migrated biliary stent:A case report and review of literature

BACKGROUND Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%.CASE SUMMARY We report a case of a 54-year-old Caucasian woman with a history of Human Immunodeficiency virus with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, portal vein thrombosis and extensive past surgical history who presented with acute abdominal pain and local peritonitis. On further evaluation she was diagnosed with small bowel perforation secondary to migrated biliary stents and underwent exploratory laparotomy with therapeutic intervention.CONCLUSION This case presentation reports on the unusual finding of two migrated biliary stents, with one causing perforation. In addition, we review the relevant literature on migrated stents.     

The Successful Treatment of Chronic Cholecystitis with SpyGlass Cholangioscopy-Assisted Gallbladder Drainage and Irrigation through Self-Expandable Metal Stents

A 34-year-old female with a history of advanced pulmonary sarcoidosis and right-sided heart failure presented with chronic, postprandial right upper quadrant pain, and weight loss. Endoscopic biliary drainage was deemed to be the most appropriate therapeutic option for her chronic cholecystitis. Endoscopic retrograde cholangiopancreatography utilizing the SpyGlass cholangioscopy system allowed us to access the cystic duct through which the gallbladder was ultimately decompressed, via biliary stent placement and gallstone irrigation. This is the first report of SpyScope assisted placement of fully covered self-expandable metal biliary stents into the cystic duct enabling definitive treatment of symptomatic chronic cholecystitis and cholelithiasis without cholecystectomy.     

Efficacy and safety of emergency endoscopic retrograde cholangiopancreatography for acute cholangitis in the elderly

AIM To investigate the efficacy and safety of emergency endoscopic retrograde cholangiopancreatography(ERCP) in elderly patients with acute cholangitis. METHODS From June 2008 to May 2016, emergency ERCPs were performed in 207 cases of acute cholangitis at our institution. Patients were classified as elderly if they were aged 80 years and older(n = 102); controls were under the age of 80 years(n = 105). The patients' medical records were retrospectively reviewed for comorbidities, laboratory data, etiology of cholangitis(presence of biliary stones, biliary stricture and malignancy), details of the ERCP(therapeutic approaches, technical success rates, procedure duration), ERCP-related complications and mortality. RESULTS The frequency of comorbidities was higher in the elderly group than the control group(91.2% vs 67.6%). Periampullary diverticulum was observed in the elderly group at a higher frequency than the control group(24.5% vs 13.3%). Between the groups, there was no significant difference in the technical success rates(95.1% vs 95.2%) or endoscopicprocedure durations. With regard to the frequency of ERCP-related complications, there was no significant difference between the two groups(6.9% vs 6.7%), except for a lower rate of post-ERCP pancreatitis in the elderly group than in the control group(1.0% vs 3.8%). Neither angiographic nor surgical intervention was required in any of the cases with ERCP-related complications. There was no mortality during the observational periods. CONCLUSION Emergency ERCP for acute cholangitis can be performed safely even in elderly patients aged 80 years and older.     

急性梗阻化脓性胆管炎的早期内镜介入与外科手术治疗的比较

目的:探讨急诊内镜微创介入与外科手术对急性梗阻化脓性胆管炎(acute obstructive suppurative cholangitis,AOSC)的治疗效果.方法:回顾性分析中国人民解放军总医院消化内科、肝胆外科2008-01/2011-06收治的72例AOSC患者的临床资料,分为内镜组54例:急诊内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopancreatogahpy,ERCP)微创介入治疗;手术组18例:手术开腹胆总管切开、留置T管引流.结果:72例患者平均年龄68.3岁±14.2岁,病因为胆道结石占88.9%、恶性肿瘤占11.1%.内镜组与手术组比较在平均年龄、性别构成、病因构成方面的差异均无统计学意义(P>0.05);在治愈率方面比较内镜组(94.4%)高于手术组(72.2%)(P<0.05);并发症(3.7%vs27.8%)及死亡率(0vs16.7%)内镜组均显著低于手术组(P<0.05),而术后住院时间(9.1d±8.0dvs16.2d±9.9d)和住院费用(3.64万元±1.52万元vs9.33万元±6.86万元),内镜组也均显著低于手术组(P<0.05).内镜组并发症:胰腺炎1例、乳头切开出血1例;手术组并发症:多脏器功能衰竭3例(均死亡)、胆漏1例、肝脓肿1例.结论:AOSC患者的外科手术并发症多、死亡率高,早期内镜微创介入治疗可显著减少并发症并降低死亡率,应成为治疗AOSC的首选方法.     

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.     

1257例ERCP的体会

为了总结经验，更好地进行诊断和治疗，对１２５７例逆行性胰胆管造影（ＥＲＣＰ）资料进行了回顾性分析。结果：成功１２２９例，成功率为９７．７７％，治疗４３５例，治疗率为３４．６１％。乳头切开及取石９４例，胆道引流３０９例。强调了胆囊显影及胆道引流的重要性。     

An unusual presentation of primary sclerosing cholangitis

This case report describes the unusual presentation of a patient who had findings which were initially suggestive of a type Ⅳ choledochal cyst. Her liver biopsy demonstrated biliary cirrhosis. She was treated with endoscopic retrograde cholangiopancreatography and biliary stent exchanges over one year. Her cholangiogram one year later demonstrated resolution of the biliary cystic dilation which led to her initial diagnosis, with beading and stricturing of the hepatic ducts consistent with primary sclerosing cholangitis. Liver-associated enzymes and physical findings also improved. A liver biopsy one year later demonstrated a marked improvement in hepatic fibrosis with no evidence of cirrhosis.     

Should a fully covered self-expandable biliary metal stent be anchored with a double-pigtail plastic stent? A retrospective study

BACKGROUND The migration rate of fully covered self-expandable metal stents(FCSEMSs) has been reported to be between 14% to 37%. Anchoring of FCSEMSs using a doublepigtail plastic stent(DPS) may decrease migration.AIM To compare stent migration rates between patients who received FCSEMS alone and those who received both an FCSEMS and anchoring DPS.METHODS We conducted a retrospective analysis of endoscopy reporting system and medical records of 1366 patients who underwent endoscopic retrograde cholangiopancreatography(ERCP) with FCSEMS placement at the University of Kentucky health care. Between July 2015 and April 2017,203 patients with FCSEMS insertion for the treatment of malignant biliary stricture,benign biliary stricture,post-sphincterotomy bleeding,bile leak,and cholangitis drainage were identified. The review and analysis were conducted through our endoscopy reporting system(ProVation~? MD) and medical records. Categorical data were analyzed using Chi-Square and Fischer exact test and continuous data using nonparametric tests. A regression analysis was performed to identify factors independently associated with increased risk of stent migration. We determinedan FCSEMS migration endoscopically if the stent was no longer visible in the major papilla.RESULTS1366 patients had undergone ERCP by three advanced endoscopists over 21-mo period; among these,203 patients had FCSEMSs placed. 65 patients had FCSEMSs with DPS,and 138 had FCSEMSs alone. 65 patients had FCSEMSs with DPS,and 138 had FCSEMSs alone. 95 patients had a malignant stricture,82 patients had a benign stricture,12 patients had bile leak,12 patients had cholangitis,and nine patients had post-sphincterotomy bleeding. The migration rate in patients with anchored FCSEMSs with DPS was 6%,and those without anchoring DPS was 10%(P = 0.35). Overall,migration was reported in 18 patients with FCSEMSs placement out of 203 patients with an overall migration rate of 9.7%. There was no significant association between anchoring the FCSEMSs with DPS and the risk of stent migration. Only patients with the previous sphincterotomy and begin biliary stricture were found to have a statistically significant difference in the migration rate between patients who had FCSEMS with DPS and FCSEMS alone(P = 0.01).CONCLUSION The risk of migration of biliary FCSEMS was 9.7 %. Anchoring an FCSEMS with DPS does not decrease the risk of stent migration.     

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures

BACKGROUNDThere is little data available on the role of new anti-reflux plastic stents (ARPSs). AIMTo compare the use of ARPSs with that of traditional plastic stents (TPSs) for patients with biliary strictures.METHODSConsecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included. The onset of stent-related cholangitis, stent patency, clinical success, and other adverse events were evaluated.RESULTSSixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses. Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group (8 patients vs 18 patients; P = 0.030). The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group (128.5 d vs 76 d; P = 0.039). The cumulative median stent patency in the ARPS group was 185 d, which was significantly longer than that in the TPS group (133 d; P = 0.001). The clinical success rates and other adverse events did not significantly differ between both groups.CONCLUSIONPlacement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.     

ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis – Analysis of the Hungarian ERCP registry data

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis.ObjectivesABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP.MethodsThe rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded.ResultsSignificantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241–2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415–9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p = 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates.ConclusionERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.