Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Treatment of postoperative bile fistulas after laparoscopic cholecystectomy by ERCP, EPT and bile duct drainage

BACKGROUND: Bile leakage as a complication following cholecystectomy can be found more frequently after laparoscopic cholecystectomy (LC) than after open cholecystectomy. The present study planned to find out the importance of ERCP, sphincterotomy and temporary drainage of the bile duct system in the treatment of bile leakage. PATIENTS AND METHODS: From July 1992 to October 1996 15 consecutive patients presenting with bile leakage following LC underwent endoscopic therapy by CBD-drainage with sphincterotomy (n = 11), CBD-drainage without sphincterotomy (n = 1) and sphincterotomy alone (n = 3). RESULTS: Closure of the bile leakage could be achieved in all cases, biliary secretion stopped after 2.1 days (1-7 days). One dislocation of the drainage into the CBD was found and could be treated endoscopically. Endoscopy-related mortality was 0%. CONCLUSIONS: Endoscopic therapy offers a safe, effective and minimal invasive method in the treatment of bile leakage following LC.     

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.     

Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients

BACKGROUND/AIMS: This paper evaluates the potential benefit of non mechanical bile duct stone lithotripsy techniques. The efficacy, limitations and risks of mechanical lithotripsy as first choice procedure were studied. MATERIAL AND METHODS: Endoscopic sphincterotomy was performed by Erlangen-type papillotomes, stone extraction by Olympus baskets and mechanical lithotripsy by the Wurbs-system. In an unselected series of 704 patients, everyone with common bile and hepatic duct stones (independent of size, number, location and stone consistency) was included in the study. RESULTS: Complete stone clearance by endoscopic sphincterotomy and basket extraction was possible in 87.6%. Additional mechanical lithotripsy led to a success rate of 98.4% and in combination with ESWL of 98.5%. In 11 patients without possibility of endoscopic stone removal (1.6%), 4 had no access transpapillary (B-II-situs or duodenal diverticulum), 5 anatomical problems (S-shaped common bile duct, intrahepatic stones or impacted stones in cystic duct orifice), and 2 refused further endoscopic interventions. Complication rate was 1.4% (thereof 1.1% successful treatment by endoscopic or surgical means), lethality rate 0.3%. CONCLUSIONS: A very high rate of stone clearance by standard endoscopic procedures is possible. In those patients where mechanical lithotripsy is not successful, other non-surgical lithotriptic procedures either cannot be applied because of anatomical reasons or if performed, the improvement in success rate is marginal.     

Endoscopic therapy for patients with a post-operative biliary leak

Twenty-three patients with a post-operative biliary leak were treated by various endoscopic methods and results were analyzed. Leaks occurred at the cystic duct in 13 patients, at the common duct in 6 patients, and at an anomalous branch of the right hepatic duct in 4 patients. Treatments included sphincterotomy alone (4 patients), stent alone (6 patients), sphincterotomy and stent (12 patients), and sphincterotomy and nasobiliary drainage catheter (1 patient). Five patients also had supplemental percutaneous catheter drainage of a biloma. All treatments were completed successfully in the absence of major morbidity, and permanent closure of the leak occurred in 100% of cases. Endoscopic therapy for patients with a post-operative biliary leak is safe and effective and should be recommended before surgical re-exploration.     

Current results of endoscopic sphincterotomy for lithiasis of the common bile duct

Between January 1989 and June 1990, endoscopic sphincterotomy was performed in 308 consecutive patients with common bile duct stones (mean age: 74 years). Complete clearance of common bile duct was achieved at the first attempt in 65% of cases. This rate was significantly related to the size and the number of biliary stones. The success rate reached 97 percent after repeated endoscopic sessions (127 patients), mechanical lithotripsy (20 patients), extracorporeal or intracorporeal lithotripsy (18 and 11 patients, respectively). During the month following the endoscopic sphincterotomy, 39 patients (13%) developed one or more complications and 11 patients (3.7%) died. The complication rate was related to the time elapsed between biliary opacification and endoscopic sphincterotomy (P = 0.04) and between endoscopic sphincterotomy and total common bile duct clearance (P = 0.0007). No patient younger than 75 years died, but death occurred in 4.5% of the patients older than 75 years. Thirty patients (10%) developed endoscopic sphincterotomy-related complications. Cholangitis and bleeding were the most frequent complications (4 and 2%, respectively). Cholangitis occurred more frequently among the patients older than 75 (P < 0.05) or when transhepatic guided endoscopic sphincterotomy or intracorporeal lithotripsy was used (P < 0.005). Cholangitis led to death in 2 patients, 86 and 87 years old (0.7%). Endoscopic sphincterotomy related complications developed within 48 hours in all but 4 patients (2 patients with pancreatitis and 2 patients with cholecystitis).     

Factors predictive of early complications of endoscopic treatment of bile duct calculi

BACKGROUND/AIMS: Factors associated with an increased early complication rate of the endoscopic sphincterotomy procedure have been identified. Precut or needle knife papillotomy has been shown to improve the success rate of endoscopic retrograde cholangiography and endoscopic sphincterotomy, but has often been reported to be hazardous. In order to identify patients with bile duct stones at risk for a complicated course in connection with endoscopic clearance of the calculi, factors predictive of early complications were sought. METHODOLOGY: 417 consecutive patients with bile duct calculi at endoscopic retrograde cholangiography were considered for endoscopic treatment in our department from 1981 to 1992. Endoscopic sphincterotomy was performed in 246 patients with intact gallbladders and in 147 with prior cholecystectomy, 55 of whom had retained calculi. RESULTS: There was a 9.4% overall and 7.1% major early complication rate of the EST procedure and a 30-day mortality of 0.5% (2 patients, non-procedure related). In 22% (6/27) of the patients with major complications, surgery was required or preferred to additional endoscopic measures. Complete stone removal failed in 35/393 patients (8.9%). The immediate and early complication rate of standard sphincterotomy was not found to be increased in patients with prior or present biliopancreatic complications, failed bile duct clearance at first attempt, or juxtapapillary diverticula. It was the same after standard sphincterotomy as after precut papillotomy followed by immediate or delayed sphincterotomy. No increased morbidity was found after failed therapy as compared to failed diagnostic precut papillotomy. There was neither a greater need for, nor an increased complication rate following, precut papillotomy in patients with, as compared to those without, juxtapapillary diverticula. Endoscopic experience did not influence the complication rate. There were no significant differences regarding outcome or risk factors associated morbidity between patients with and without intact gallbladder. CONCLUSIONS: These findings confirm that endoscopic treatment is safe and that precut papillotomy can be performed without increased morbidity. Furthermore, none of the commonly identified factors associated with increased morbidity were found to be risk factors in this study.     

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post-endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.     

Spontaneous rupture of an intrahepatic bile duct with biloma treated by percutaneous drainage and endoscopic sphincterotomy

A case of spontaneous rupture of an intrahepatic bile duct with biloma formation treated by percutaneous drainage and endoscopic sphincterotomy is reported. A 73-yr-old woman was admitted with fever and abdominal pain. There was no past history of abdominal surgery, instrumentation, or trauma. Ultrasound and computed tomography revealed a massive fluid collection in the abdominal cavity. Endoscopic retrograde cholangiography demonstrated extravasation of contrast medium from a distal biliary radicle in the left lobe of the liver. After successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient did well. Ultrasound and computed tomography showed resolution of the biloma. Nontraumatic bilomas are very rare: in fact, only 24 cases of spontaneous biloma have been reported. Endoscopic treatment for patients with spontaneous bilomas can be safe and effective, and should be considered.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Does endoscopic sphincterotomy prevent recurrent biliary pancreatitis?

Endoscopic sphincterotomy was electively performed as the definitive procedure on 8 high-risk patients with biliary pancreatitis; the gallbladder was left in situ. After a mean follow-up of 21 months, 2 patients had biliary symptoms for which 1 required cholecystectomy and exploration of the common bile duct. No patient developed recurrent pancreatitis during the follow-up period. When the risk of elective surgery is high, endoscopic sphincterotomy appears to protect the patient against recurrent episodes of pancreatitis, and is the initial procedure of choice for the high-risk patient with biliary pancreatitis.     

Endoscopic retrograde cholangiopancreatography in the orthotopic liver transplant patient

BACKGROUND AND STUDY AIMS: Diagnostic imaging of the biliary tract is often required in liver transplant recipients, preoperatively to assess extent of biliary tract disease and postoperatively in patients with a suspected biliary complication due to an abnormal postoperative course. PATIENTS AND METHODS: Over a six-year period, 115 patients received 127 liver transplantations at our institution. Twenty-three preoperative ERCPs were performed in 17 patients, while 25 ERCPs were performed on 15 patients after liver transplantation. RESULTS: Preoperative ERCP in seven of 17 patients revealed a dominant biliary stricture as a result of primary sclerosing cholangitis (PSC); five of these patients were managed successfully with the placement of biliary endoprosthesis. An additional nine patients with PSC underwent brush cytology of the extrahepatic bile ducts to rule out coexisting cholangiocarcinoma; there were no positive results, although three were found to have coexisting cholangiocarcinoma after examination of the explanted liver. Postoperatively, nine of 15 patients were found to have biliary tract disease. These included five biliary strictures (three treated successfully by endoscopic dilation and stent therapy), two biliary leaks (treated by biliary endoprosthesis), one biloma (treated by percutaneous drainage) and one intraductal stone (treated successfully by sphincterotomy and stone extraction). The remaining six patients showed no abnormality at ERCP, and were subsequently diagnosed with allograft rejection. CONCLUSIONS: Diagnosis of biliary complications after hepatic transplantation is often problematic. Definitive characterization frequently requires cholangiography. Interventional biliary procedures, both endoscopic and percutaneous, can be used successfully to treat these complications; however, surgical revision and retransplantation are sometimes required.     

A patient with choledocholithiasis--no therapy without risk

A 73-year-old man was admitted to the hospital because of recurrent fever and intermittent cholestasis. A cholecystectomy with hepatico-duodenostomy was performed ten years ago because of acute cholecystitis and impacted bile duct stones. Recurrent episodes of cholangitis occurred postoperatively and ERCP showed shrinkage of the hepatico-duodenal anastomosis with sump syndrome and recurrent bile duct stones. Endoscopic sphincterotomy for the improvement of bile flow was considered too dangerous at this time-point because of unfavourable intraduodenal position of the papilla Vateri. The patient refused reoperation. During the present hospitalization, endoscopic sphincterotomy and gallstone removal were performed. Within hours after intervention, necrotizing pancreatitis developed which could be managed without operation. No further episodes of cholangitis reoccurred after discharge from hospital. This case report demonstrates the risks of bile duct surgery and endoscopic sphincterotomy.     

Introduction to instrument development: scaling methods

Endoscopic removal of biliary calculi is a safe and effective alternative to surgical exploration of the common bile duct. However, as stones increase in diameter, endoscopic retrieval becomes more difficult and hazardous. Mechanical lithotripsy is an endoscopic technique used to crush common bile duct stones that are too large to be removed by conventional methods. In the 3 years following the introduction of this technique at our institution, 145 patients underwent endoscopic retrograde cholangiopancreatography for symptomatic choledocholithiasis. Endoscopic mechanical lithotripsy improved the overall success rate of common bile duct clearance from 86.2% to 94.5%. No morbidity or mortality was associated with the procedure. Therefore, we recommend mechanical lithotripsy when bile duct stones cannot be removed with conventional techniques.     

Biliary complications of Fasciola hepatica: the role of endoscopic retrograde cholangiography in management

The parasite Fasciola hepatica resides in the biliary tree but rarely causes significant clinical sequelae. In this report, we review our experience with four patients in whom F. hepatica infection resulted in biliary complications, especially severe biliary colic and jaundice. The diagnosis was achieved with endoscopic retrograde cholangiography which demonstrated the worms in the extrahepatic bile ducts. Endoscopic sphincterotomy was performed uneventfully in all patients allowing balloon extraction of the parasites and resolution of their symptoms.     

The vaccine adverse event reporting system

BACKGROUND: Endoscopic papillary dilation (EPD) by balloon in the management of bile duct stones has recently been claimed to be effective for removing bile duct stones. METHODS: Without endoscopic sphincterotomy, we attempted to remove large or multiple bile duct stones through EPD combined with drip infusion of isosorbide dinitrate in 35 patients. Isosorbide dinitrate, at a rate of 5 mg/h, was administered intravenously, and a balloon dilator with a 10-mm diameter was inflated within 3 min across the papilla. Stones were then smashed using a mechanical lithotriptor, and the fragments were extracted with a basket or the balloon. RESULTS: Extraction of stones was successful in 33 (94%) of 35 patients by the combined therapy. Two of them (6%) developed mild pancreatitis. CONCLUSION: EPD combined with medical sphincter dilation was effective for large and multiple bile duct stones.     

Long-term results of endoscopic treatment of biliary duct obstruction due to pancreatic disease

BACKGROUND/AIMS: Endoscopic stenting has become an established method of providing palliative treatment in cases of malignant biliary obstruction, as well as in benign biliary stenosis. Several problems associated with the types of stent used have not yet been resolved, and an ideal stent has yet to be designed. Observation of the clinical course for patients with biliary obstruction of various etiologies, and evaluation of the results with various treatment methods are the aims of this study. METHODOLOGY: In 1993 and 1994, biliary obstruction was treated endoscopically in 47 patients with a malignant pancreatic tumor and in 18 patients with chronic pancreatitis. The primary intervention was assessed retrospectively on the basis of the patients' records, and information concerning the clinical course was obtained by contacting the patients or their relatives or general practitioners. RESULTS: Primary endoscopic drainage was successful in all cases. Only one of the patients with pancreatic tumors is still alive; survival after stent placement averaged 6.2 months. Metal stents remained patent significantly longer than plastic stents and percutaneous transhepatic biliary drains (PTBDs)(8.2 versus 3.5 or 1.9 months; p < 0.001). In cases of chronic pancreatitis, three of the nine patients who received only endoscopic treatment, without stenting, were able to continue without stents in the longer term, whereas seven of the nine who underwent surgery had no further problems. CONCLUSIONS: Endoscopic drainage of biliary obstruction provides excellent short-term results. In long-term treatment for purely palliative purposes, metal stents remain patent for longer than plastic stents. In chronic pancreatitis, surgical treatment clearly seems to provide better long-term results than endoscopic therapy.     

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis

OBJECTIVE: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. METHODS: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups. RESULTS: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%; p < 0.05). There were no deaths. CONCLUSIONS: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.     

Bile immunoglobulins and blockage of biliary endoprosthesis: an immunohistochemical study

BACKGROUND: Endoscopic biliary stenting for pancreaticobiliary malignancy is often limited by recurrent stent occlusion as a result of bacterial biofilm formation and sludge deposition. Bile immunoglobulins are thought to be important in combating biliary sepsis. OBJECTIVES: To investigate whether bile immunoglobulins are involved in the pathogenesis of stent blockage. DESIGN: Immunohistochemical technique was used to study the distribution of bile immunoglobulins, bacteria and sludge in blocked biliary stents. METHODS: Patients with malignant obstructive jaundice were palliated by endoscopic insertion of a 10-FG polyethylene stent into the biliary tract. Blocked stents were retrieved from those who presented with recurrent jaundice and fever. The stents were cross-sectionally cut into slices and fixed in formalin. Immunoglobulins were demonstrated by the peroxidase-anti-peroxidase staining procedure using rabbit anti-serum. RESULTS: The central bulk of the stent deposits appeared as an amorphous, structureless material. IgA was found as a rim of dark brown discoloration at the periphery. IgG showed similar distribution and intensity to that of IgA whereas little IgM was detected. CONCLUSIONS: Bile immunoglobulins may facilitate bacterial adhesion, clumping, and hence biofilm formation on the stent surface.