Complications of endoscopic biliary sphincterotomy

Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis

OBJECTIVES

ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated.

METHODS

Prospective cohort study of patients referred for ERCP with suspected biliary disease. MRCP and EUS were performed within 24 h before ERCP. The investigators were blinded to the results of the alternative imaging studies. A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients.

RESULTS

A total of 30 patients were studied. ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram. EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity. MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0.41-0.78) compared to 89% (CI = 0.72-0.98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p < 0.02). The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP.

CONCLUSIONS

In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis. EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP. Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations.

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

OBJECTIVES

The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP.

METHODS

A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented.

RESULTS

At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option.

CONCLUSIONS

Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.

Serum lipase, C-reactive protein, and interleukin-6 levels in ERCP-induced pancreatitis

BACKGROUND

C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated in acute pancreatitis. Limited studies have evaluated their role in ERCP-induced pancreatitis. The aim of this study was to assess the role of serum lipase, CRP, and IL-6 in ERCP-induced pancreatitis.

METHODS

Eighty-five patients (62 women, 23 men; mean age 43 years; range 16-85 years) who underwent ERCP were entered in a prospective trial. ERCP-induced pancreatitis was classified as mild, moderate, or severe. Serum levels of lipase, CRP, and IL-6 were measured before ERCP and at 12 to 24 hours and 36 to 48 hours after ERCP.

RESULTS

Mild, moderate, and severe pancreatitis occurred, respectively, in 9, 7, and 4 patients after ERCP. There were significant differences in levels of CRP and IL-6 but not lipase for patients with mild versus moderate and moderate versus severe pancreatitis. The mean CRP levels (mg/dL) at 12 to 24 hours were 0.98 +/- 0.24 in mild pancreatitis, 3.89 +/- 0.32 in moderate pancreatitis, and 12.0 +/- 1.60 in severe pancreatitis. The levels, respectively, at 36 to 48 hours were 1.60 +/- 0.31, 7.60 +/- 0.74, and 25.0 +/- 2.9. The mean IL-6 levels (pg/mL) at 12 to 24 hours were 16.6 +/- 2.06 in mild pancreatitis, 73.0 +/- 15.60 in moderate pancreatitis, and 235.5 +/- 26.31 in severe pancreatitis. The levels at 36 to 48 hours were, respectively, 18.92 +/- 3.28, 100.17 +/- 11.56, and 438.2 +/- 71.50.

CONCLUSIONS

Serum CRP and IL-6 levels may be useful early markers for predicting the severity of ERCP-induced pancreatitis.

The rendezvous technique for the treatment of choledocholithiasis

BACKGROUND

The rendezvous technique combines endoscopy with percutaneous transhepatic cholangiography to facilitate cannulation of the bile duct when previous attempts have failed.

METHODS

Over a 7-year period, a total of 1753 ERCPs were performed. Twelve of these patients with a diagnosis of choledocholithiasis were poor candidates for surgery. Percutaneous transhepatic cholangiography as well as ERCP with precut papillotomy failed to resolve biliary obstruction. In a further 2 cases the percutaneous approach was used by means of a T-tube positioned at a prior cholecystectomy.

OBSERVATIONS

The combined procedure was successful in 13 patients (93%). It was unsuccessful in 1 patient because of a stone lodged distally near the papilla. There was only 1 complication (7%), a retroperitoneal perforation that occurred during papillotomy; no mortality was directly attributable to the technique.

CONCLUSIONS

The rendezvous technique is recommended for patients who are not eligible for surgery when ERCP is unsuccessful and when it is impossible to resolve biliary obstruction by percutaneous transhepatic cholangiography.

Endoscopic management of biliary tract disease

New investigations, evaluation of controversial issues, and advances in technology continue to shape the endoscopic management of biliary disorders. This article discusses recent literature related to the diagnosis and therapy of biliary tract disease. Specifically, the diagnosis and management of choledocholithiasis, complications of biliary endoscopy and potential preventive measures, roles for endosonography in the evaluation of biliary disease, and endoscopic therapy of postoperative liver transplantation complications are reviewed. Recent advances in biliary stents and the use of cholangioscopy in biliary disorders are also assessed.

Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis

BACKGROUND

One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis.

METHODS

In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5.

RESULTS

The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0.05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0.012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0.032).

CONCLUSION

Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.

Idiopathic acute recurrent pancreatitis

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Gallstones and biliary disease

Gallstones are common in the US and western countries. This article describes the pathogenesis of gallstone formation and the clinical manifestations and current approaches to diagnosis and treatment of the most common clinical conditions caused by gallstones: biliary colic, acute cholecystitis, choledocholithiasis, and acute gallstone pancreatitis. The role of widely used imaging techniques (transabdominal ultrasound, CT scan, MR imaging, and MRCP) and diagnostic and therapeutic endoscopy (endoscopic ultrasound, ERCP) is emphasized. This article is intended mainly for general practitioners, primary care physicians, and other specialists providing medical care to patients with gallstones and their complications.

Prediction of pancreatitis following endoscopic retrograde cholangiopancreatography by the 4-h post procedure amylase level

BACKGROUND

Pancreatitis is the commonest and most significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Early detection of post-ERCP pancreatitis would allow the safe discharge of day-case patients and targeted use of preventive therapies. Clinical diagnosis is inaccurate, and the aim of this study was to evaluate the 4-h post-ERCP hyperamylasemia as a predictor of pancreatitis.

METHODS

Two hundred and sixty-three consecutive ERCPs performed at one center were prospectively analyzed, examining patient and procedure characteristics, as well as the amylase level as predictors of pancreatitis.

RESULTS

Younger age (< 25 years), Sphincter of Oddi dysfunction, pancreatogram and failed cannulation were risk factors for pancreatitis; sphincterotomy conferred an increased risk, which was not statistically significant. Hyperamylasemia was a highly sensitive and moderately specific predictor of pancreatitis. A cut-off level of 1.5-fold higher than normal was useful for the exclusion of pancreatitis, while a cut-off level of threefold higher than normal was more specific, so as to target potential preventive therapies.

CONCLUSIONS

The 4-h post-ERCP amylase level is a useful test to base management decisions on. It needs to be interpreted in conjunction with clinical assessment as well as identifiable risk factors related to the patient or the procedure.

Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy

BACKGROUND

Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied.

METHODS

Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones.

RESULTS

The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum.

CONCLUSION

The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.

A randomized, double blind study of interleukin 10 for the prevention of ERCP-induced pancreatitis

OBJECTIVES

Inflammatory cytokines are released during acute pancreatitis. Interleukin 10 (IL-10) is a potent antiinflammatory cytokine with immunosuppressive and antiinflammatory activities. IL-10 has been shown to attenuate pancreatitis in an animal model. A double blind, placebo-controlled pilot study was conducted to evaluate the safety and efficacy of low dose IL-10 for the prevention of ERCP-induced pancreatitis.

METHODS

Patients were randomized to receive a single i.v. dose of recombinant human IL-10 (8 microg/kg) or a placebo i.v. bolus injection 15 min before the procedure. Pancreatitis was defined as abdominal pain radiating to the back associated with elevated amylase or lipase two or more times the upper limit of normal requiring hospitalization for > or =2 days. Severity of pancreatitis was based on days of hospitalization.

RESULTS

Two hundred patients were enrolled (101 IL-10, 99 placebo). No difference in age, gender, degree of pancreatic duct filling, therapeutic intervention, or complication was detected between the two groups. Eleven patients in the IL-10 group and nine patients in the placebo group had pancreatitis (p = 0.65). The median length of hospitalization was 4 days in the IL-10 group and 3 days in the placebo group (p = 0.75).

CONCLUSIONS

IL-10 at the 8-microg/kg i.v. dose was not effective in reducing the incidence or severity of ERCP-induced pancreatitis. Further investigations are necessary to determine if manipulation of the cytokine pathway can prevent ERCP-induced pancreatitis.

Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial

BACKGROUND

Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more.

AIM

To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors.

METHODS

A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 microg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (< 8 mm).

RESULTS

A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant.

CONCLUSION

Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.

Diagnostic and therapeutic ERCP: a large single centre's experience

BACKGROUND

Most large published series on endoscopic retrograde cholangiopancreatography (ERCP) are multicentre-based and consequently reflect varying experience.

AIMS

To assess morbidity and mortality rates of ERCP in a single tertiary referral centre.

METHODS

A series of 1,758 consecutive ERCPs performed in 1,148 patients between 1991 and 1994 were reviewed to evaluate indications, findings, procedures, success, complication and mortality rates.

RESULTS

There were 1,108 (63%) successful initial ERCPs, 11% failed cannulation attempts and 26% follow-up ERCPs. The desired duct was successfully cannulated in 96.5% of cases. Initial cannulation failure rate was 8.8%. Twenty-seven per cent had normal ERCPs, 30% had choledocholithiasis and 22% had strictures. Fifty-five per cent had therapeutic ERCPs. Major complications occurred in 3.5% with four ERCP-related deaths (0.35%). Therapeutic ERCP had a higher incidence of major complications compared to diagnostic ERCP: 4.6% vs 2.1%, (p=0.02); and mortality rate was 0.5% vs 0.2%, (p=0.4). Significant haemorrhage secondary to biliary sphincterotomy, pre-cut papillotomy and snare papillectomy accounted for most of the difference (1.6%).

CONCLUSIONS

The majority of ERCPs were performed in elderly patients, over half of whom required therapeutic ERCP. Therapeutic ERCP carried significantly higher complication rate compared with diagnostic ERCP. Unsuccessful cannulation and follow-up ERCP accounted for 11% and 26% of ERCP workload, respectively.

[Endoscopic treatment of obstructive jaundice at a second level national health system hospital]

BACKGROUND AND AIMS

The difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) in our patients in the reference hospitals within a few days of diagnosis of obstructive jaundice led us to perform this technique in our center. We expected to perform a small number of ERCP annually. We analyzed the success rate of initial biliary drainage and the complications of this procedure.

PATIENTS AND METHODS

We performed a retrospective study. From 1997-1999 we carried out 240 ERCP. In 128 patients, 140 ERCP were performed for obstructive jaundice (58,3%). The final diagnosis was choledocholithiasis in 69 patients (54%), tumors in 35 (27%), dilatation of the biliary tract without obstruction at cholangiography in 21 (17%) and benign stenosis of the biliary tract in 3 (2%).

RESULTS

The mean procedure time for ERCP was 5.26 ( 2.8) days. Cholangiography was successfully performed in 117 patients (91.4%). Effective therapeutic endoscopy was performed in 111 patients (86.7%). Jaundice was resolved in 62 patients (90%) with choledocholithiasis, 55 (80%) by stone removal and in 7 (10%) by prosthesis. Resolution was also achieved in 25 (71.5%) tumors, mainly by prosthesis, and in 100% of patients with benign stenosis. In all patients with dilatation of the biliary tract without obstruction, biliary sphincterotomy was performed. Complications were found in 15 patients (11.7%) and two (1.56%) died.

CONCLUSIONS

The majority of patients with obstructive jaundice can be satisfactorily treated in a center with our characteristics. However, in tumors, the figures for drainage were slightly lower than those reported in the medical literature.

Pancreatitis caused by common bile duct stones in a 3-year-old boy with prior surgery for a choledochal cyst

Pancreatitis in children is uncommon. Compared to adults, pancreatitis in children is usually related to trauma, anatomic anomalies, infections, hereditary, and systemic disease, but not gallstones or alcohol. Most cases do not require endoscopic intervention. We report an unusual case of recurrent pancreatitis in a child related to common bile duct stones requiring endoscopic treatments after surgical treatment for choledochal cyst.

Ability of MR cholangiography to reveal stent position and luminal diameter in patients with biliary endoprostheses: in vitro measurements and in vivo results in 30 patients

OBJECTIVE

Our goal was to evaluate the ability of MR cholangiography to show stent position and luminal diameter in patients with biliary endoprostheses.

MATERIALS AND METHODS

Susceptibility artifacts were evaluated in vitro in three different stent systems (cobalt alloy-based, nitinol-based, and polyethylene) using two breath-hold sequences (rapid acquisition with relaxation enhancement, half-Fourier acquisition single-shot turbo spin echo) on a 1.5-T MR imaging system. The size of the stent-related artifact was measured, and the relative stent lumen was calculated. In vivo stent position and patency were determined in 30 patients (10 cobalt alloy-based stents, five nitinol-based stents, and 15 polyethylene stents).

RESULTS

In vitro, the susceptibility artifact of the cobalt stent caused complete obliteration of the stent lumen. The relative stent lumens of the nitinol-based and polyethylene stents were 38-50% and 67-100%, respectively. In vivo, all stents were patent at the time of imaging. The position of the cobalt alloy-based stent could be determined in nine of 10 patients, but stent patency could not be evaluated. Stent position of nitinol stents could not be adequately evaluated in any of the five patients, and internal stent diameter could be visualized in only one patient. In nine of 15 patients, the fluid column within the implanted polyethylene stent was seen on MR cholangiography.

CONCLUSION

The internal stent lumen could be visualized in most patients with an indwelling polyethylene stent, but not in patients with cobalt alloy- or nitinol-based stents.

Efficacy of biliary scintigraphy in suspected sphincter of Oddi dysfunction

Sphincter of Oddi dysfunction (SOD) can pose diagnostic challenges for the physician. SOD is classified into types I, II, and III, but clinical outcome after sphincterotomy for suspected types II and III SOD has been unpredictable. Therefore, accurate diagnosis of types II and III SOD is important because of the increased risk of sphincterotomy in patients with SOD. Endoscopic sphincter of Oddi manometry (ESOM) is the gold standard for diagnosis of SOD; however, it is associated with significant morbidity and is not an appropriate screening test. Quantitative hepatobiliary scintigraphy (QHBS) has demonstrated good sensitivity as a screening test for SOD in patients following cholecystectomy; however, studies using this methodology are criticized for poor design and patient selection. Recent publications address these criticisms and provide evidence that QHBS and ESOM are comparable diagnostic tools after exclusion of organic biliary obstruction. QHBS can effectively replace invasive ESOM in the diagnostic algorithm of SOD.

Bacterial Cholangitis

The treatment of acute bacterial cholangitis requires broad-spectrum antibiotics to cover against gram-negative aerobic enteric organisms (Escherichia coli, Klebsiella species, and Enterobacter species), gram-positive Enterococcus and anaerobic bacteria (Bacteroides fragilis and Clostridium perfringens). Approximately 20% of patients with acute cholangitis fail to respond to conservative treatment with antibiotic therapy and require urgent biliary decompression, which is the mainstay of therapy. This is best accomplished by endoscopic retrograde cholangiopancreatography (ERCP) and placement of a nasobiliary drainage tube or a large bore (10 F or larger) indwelling plastic stent. Alternative therapy includes percutaneous transhepatic biliary drainage or surgical biliary decompression, but these carry a significantly higher morbidity and mortality. Supportive care includes intravenous fluid hydration to prevent renal failure and close monitoring of vital signs for determination of potential septicemia.

Complications of endoscopy

BACKGROUND

Although most gastrointestinal endoscopic procedures are performed by gastroenterologists, surgeons often assist in the management of patients with complications. This review provides an introduction to the incidence, prevention, and treatment of complications that may occur after upper endoscopy, colonoscopy, percutaneous endoscopic gastrostomy, and endoscopic retrograde cholangiopancreatography.

METHODS

Systematic review of the literature.

RESULTS

Preprocedural complications include medication effects and adverse effects of bowel preparation. Major procedural complications consist primarily of perforation and hemorrhage. Percutaneous endoscopic gastrostomy tube placement may be complicated by fistula and obstruction. There is also a risk of infectious disease transmission, both to and from the patient.

CONCLUSIONS

Endoscopy, like all invasive procedures, carries significant potential risks for the patient. In practiced hands, and with awareness of the problems that may arise, many complications may be avoided and others successfully managed.

Precut sphincterotomy: indications, pitfalls, and complications

Precut sphincterotomy is a technique employed to gain access to the common bile duct (CBD) when standard methods using catheters, cannulatomes, and guidewires have failed. It is particularly useful in cases of distal biliary strictures or distal impacted stones and in patients with Billroth II gastrectomies who require papillotomy. It significantly improves the overall success rate of CBD access. This technique should only be used, however, when a therapeutic maneuver is anticipated, and it has no place in diagnostic imaging. In the hands of experienced, skillful endoscopists, the complication rate is comparable with that of standard sphincterotomy.

Endoscopic management of bile duct stones

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.

Hybrid classification of sphincter of Oddi dysfunction based on simplified Milwaukee criteria: effect of marginal serum liver and pancreas test elevations

To date, when using the Milwaukee classification for sphincter of Oddi dysfunction (SOD), one cannot accurately classify patients with marginal elevations in laboratory tests; ie, < 1.5 x the upper limit of normal (ULN). Since subsequent treatment may depend on how they are classified, we sought to determine whether these patients should be considered as type II or type III. Between January 1993 and October 1996, 113 consecutive patients (82 females and 31 males; ages 12-87 years) without prior sphincterotomy were referred to consider a diagnosis of SOD type II or III. SOD II patients had pancreaticobiliary-type pain and laboratory elevations >1.5 x ULN or dilated ducts, while SOD III patients had pain only. Hybrid patients had pain and marginal laboratory elevations <1.5 x ULN, with normal duct diameters. Drainage times, frequency, duration, and propagation were not assessed. Sphincter of Oddi manometry (SOM) was performed in each case, and the frequency of abnormal biliary and/or pancreatic basal sphincter pressure was compared, with respect to type II, III, and hybrid SOD. Successful SOM was obtained in 113/114 patients: Abnormal basal sphincter pressure was found in 65, 89, and 43% of type II, hybrid, and type III SOD, respectively. We found no statistical difference between type II and hybrid patients. In contrast, there was statistical difference between types II and III patients and between type III and hybrid patients. In conclusion, there was no significant difference in the frequency of elevated basal sphincter pressure in SOD type II versus hybrid, and thus they should be considered as one group.

Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

OBJECTIVES

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study.

METHODS

One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists.

RESULTS

Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (< or = 60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater.

CONCLUSIONS

The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.

Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction

Management of common bile duct (CBD) stones during pregnancy is a difficult problem. The authors reported the case of a patient who was 22 weeks' pregnant who had a symptomatic CBD stone successfully treated by the association of magnetic resonance cholangiography and laparoscopic CBD stone removal. The patient delivered a healthy baby boy at 39 weeks. Magnetic resonance cholangiography and laparoscopic CBD exploration is a viable option in the management of CBD stones in pregnant patients that carries a low risk for the fetus while preserving the advantages of minimally invasive surgery for the mother.

Endoscopic treatment of pancreatico-biliary malignancies

Biliary obstructions, due to pancreatic cancer and cholangiocarcinoma, have an ominous prognosis. At the time of diagnosis, most patients are beyond any curative treatment. Palliative therapies, such as transhepatic biliary drainage, bypass surgery, and endoscopy, have an established role in the management of such patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic and bioptic specimens, and insertion of large-bore biliary stents. The major drawback of plastic stents is the high rate of clogging, requiring frequent stent exchange. In the 1990s, self-expanding metal stents (SEMS) were developed and randomized studies have shown their superiority over plastic stents. SEMS can be successfully used in patients with hilar tumors. Duodenal obstruction due to biliopancreatic neoplasms can also be managed endoscopically. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

Interleukin 10 reduces the incidence of pancreatitis after therapeutic endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS

Prophylactic administration of interleukin (IL)-10 decreases the severity of experimental pancreatitis. Prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in humans is a unique model to study the potential role of IL-10 in this setting.

METHODS

In a single-center, double-blind, randomized, placebo-controlled study, the effect of a single injection of 4 microg/kg (group 1) or 20 microg/kg (group 2) IL-10 was compared with that of placebo (group 0), all administered 30 minutes before therapeutic ERCP. The primary endpoint was the effect of IL-10 on serum levels of amylases and lipases measured 4, 24, and 48 hours after ERCP. The secondary objective was to evaluate changes in plasma cytokines (IL-6, IL-8, tumor necrosis factor) at the same time points and the incidence of acute pancreatitis in the 3 groups. Subjects undergoing a first therapeutic ERCP were eligible for inclusion.

RESULTS

A total of 144 patients were included. Seven were excluded based on intention to treat (n = 1) or per protocol (n = 6). Forty-five, 48, and 44 patients remained in groups 0, 1, and 2, respectively. The 3 groups were comparable for age, sex, underlying disease, indication for treatment, type of treatment, and plasma levels of C-reactive protein (CRP), cytokines, and hydrolases at baseline. No significant difference was observed in CRP, cytokine, and hydrolase plasma levels after ERCP. Forty-three patients developed hyperhydrolasemia (18 in group 0, 14 in group 1, and 11 in group 2; P = 0.297), and 19 patients developed acute clinical pancreatitis (11 in group 0, 5 in group 1, 3 in group 2; P = 0.038). Two severe cases were observed in the placebo group. No mortality related to ERCP was observed. Logistic regression identified 3 independent risk factors for post-therapeutic ERCP pancreatitis: IL-10 administration (odds ratio [OR], 0.46; 95% confidence interval [95% CI], 0.22-0.96; P = 0.039), pancreatic sphincterotomy (OR, 5.04; 95% CI, 1.53-16.61; P = 0.008), and acinarization (OR, 8.19; 95% CI, 1.83-36.57; P = 0.006).

CONCLUSIONS

A single intravenous dose of IL-10, given 30 minutes before the start of the procedure, independently reduces the incidence of post-therapeutic ERCP pancreatitis.

Recurrent acute pancreatitis: an algorithmic approach to identification and elimination of inciting factors

Recurrent acute pancreatitis represents a challenging clinical problem associated with significant morbidity, impairment in quality of life, and expense. If unchecked, recurrent episodes of acute pancreatitis may lead to chronic pancreatitis. In this work we have combined the opinion of experts in pancreatology and an extensive review of the literature to develop a logical algorithm that facilitates the stepwise identification and elimination of inciting factors using current technology. The approach taken in recurrent acute pancreatitis is clearly dependent on adequate and appropriate evaluation and treatment of the patient with an initial episode of acute pancreatitis. Future advances in the treatment of these patients will almost certainly depend on improved imaging modalities, prospective clinical trials assessing the efficacy of endoscopic and surgical intervention, a better understanding of mutations and pathophysiologic mechanisms responsible for recurrent acute pancreatitis, and the development of novel, effective preventive and therapeutic strategies.

A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy

BACKGROUND

A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation.

METHODS

Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST.

RESULTS

All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05).

CONCLUSIONS

A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients.

Minimally invasive management of bile leak after laparoscopic cholecystectomy

BACKGROUND

Bile leakage is an uncommon complication of cholecystectomy.The bile may originate from the gallbladder bed, the cystic duct or rarely from injury to a major bile duct.This study aims to evaluate the efficacy of minimal access endoscopic and percutaneous techniques in treating symptomatic bile leak.

PATIENTS AND METHODS

Twenty-one patients with symptomatic bile leak following laparoscopic cholecystectomy underwent assessment of the extent of the bile leak via ultrasound/CT and ERCP. Following diagnosis, the patients were treated by sphincterotomy and biliary drainage and, if necessary, percutaneous drainage of the bile collection.

RESULTS

Only one patient required primary surgical treatment following diagnosis of a major duct injury.The other 20 were treated by a combination of sphincterotomy (including a stent in most) plus percutaneous drainage in six. In 19 of 20, this minimal access approach stopped the leak.

DISCUSSION

Most patients who present with bile leakage after cholecystectomy can be managed successfully by means of ERCP with percutaneous drainage of any large bile collection.

A non-icteric cholecystectomized patient with recurrent attacks of right epigastric pain and dilated common bile duct--do liver function tests predict bile duct stones?

Cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct are a clinical challenge. In a number of these patients dilatation of the common bile duct is explained as a normal postoperative state following cholecystectomy and the recurrent pain attacks are of origin other than bile disorder, but in some cases dilatation of the common bile duct and attacks are caused by bile duct stones. The aim of the present work was to study the value of common plasma liver function tests in predicting bile duct stones in the group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. The study population comprised 24 consecutive non-icteric cholecystectomized patients admitted for elective endoscopic retrograde cholangiopancreatography because of attacks of right epigastric pain and dilated common bile duct in ultrasonography. All the liver function tests seemed to assist in separating patients with bile duct stones (n=11) from those without (n=13). Alanine aminotransferase levels were significantly higher (p=0.05) in patients with bile duct stones than in those without, but also alkaline phosphatase (p=0.07), gamma-glutamyl transferase (p=0.09) and bilirubin (p=0.09) levels seemed to be higher in patients with bile duct stones than in those without, although the differences in these values did not reach statistical significance. In conclusion, common plasma liver function tests assist in separating patients with bile duct stones from those without in this small but clinically important group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. However, the actual value of these measurements is limited in clinical decision making since overlapping of values occured.

A comparison of common bile duct pressures after botulinum toxin injection into the sphincter of Oddi versus biliary stenting in a canine model

BACKGROUND

Botulinum toxin A (Botox) functionally paralyzes the sphincter of Oddi in both animals and humans, resulting in reduced pressures. No study, however, has specifically addressed common bile duct (CBD) pressures after Botox injection into the sphincter of Oddi with regard to treating biliary leaks and fistulae. The goals of this present study are to compare, versus biliary stenting, the change in CBD pressures after Botox injection into the sphincter of Oddi, as well as to evaluate the timing of onset and duration of these effects on sphincteric relaxation.

METHODS

After midline laparotomy in 20 mongrel dogs, a pediatric umbilical catheter was inserted into the CBD via a small cholecystotomy and attached to a water-perfused pressure transducer. After baseline CBD pressure readings, a lateral duodenotomy was performed. A total of 100 units of Botox was injected with an endoscopic sclerotherapy needle into all four quadrants of the ampulla. The dogs were randomly divided into four groups to undergo repeat laparotomy at either postoperative day 1 (group I), postoperative day 3 (group II), postoperative day 7 (group III), or postoperative day 14 (group IV). At the time of second laparotomy, a pressure-sensing catheter was reinserted into the CBD and pressures recorded. Each dog then underwent transpapillary biliary stenting with a 7 Fr. x 5 cm Cotton-Leung biliary stent and CBD pressures were again recorded.

RESULTS

CBD pressures were significantly lower as compared with baseline for all groups after Botox injection and after biliary stenting (P <0.001) In addition, no significant differences in the degree of CBD pressure reduction were identified between groups I through IV after Botox injection. The measured decrease in CBD pressure from baseline after Botox injection as compared with biliary stenting was significantly different for groups I and II (P <0.05) but not for groups III and IV.

CONCLUSION

Botox injection into the sphincter of Oddi results in significant CBD pressure reduction within 24 hours and continues for 14 days. Also, after postoperative day 3, there is no significant difference in the reduction of CBD pressure from baseline between Botox injection and biliary stenting. Based on these findings, Botox injection into the sphincter of Oddi may be a beneficial alternative to biliary stenting for the treatment of biliary leaks and fistulae.

Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration

BACKGROUND

There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC).

METHODS

Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model.

RESULTS

LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was <80%.

CONCLUSIONS

Compared to other common approaches, laparoscopic CBD exploration is a cost-effective method of managing CBD stones in patients who undergo LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD stones is very high (>80%).

Extracorporeal shock wave lithotripsy for clearance of bile duct stones resistant to endoscopic extraction

BACKGROUND

Endoscopic extraction of bile duct stones after sphincterotomy has a success rate of up to 95%. Failures occur in patients with extremely large stones, intrahepatic stones, and bile duct strictures. This study examined the efficacy and the safety of extracorporeal shock-wave lithotripsy in a large cohort of patients in whom routine endoscopic measures including mechanical lithotripsy had failed to extract bile duct stones.

METHODS

Out of 1587 consecutive patients, endoscopic stone extraction including mechanical lithotripsy was unsuccessful in 313 (20%). These 313 patients (64% women, median age, 73 years) underwent high-energy extracorporeal shock-wave lithotripsy. Stone targeting was performed fluoroscopically (99%) or by ultrasonography (1%).

RESULTS

Complete clearance of bile duct calculi was achieved in 281 (90%) patients. In 80% of the patients, the fragments were extracted endoscopically after shock-wave therapy; spontaneous passage was observed in 10%. For patients with complete clearance compared with those without there were no differences with regard to size or number of the stones, intrahepatic or extrahepatic stone location, presence or absence of bile duct strictures, or type of lithotripter. Cholangitis (n = 4) and acute cholecystitis (n = 1) were the rare adverse effects.

CONCLUSIONS

In patients with bile duct calculi that are difficult to extract endoscopically, high-energy extracorporeal shock-wave lithotripsy is a safe and effective therapy regardless of stone size, stone location, or the presence of bile duct stricture.

Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis

BACKGROUND

The frequency of post-ERCP/sphincterotomy pancreatitis is between 1.3% and 7.6% in prospective studies. This range likely reflects differences in definitions of pancreatitis and methods of data collection.

METHODS

To identify clinical findings and enzymatic values consistent for clinical pancreatitis at 24 hours, the post-ERCP/sphincterotomy course of 1185 procedures was prospectively recorded. Patients were evaluated for pancreatic-type pain, white blood cell count, and serum amylase before and 24 hours after the procedure; pain and amylase levels were also recorded 6 to 8 hours after the procedure. CT was performed in all patients with pain associated with amylase levels greater than 3 times normal. All patients were evaluated clinically at 48 hours.

RESULTS

Pancreatic-type pain never occurred in cases with amylase levels lower than 3 times normal; it was significantly (p < 0.001) associated with amylase levels greater than 5 times normal, either 6 to 8 hours or 24 hours after the procedure. Leukocytosis and CT findings consistent with pancreatitis were observed only in patients (41.7% and 29.5%, respectively) with 24-hour amylase levels greater than 5 times normal. None of the 18 patients with pain at 24 hours and serum amylase lower than 5 times normal had symptoms that persisted at 48 hours. Twenty-five (41.7%) of the 60 patients with pain at 24 hours and amylase higher than 5 times normal had 48-hour pain at 48 hours and hyperamylasemia.

CONCLUSIONS

Features consistent with clinical pancreatitis were present only among patients with pancreatic-type pain at 24 hours and amylase levels higher than 5 times normal. Additional follow-up is required for these patients.

Hypotension during ERCP is common but not a risk factor for post-ERCP pancreatitis

BACKGROUND

In patients undergoing cardiopulmonary bypass, hypotension is a risk factor for developing acute pancreatitis. Hypotension in animal models can also induce pancreatitis. We sought to determine whether or not relative hypotension during ERCP is a risk factor for developing acute pancreatitis.

PATIENTS AND METHODS

A nested, case-control study reviewed all cases of post-ERCP pancreatitis resulting from ERCPs performed at this institution between May 1993 and May 1998. Post-ERCP pancreatitis was defined as abdominal pain requiring hospitalisation and elevation of serum amylase or lipase more than four times the upper limit of normal 24 hours or more after ERCP. Non-invasive blood pressure measurements were recorded automatically at least every 5 min during ERCP. Hypotension was defined as any systolic blood pressure (SBP) <100 mmHg, diastolic blood pressure (DBP) <60 mmHg, or mean blood pressure (MBP) <80 mmHg. Controls were chosen randomly from ERCPs performed on the same or the nearest day as each index case.

RESULTS

In total, 1854 ERCPs were reviewed from the study period.There were 96 cases of post-ERCP pancreatitis,giving an incidence of 5.2%. The average age of cases was 48 years, while that of controls was 55 years (p < 0.003).There were no differences between the groups regarding gender, ERCP findings, need for sphincterotomy nor acinar filling on the pancreatogram (acinarisation). At least one episode of hypotension was recorded in 32% of cases and 30% of controls (p = 0.75). There were no differences between cases and controls comparing mean pre- and intra-procedure SBP, DBP and MBPs, or lowest procedure SBP, DBP and MBP.

DISCUSSION

Episodes of acute hypotension are common during ERCP but are not a risk factor for developing post-ERCP pancreatitis.

Impact of laparoscopic cholecystectomy: a population-based study

BACKGROUND

We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice.

METHODS

Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay.

FINDINGS

From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015).

INTERPRETATION

The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

What are the risks of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography?

BACKGROUND

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been practised widely over the last 20 years, and it has revolutionized the diagnosis and management of biliary and pancreatic conditions. More recently newer techniques (magnetic resonance imaging) for diagnosis and therapy (laparoscopic biliary surgery) have evolved. The present paper evaluates the risks of ERCP procedures in a modern setting.

METHODS

A prospective audit of all ERCP carried out by a single unit across two campuses over 12 months was undertaken. All procedures were included and predetermined morbidity criteria were recorded and evaluated by independent observers who did not perform the procedures.

RESULTS

During this period 372 procedures were performed. A total of 9.4% of procedures failed to achieve the preprocedure-stated goal. There were five deaths (30-day mortality of 1.3%) and in 16 patients complications were recorded (morbidity of 4.3%). Two clinical and two technical factors were shown to be associated with the morbidity and mortality by multiple logistic regression analysis: diagnosis of sphincter of Oddi dysfunction; presence of jaundice; need to perform percutaneous transhepatic drainage of an obstructed biliary system after a failed endoscopic approach; and multiple ERCP.

CONCLUSIONS

These results compare favourably with results from other reported series and serve to illustrate the relative safety of diagnostic and therapeutic ERCP.

ERCP-induced Pancreatitis

The most important consideration in preventing ERCP-induced pancreatitis is patient selection. If you want to avoid pancreatitis, avoid performing ERCP in young patients for sphincter of Oddi dysfunction. Sphincter of Oddi manometry, difficult biliary cannulations (repeated pancreatic duct cannulations/injections), and precut and pancreatic sphincterotomy are associated with increased risk of pancreatitis. Pancreatic endotherapy, precut sphincterotomy, and Sphincter of Oddi manometry should be reserved for expert endoscopists. Short-term pancreatic stenting appears to decrease the risk of pancreatitis in patients undergoing these higher-risk procedures. Chemoprevention for ERCP-induced pancreatitis appears promising, but needs further critical study with larger patient populations and agents amenable to outpatient use. Fortunately, most ERCP-induced pancreatitis is mild. More severe pancreatitis requires a team approach to management with surgery, radiology, gastroenterology, and other specialists (eg, nephrologist) as indicated participating in the patient's care.

Advances in diagnostic and therapeutic endoscopy

Endoscopy is extremely valuable in the evaluation of disorders of the luminal gastrointestinal tract, pancreas, and biliary system. Endoscopy as a medical discipline continues to evolve and is becoming increasingly therapeutic in nature. Minimally invasive endoscopic intervention now is effective in a wide variety of disorders, including gastrointestinal hemorrhage, obstructive diseases of the intestinal or biliary tree, and early detection or prevention of neoplastic disease of the colon and esophagus. The development of EUS technology has expanded greatly the potential utility of endoscopy as a diagnostic and a therapeutic modality, and further technologic advances are anticipated.

Endoscopic management of biliary disease

Endoscopic management of biliary disease remains at the forefront of minimally invasive means of providing therapy, as well as contributing important diagnostic information in complex clinical scenarios. The authors review recent advances and reported trials of therapy and revisit important controversial issues. The management and diagnosis of choledocholithiasis are discussed, as well as endoscopic techniques for attaining biliary access at endoscopic retrograde cholangiopancreatography. In addition, management of biliary anastomotic strictures in liver transplant patients, role of cholangioscopy, and recent advances in stent technology are reviewed.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.