Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage: Technical and clinical outcomes

The purpose of this study is to evaluate the technical and clinical outcome of percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage. All patients who underwent ultrasound-assisted PTBD between January 2017 and December 2021 due to biliary leakage with nondilated biliary systems were retrospectively evaluated for periprocedural characteristics, medical indications, technical success (successful placement of drainage catheter), clinical success (resolved leak without additional procedures), fluoroscopy time, procedure duration, and clinical outcomes. 74 patients with a mean age of 64.1 ± 15.1 years were identified. Surgery was the most common etiology of biliary leak with 93.2% of the cases. PTBD had a 91.8% (68/74) technical success rate and an 80.8% clinical success rate. The mean procedure and fluoroscopy duration were 43.5 and 18.6 minutes. Age > 65 years (P = .027) and left-sided drainage (P = .034) were significant risk factors of clinical failure. Procedure-related major complications were 2 bleedings from the liver and 1 bleeding from an intercostal artery (major complication rate 4%). PTBD is a feasible, safe, and effective treatment option in patients with biliary leakage with low complication rates.

A Unique Presentation of Jaundice

Obstructive jaundice has many common etiologies, which might cause us to overlook diagnoses that are far worse. This is a case of a Hispanic male who presented with jaundice and worsening liver function. During his hospitalization, he was erroneously diagnosed before being diagnosed with gastric cancer. Even though biliary obstruction has many common etiologies, there are cases that can't be explained, which warrants further investigation such as malignant etiologies.

CO2 enterography in endoscopic retrograde cholangiography using double-balloon endoscopy: A randomized clinical trial

BACKGROUND AND AIM

Double-balloon endoscopic retrograde cholangiography (DBERC) is a valuable procedure for patients with altered gastrointestinal anatomy. Nonetheless, it is time-consuming and burdensome for both patients and endoscopists, partly because route selection in the reconstructed bowel with complicating loop is challenging. Carbon dioxide insufflation enterography is reportedly useful for route selection in the blind loop. This prospective randomized clinical trial investigated the usefulness of carbon dioxide insufflation enterography for route selection by comparing it with conventional observation.

METHODS

Patients scheduled to undergo DBERC were consecutively registered. They were divided into carbon dioxide insufflation enterography and conventional groups via randomization according to stratification factors, type of reconstruction methods, and experience with DBERC. The primary endpoint was the correct rate of initial route selection. The secondary endpoints were the insertion time, examination time, amount of anesthesia drugs, and complications.

RESULTS

The correct rate of route selection was significantly higher in the carbon dioxide insufflation enterography group (23/25, 92%) than in the visual method (15/25, 60%) (P = 0.018). The insertion time was significantly shorter in the carbon dioxide insufflation enterography group than in the visual group (10.8 ± 11.1 min vs 29.8 ± 15.7 min; P < 0.001). No significant differences in complications were noted between the two groups. The amounts of sedatives and analgesics used were significantly lower in the carbon dioxide insufflation enterography group (P < 0.001 and P < 0.001, respectively).

CONCLUSIONS

Carbon dioxide insufflation enterography can reduce the burden of DBERC on patients and endoscopists by shortening the examination time and reducing the amount of medication.

The role of interventional radiology in the management of refractory bile leaks

Refractory bile leaks represent a damaging sequela of hepatobiliary surgery and direct trauma. Management of bile leaks represents a challenging clinical problem. Despite advances in endoscopic techniques, interventional radiology continues to play a vital role in the diagnosis and management of refractory bile leaks. This article reviews strategies for optimizing the diagnosis and management of bile leaks and provides an overview of management strategies, including the management of complicated biliary leaks.

Total Fluoroscopy Time Reduction During Ultrasound- and Fluoroscopy-Guided Percutaneous Transhepatic Biliary Drainage Procedure: Importance of Adjusting the Puncture Angle

BACKGROUND The purpose of this observational cohort study was to assess patient and operator-dependent factors which could have an impact on total fluoroscopy time during ultrasound and fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD). MATERIAL AND METHODS Between October 2016 and November 2020, 127 patients with malignant biliary obstruction underwent ultrasound- and fluoroscopy-guided PTBD with the right-sided intercostal approach. The initial bile duct puncture was ultrasound-guided in all patients, and the puncture angle was measured by ultrasound. Any subsequent steps of the procedure were performed under continuous fluoroscopy (15 fps). The patients were divided in 2 groups based on the puncture angle: ≤30° (group I) and >30° (group II). In a retrospective analysis, both groups were compared for inter- and intragroup variability, technical success, total fluoroscopy time, and complications. RESULTS In group II, the recorded total fluoroscopy time (232.20±140.94 s) was significantly longer than that in group I (83.44±52.61 s) (P<0.001). In both groups, total fluoroscopy time was significantly longer in cases with a lesser degree of bile duct dilatation, intrahepatic bile duct tortuosity, presence of liver metastases, and multiple intrahepatic bile duct strictures. CONCLUSIONS The initial bile duct puncture angle was identified as an operator-dependent factor with the possible impact on total fluoroscopy time. The puncture angle of less than 30° was positively correlated with overall procedure efficacy and total fluoroscopy time reduction.

Recent advances of endoscopic retrograde cholangiopancreatography using balloon assisted endoscopy for pancreaticobiliary diseases in patients with surgically altered anatomy: Therapeutic strategy and management of difficult cases

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic modality established for diagnosis and treatment of pancreaticobiliary diseases. However ERCP in patients with surgically altered anatomy (SAA) has been difficult, and more invasive therapies have been primarily selected. The development of balloon assisted endoscopes (BAEs) innovatively facilitated ERCP in such patients. Recent advances of BAEs and other devices greatly contributed to increasing success of ERCP using BAEs (BAE-ERCP). Furthermore, interventions using Endoscopic Ultrasound (EUS-intervention) have been reported to be useful for pancreaticobiliary diseases in patients with SAA, which provide more options for endoscopic therapies and are also expected as a rescue therapy for difficult cases of BAE-ERCP. In order to thoroughly complete endoscopic treatment for pancreaticobiliary diseases with SAA, it is important to standardize the BAE-ERCP procedures based on the features of respective endoscopes and to establish a strategy for endoscopic treatment which includes analysis of BAE-ERCP difficult cases and selection of cases for rescue therapy. In addition, it is essential to be acquainted with the characteristics of possible adverse events of the procedure and to be able to deal with them for safe accomplishment of endoscopic treatment.

Endoscopic management of difficult common bile duct stones

INTRODUCTION

Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones.

EVIDENCE ACQUISITION

A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS).

EVIDENCE SYNTHESIS

This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones.

CONLCLUSIONS

For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.

Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the gold standard for diagnosis and interventions in biliopancreatic diseases. However, ERCP in patients with surgically altered anatomy (SAA) appears to be more difficult compared to cases with normal anatomy. Since the production of a balloon enteroscope (BE) for small intestine disorders, BE had also been used for biliopancreatic diseases in patients with SAA. Since the development of BE-assisted ERCP, the outcomes of procedures, such as stone extraction or drainage, have been reported as favorable. Recently, an interventional endoscopic ultrasound (EUS), such as EUS-guided biliary drainage (EUS-BD), has been developed and is available mainly for patients with difficult cases of ERCP. It is a good option for patients with SAA. The effectiveness of interventional EUS for patients with SAA has been reported. Both BE-assisted ERCP and interventional EUS have advantages and disadvantages. The choice of procedure should be individualized to the patient’s condition or the expertise of the endoscopists. The aim of this review article is to discuss recent advances in interventional ERCP and EUS for patients with SAA.

Percutaneous transhepatic biliary drainage in patients at higher risk for adverse events: experience from a tertiary care referral center

BACKGROUND

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events.

MATERIAL

Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded.

RESULTS

During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed.

CONCLUSION

PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

Double balloon enteroscopy improves ERCP success in patients with modified small bowel anatomy

OBJECTIVE:

The aim of this study was to evaluate the effect of double-balloon enteroscopy (DBE) on the success of endoscopic retrograde cholangiopancreatography (ERCP) procedures in patients with surgically modified gastrointestinal (GI) tract anatomy.

METHODS:

The medical records of patients who underwent ERCP in the Gastroenterology Department of Kocaeli University School of Medicine hospital between December 2008 and September 2014 were examined. From the patient group that was scheduled to undergo DBE-ERCP, the details of cases in which ERCP via standard duodenoscope or DBE-ERCP was performed during the same session because standard ERCP failed were included. Procedure parameters, outcomes, and complications related to the procedure in both groups were analyzed. Patients who underwent the DBE-ERCP procedure directly, those who underwent push enteroscopy, or gastroscopy to evaluate the GI tract anatomy before the day of ERCP, and who underwent DBE-ERCP on a day other than the initial ERCP session were excluded. Afferent loop intubation, access to the major papilla, selective cannulation, therapeutic success rates, and the effect of DBE on overall procedure success were evaluated.

RESULTS:

Fifty-one patients with a history of BII gastrojejunostomy and 11 patients with hepaticojejunostomy (with or without Roux-en-Y) were included in the study. In all patients, the ERCP procedure was initiated with a standard duodenoscope. If intubation of the afferent loop was unsuccessful in reaching the major papilla or enterobiliary anastomosis, DBE was used. In 30 (48.4%) of the 62 patients whose GI tract was anatomically altered, the duodenoscope was successfully advanced to the ampulla and 27 (43.5%) were cannulated successfully. Thirty-one patients underwent DBE-ERCP. DBE reached the ampulla or enterobiliary anastomosis in 30 patients (96.8%) and selective choledocus cannulation was achieved in all patients but 3 (90%), including 1 patient with a hepaticojejunostomy. The overall ERCP success rate increased from 43.5% (27/62) to 87.1% (54/62). Two perforations (1 during standard duodenoscopy and 1 with DBE-ERCP) were observed.

CONCLUSION:

The overall success rate of ERCP increased with use of the DBE technique in patients with small bowel anatomic variations that were the result of previous surgery.

The Feasibility of Conventional Forward-viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Gastrointestinal Anatomy

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has been commonly used for biliopancreatic diseases of patients with normal gastrointestinal (GI) anatomy with a success rate of >90%. However, this procedure may also be necessary in patients with altered GI anatomy such as Billroth II or Roux-en-Y reconstructions. Performing ERCP in these patients may pose extreme technical challenges, and increase the risk of complications. The aim of this study was to analyze the feasibility of ERCP using forward-viewing endoscopy in patients with altered GI anatomy.

MATERIALS AND METHODS

Twenty-three patients with previous gastric resections and GI anastomosis, who underwent ERCP between 2012 and 2017, were included in this retrospective study. The major indication for ERCP was choledocholithiasis in 19 patients, and the others were acute cholangitis, sphincter Oddi dysfunction, and biliary pancreatitis. The sedation was induced using a combination of midazolam and propofol, and all procedures were performed using a forward-viewing endoscope.

RESULTS

Among the 23 patients, 14 were male individuals and 9 were female individuals, with an average age of 62 (range: 58 to 73) years. The median procedure time was 24 (range: 19 to 43) minutes. The success rate of bile duct cannulation was 91.3% (21/23 patients) and that of stone extirpation was 89.4% (17/19 patients with choledocholithiasis). Plastic stents were placed in the 2 patients in whom stone extirpation was not successfully performed. ERCP was repeated in these patients 8 weeks after the initial approach, and stone extraction procedures were successfully completed. The only procedure-related complication was edematous pancreatitis, which was observed in 1 patient (4.7%). The mean length of hospitalization was 2 (range: 1 to 5) days.

CONCLUSIONS

Forward-viewing endoscopes can be effectively used in patients with altered GI anatomy by facilitating the access to the papilla and bile duct cannulation without increasing the incidence of complications.

Percutaneous Transcholecystic Removal of Common Bile Duct Stones: Case Series in 114 Patients

Purpose To evaluate the safety and effectiveness of percutaneous transcholecystic removal of common bile duct (CBD) stones in 114 patients. Materials and Methods This retrospective study was approved by the institutional review board. From September 2011 through February 2017, 114 consecutive patients (68 men, 46 women; mean age, 73 years) underwent percutaneous transcholecystic removal of CBD stones. All patients had acute cholangitis or cholecystitis. Stones were extracted through a 12-F sheath by using a Wittich nitinol stone basket uder fluoroscopic guidance. Technical success rates, complications, and long-term follow-up were evaluated. Results Technical success was achieved in 96 of 114 (84.2%) patients. In 18 patients, stone removal was unsuccessful due to failure of cystic duct cannulation (n = 11), proximal migration of the CBD stone (n = 3), multiple CBD stones (n = 3), and low insertion of the cystic duct (n = 1). No major procedure-related complications were seen. During the mean follow-up of 644 days (range, 11-2206 days), CBD stones recurred in 12 patients after a mean of 884 days (range, 439-1799 days) after the procedure. Conclusion Percutaneous transcholecystic removal of common bile duct stones seems to be a safe and effective method. © RSNA, 2018 Online supplemental material is available for this article . See also the editorial by vanSonnenberg and Panchanathan in this issue.

Utility of newly developed short-type double-balloon endoscopy for endoscopic retrograde cholangiography in postoperative patients

BACKGROUND AND AIM

The utility of conventional short-type double-balloon endoscopy (DBE) for pancreatobiliary disease in patients with postoperative anatomy had been widely acknowledged and accepted. However, some technical difficulties yet remained. In an attempt to solve these problems, the new short-type DBE (N-short DBE) was uniquely designed for therapeutic endoscopic retrograde cholangiography (ERC) in postoperative patients. The aim of this study was to evaluate the usefulness of N-short DBE for ERC in postoperative patients.

METHODS

From August 2015 to April 2016, ERC using N-short DBE (DB-ERC) was performed in 100 postoperative patients (112 procedures). We retrospectively studied the success rate of reaching the blind end, the median time to reach the blind end, the diagnostic success rate, the therapeutic success rate, the median time to complete ERC-related interventions, the overall success rate, the median time to complete DB-ERC, and adverse events.

RESULTS

The success rate of reaching the blind end was 99.1%. The median time to reach the blind end was 10 min (interquartile range [IQR], 6-19 min). The diagnostic success rate was 98.2%. The therapeutic success rate was 100%. The median time to complete ERC-related interventions was 36 min (IQR, 22-62 min). The overall DB-ERC success rate was 97.3%. The median time to complete DB-ERC was 54 min (IQR, 37-73 min). The occurrence of adverse events was 2.7%.

CONCLUSIONS

The N-short DBE for ERC in postoperative patients is useful and safe. DB-ERC is promising therapeutic modality in such patients and should be selected as the first-line policy.

Predictors of success for double balloon-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-Y anastomosis (REYA) is challenging. Use of double balloon enteroscope-assisted ERCP (DBE-ERCP) has been successful. We aim to determine predictors of successful biliary cannulation with DBE-ERCP in patients with REYA.

METHODS

We retrospectively studied patients with REYA who had DBE-ERCP between 2009 and 2015.

RESULTS

86 DBE-ERCP were done on 52 patients. Patients had REYA for liver transplant (n = 26), gastrojejunostomy (n = 9), previous bile duct injury (n = 9), biliary atresia (n = 2) and other (n = 6). The biliary-enteric anastomosis was reached in 76% and cholangiogram was successful in 70%. Highest success rates were in patients with previous bile duct injury (94%) or gastrojejunostomy (89%). Post-transplant patients had intermediate success (64%). Patients with redo surgery (46%) and childhood surgery (38%), especially Kasai procedure (20%), had low success. Patients with previous bile duct injury were more likely to succeed (94% vs 63%, P = 0.010). Those more likely to fail were patients with childhood surgery (38% vs 73%, P = 0.037), biliary atresia (20% vs 73%, P = 0.013) and second operation post-transplant (25% vs 70%, P = 0.046).

CONCLUSION

Indication for REYA impacts on successful biliary cannulation in patients undergoing DBE-ERCP. The procedure is most successful in non-liver transplant adult surgery and post-transplant patients without a second operation. It is least successful in patients with surgically corrected biliary atresia and post-transplant patients with second operation. Alternative methods of biliary access should be considered in these patients.

Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis

BACKGROUND/AIMS

The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis.

MATERIALS AND METHODS

A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test.

RESULTS

Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65-94.30%], 79.92% (95% CI: 68.06-89.59%), and 63.55% (95% CI: 53.70-72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61-11.38%).

CONCLUSION

Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.

Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan

OBJECTIVES

To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy.

METHODS

This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study.

RESULTS

A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery.

CONCLUSIONS

ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.

Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy

The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.

Evaluation of endoscopic retrograde cholangiopancreatography using a newly developed short-type single-balloon endoscope in patients with altered gastrointestinal anatomy

BACKGROUND AND AIM

Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy had been impractical until the development of balloon-assisted endoscope (BAE) made it feasible. The aim of the present study was to evaluate the usefulness of a newly developed short-type single-balloon endoscope (s-SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal anatomy.

METHODS

From March 2013 to November 2013, s-SBE-assisted ERCP was done in our hospital in 26 postoperative patients who had surgically altered anatomy. We retrospectively evaluated the success rate of reaching the blind end, the mean time required to reach the blind end, the diagnostic success rate, the therapeutic success rate, the mean procedure time, and complications.

RESULTS

The success rate of reaching the blind end was 92.3%. The mean time required to reach the blind end was 25.3 min. The diagnostic success rate was 91.7%. The diagnostic success rate for naïve papilla was 75%. The mean procedure time was 56.0 min. The success rate of overall s-SBE-assisted ERCP was 84.6%. The complication rate was 3.8%.

CONCLUSION

Diagnostic and therapeutic ERCP using a newly developed s-SBE is sufficiently effective.

Percutaneous transhepatic biliary drainage in patients with postsurgical bile leakage and nondilated intrahepatic bile ducts

OBJECTIVE AND BACKGROUND

Bile leakage is a serious postoperative complication and percutaneous transhepatic biliary drainage (PTBD) may be an option when endoscopic treatment is not feasible. In this retrospective study, we established technical and clinical success rates as well as the complication rates of PTBD in a large group of patients with postoperative bile leakage.

METHODS

Data on all patients with nondilated intrahepatic bile ducts who underwent a PTBD procedure for the treatment of bile leakage between January 2000 and August 2012 were retrospectively assessed. Data included type of surgery, site of bile leak, previous attempts of bile leak repair, interval between surgery and PTBD placement. Outcome measures were the technical and clinical success rates, the procedure-related complications, and mortality rate.

RESULTS

A total of 63 patients were identified; PTBD placement was technically successful in 90.5% (57/63) after one to three attempts. The clinical success rate was 69.8% (44/63). Four major complications were documented (4/63; 6.3%): liver laceration, pneumothorax, pleural empyema, and prolonged hemobilia. One minor complication involved pain.

CONCLUSIONS

PTBD is an effective treatment with low complication rates for the management of postsurgical bile leaks in patients with nondilated bile ducts.

Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy

Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy and to cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.

Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study

OBJECTIVE

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE-ERCP) is an effective method for interventions in the pancreaticobiliary system in the post-surgical patient. However, use of currently available endoscopic accessories during this procedure is limited due of the length of the conventional instrument (200 cm). The aim of this study was to explore the utility of the short DBE (152 cm) for the management of pancreaticobiliary disorders in patients with surgically altered anatomies.

METHODS

Data were collected retrospectively on patients with various anatomic variations in whom ERCP was performed using the short DBE from April 2008 to November 2011. Basic demographic information, clinical presentation, preoperative imaging, and type of surgery, procedural technical success rate, and adverse events were evaluated. Descriptive analysis was used to document the demographic and clinical data of the patients.

RESULTS

We identified 79 patients in whom DBE-ERCP was attempted (38 % male, mean age 58 years). Indications for the procedure were removal of a previously placed stent (n = 5), suspected sphincter of Oddi dysfunction type 1 (n = 3), surgical biliary leak (n = 3), pancreatic anastomotic stricture (n = 2), suspected biliary stones (n = 48), and biliary strictures visualized on imaging (n = 18). Overall, the success rate of DBE-ERCP in all patients was 81 % (64/79). The scope could not reach the papilla or surgical anastomosis in 8 cases and duct cannulation failed in 7 cases. The following interventions were performed: biliary sphincterotomy (n = 39), dilation of CBD stenosis with a balloon (n = 30), biliary stent insertion (n = 25), stone removal (n = 35), brushing cytology of biliary strictures (n = 3), and stent retrieval (n = 4). Three patients developed post-procedure pancreatitis. There was 1 episode of self-limited bleeding.

CONCLUSIONS

The current study demonstrates that DBE assisted ERCP for pancreaticobiliary interventions using a short enteroscope are feasible in patients with surgically altered anatomy.

'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a 'short' DBE in patients with surgically altered anatomy.

METHODS

A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a 'short' DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed.

RESULTS

A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple's operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications.

CONCLUSION

DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard 'long' DBEs have limitations of long working length and the need for modified ERCP accessories. 'Short' DBEs are equally as effective in reaching the target limb as standard 'long' DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts

OBJECTIVE

The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach.

MATERIALS AND METHODS

Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded.

RESULTS

The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner.

CONCLUSION

T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

[Extracorporeal percutaneous biliary-gastric "bypass" in patients with irreversible cholestasis of malignant etiology]

Authors present rarely and unusual original methods for billiary drainage type as combination of exsternal drainage and percutaneus gastrostomy. Method used in four patients with irreversibile obstruction during the last 3 years in Inteventional Radiology Dept. Clinical Center of Serbia. In all cases we have satisfactory results with survival time of about 30 days.

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p=0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p=0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.

Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system

OBJECTIVES

Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient by conventional endoscopic retrograde cholangiopancreaticography (ERCP) are difficult and, depending on the surgical procedure, in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients.

METHODS

In a retrospective analysis of all DBE procedures at our department between November 2004 and June 2007, 11 patients were identified with various anatomic variations in whom ERCP was performed using a DBE.

RESULTS

In 72% of the patients, previous conventional ERCP examinations failed (8/11). In these patients, DBE-ERCP was successful in 63%. The overall success rate of DBE-ERCP in all patients was 64% (7/11 patients). In those patients, interventions such as papillotomy, calculus extractions, as well as stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite most of the DBE-ERCPs having included therapeutic interventions, no major complications occurred in our case series and minor side effects were restricted to meteorism and mild to moderate abdominal pain.

CONCLUSIONS

DBE-ERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary as well pancreatic system in the operated patient. However, it should be limited to selected patients, e.g., with contraindications for PTC, as it is a time-consuming as well as a cost-intensive procedure.

Choledochal cyst cholangiocarcinoma arising from adenoma: case report and a review of the literature

A case of cholangiocarcinoma arising in an unresected choledochal cyst in adulthood is presented. Although typically diagnosed in pediatric population, as many as 20% to 30% of choledochal cysts can be discovered in adulthood. Unresected choledochal cyst is clearly associated with increased risk of cholangiocarcinoma. Proper surgical treatment includes cyst resection and bilioenteric anastomosis. Asymptomatic patients with choledochal cyst previously treated by biliary diversion without cyst resection present a challenging issue and should be considered for cyst resection. Association of choledochal cyst with pancreaticobiliary anomalies is reviewed.

Value of adding T1-weighted image to MR cholangiopancreatography for detecting intrahepatic biliary stones

OBJECTIVE

The purpose of this study was to assess the value of adding a T1-weighted image to MR cholangiopancreatography (MRCP) to detect bile duct stones.

MATERIALS AND METHODS

During a 30-month period, 148 patients suspected of having biliary stones and who underwent MRI including MRCP, a fat-suppressed T1-weighted fast low-angle shot (FLASH) sequence, and an axial HASTE sequence were enrolled in this study. The biliary stones were confirmed by ERCP, surgery, and percutaneous transhepatic cholangiography. Of these 148 patients, 73 had extrahepatic stones, 45 had intrahepatic stones, 20 had both extrahepatic and intrahepatic stones, and 10 had no biliary stones. Two separate sets of images, the MRCP set (composed of MRCP and axial HASTE) and the combined interpretion of the MRCP set and the T1-weighted image, were analyzed independently and separately by two observers. The diagnostic accuracy was evaluated using the receiver operating characteristic method. The sensitivity and specificity were also calculated.

RESULTS

For common duct stones, the diagnostic accuracy and the sensitivity of both image sets showed similar values without any significant difference (0.998 [97.8%] for the combined interpretation; 0.988 [97.8%] for observer 1 and 0.995 [96.8%] for observer 2 for the MRCP set). However, for the intrahepatic stones, the diagnostic accuracy (0.993) and the sensitivity (98.5%) of the combined interpretation were significantly higher than those of the MRCP set for the two observers (0.926 [83.8%] for observer 1 and 0.922 [85.3%] for observer 2) (p < 0.05). No significant difference was seen in the specificity of the two image sets for both the intrahepatic and the common duct stones.

CONCLUSION

Combining the axial T1-weighted image with MRCP is valuable for detecting intrahepatic stones.

Chemotherapy-induced sclerosing cholangitis: long-term response to endoscopic therapy

BACKGROUND

Hepatic arterial infusion of fluoropyrimidines has been widely used for the treatment of hepatic metastasis from colorectal cancer. One major complication of such treatment is biliary sclerosis resembling primary sclerosing cholangitis, which has an incidence ranging from 8% to 26%.

AIM

We evaluated the efficacy and long-term outcome of endoscopic therapy in the management of chemotherapy-induced sclerosing cholangitis (CISC).

METHODS

With the use of an endoscopic retrograde cholangiopancreatography (ERCP) database, all patients with a diagnosis of CISC who had endoscopic therapy between March 1995 and March 2005 were identified. The indications, findings, therapies, and complications for all patients undergoing ERCP were recorded in this database. Additional information was obtained by review of medical records.

RESULTS

Eleven patients (six men and five women) were identified. The mean age at presentation was 59.5 years (range, 36-76 years). Cholangiogram findings revealed stricture confined to the common hepatic duct in two patients, involving the hilum in seven patients, involving the right and/or left main hepatic ducts in nine patients, and extending to the intrahepatic radicals in two patients. All patients had successful endoscopic therapy to alleviate the presenting symptom. The grade and extent of biliary strictures did not change in five patients, improved in one patient, recurred in two patients, and progressed in two patients over the follow-up period of 28.2 months (range, 4-60 months).

CONCLUSION

Although long-term follow-up of patients with CISC is limited by the dismal prognosis of the underlying malignancy, CISC has a recalcitrant pattern that rarely improves with endoscopic therapy. However, endoscopic therapy seems to be an effective method of palliation.

Use of CT cholangiography to evaluate the biliary tract after liver transplantation: initial experience

Evaluation of the biliary tract after liver transplantation, particularly when a Roux-en-Y hepatojejunostomy precludes endoscopic retrograde cholangiography, may be challenging. We present five cases of suspected biliary obstruction after liver transplantation in which multidetector-row computed tomography (CT) cholangiography was used. In conclusion, it was determined that multidetector-row CT cholangiography may be a useful modality for demonstrating patent biliary-enteric anastomoses and excluding flow-limiting biliary anastomotic strictures.

Usefulness of a Percutaneous Transhepatic Coaxial Micropuncture Needle Technique in Patients with Nondilated Peripheral Intrahepatic Ducts

OBJECTIVE

I sought to develop an efficacious transhepatic technique for localizing normal or minimally dilated biliary radicles using 25- to 27-gauge needles threaded through 21- to 22-gauge needles.

CONCLUSION

The micropuncture needle is a useful adjunct for performing transhepatic cholangiography in patients whose bile ducts are nondilated or in whom the standard transhepatic needle technique has failed.

Diagnosis of choledocholithiasis and bile duct stenosis by magnetic resonance cholangiogram

We evaluated the diagnostic accuracy of magnetic resonance cholangiography (MRC) in the diagnosis of bile duct calculi and stenosis. Two-dimensional fast spin echo (FSE) MR cholangiograms were performed using torso multicoil array as a surface coil and respiratory triggering in 50 patients suspected of having bile duct disease. Coronal and axial images were acquired and reviewed prospectively by two radiologists. Direct cholangiographic correlation (endoscopic retrograde cholangiopancreatography [ERCP], intraoperative cholangiogram, percutaneous transhepatic cholangiogram) and surgery were available for comparison and were reviewed by two radiologists. The sensitivity, specificity and accuracy of MRC in diagnosing bile duct dilatation, choledocholithiasis and stenosis were evaluated. It yielded a sensitivity and a specificity of 100% in diagnosing bile duct dilatation. In the diagnosis of choledocholithiasis, MRC yielded a sensitivity of 95%, a specificity and an accuracy of 96%. Bile duct stenosis was diagnosed with a sensitivity and a specificity of 100%. We concluded that MRC exhibited high accuracy in diagnosing bile duct stenosis and choledocholithiasis.