Self-expandable metallic stents for malignant biliary obstruction with an anomalous pancreaticobiliary junction

Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups.

PATIENTS AND METHODS

Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90.

RESULTS

Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.

Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture

Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.

Percutaneous transhepatic cholangiography in diagnosis of pancreaticobiliary maljunction

AIM: To investigate the feasibility of percu-taneous transhepatic cholangiography (PTC) in the diagnosis of adult pancreaticobiliary maljunction (PBM), and to summarize its radiological characteristics.

METHODS: The clinical data of consecutive 257 patients with obstructive jaundice (OJ) receiving the PTC drainage in our hospital from January 1999 to February 2007 were collected. Clinical findings and cholangiopancreatographic results were retrospectively analyzed. Meanwhile the standard for selecting cases and diagnosing PBM was established. A total of 35 cases were selected and both biliary and pancreatic ducts were opacified. The obtained data were statistically analyzed.

RESULTS: PBM was diagnosed in 31 cases, and PTC detection rate was 12.06% (31/257). The length of common duct and the confluence angle of the pancreaticobiliary ducts were 9.87 ± 4.55 mm, which were significantly different from normal values (P < 0.05). The site of duodenal papilla had influences on the length of common duct. The diameters of common bile duct, pancreatic duct and common duct near the confluence were 3.20 ± 1.62 mm, 2.06 ± 0.82 mm, 3.03 ± 1.03 mm, respectively. There was no statistical difference between them and the normal values.

CONCLUSION: PTC is safe, effective and available to diagnose PBM. PTC finding of PBM has its own characteristics to some extent.