Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Endoscopic retrograde cholangiopancreatography outcomes in inflammatory bowel disease patients: a 12-year analysis of a national database

BACKGROUND

Despite inflammatory bowel disease's (IBD) association with hepatobiliary disorders and the use of endoscopic retrograde cholangiopancreatography (ERCP) for both diagnostic and therapeutic evaluation of these diseases, it remains a poorly studied area within the literature. The purpose of this study is to examine the effect of IBD on the occurrence of adverse events (AE) pertaining to ERCP.

METHODS

This project utilized the National Inpatient Sample (NIS) database, the largest inpatient database in the USA. All patients 18 years or older with and without IBD undergoing ERCP were identified from 2008 to 2019. Post-ERCP AEs were analyzed using multivariate logistic or linear regression controlling for age, race, and existing comorbidities using the Charlson comorbidity index (CCI).

RESULTS

There was no difference in post-ERCP pancreatitis (PEP) or mortality. IBD patients were also found to have a lower risk of bleeding and decreased length of stay (LOS) despite adjustment for comorbidities. They also underwent less sphincterotomies when compared to the non-IBD cohort. Subgroup analysis between ulcerative colitis (UC) and Crohn's disease (CD) did not find any significant differences in outcomes.

CONCLUSION

To our knowledge, this is the largest study to date evaluating ERCP outcomes in IBD patients. After adjustment of co-variates, there was no difference in the occurrence of PEP, infections, and perforation. IBD patients were less likely to experience post-ERCP bleeding and mortality and had shorter LOS which may be due to the decreased frequency of sphincterotomy in this population.

Risk of thromboembolic events in relation to the management of anticoagulant and antiagregant therapy in patients subjected to endoscopic retrograde cholangiopancreatography

BACKGROUND AND OBJECTIVES

The main clinical practice guidelines recommend adequate periprocedural withdrawal and reintroduction of antithrombotic drugs in case of invasive techniques. The main objective of this study was to assess whether, in patients receiving anticoagulant or antiplatelet therapy, the suppression or reduction of the pharmacological dose for the performance of endoscopic retrograde cholangiopancreatography (ERCP) implies a greater risk of thromboembolic events.

PATIENTS AND METHODS

A prospective observational study was carried out, which included 644ERCP performed with therapeutic intention during 2019 at the Reina Sofía University Hospital with follow-up during the 30days after the endoscopic intervention.

RESULTS

Six patients presented a thromboembolic event, finding no differences between the incorrect withdrawal/reintroduction of antithrombotic treatment and a higher proportion of thromboembolic or hemorrhagic events after the procedure (P>.05). The incidence of thrombotic events was significantly higher in patients treated with heparin or apixaban (P=.001), as well as with a history of atrial fibrillation (P=.05), rheumatic valve disease (P=.037) and recurrent pulmonary embolism (P=.035), this being also an independent risk factor. Likewise, the incidence of hemorrhage in the 30days post-sphincterotomy was significantly lower in those with implantation of a biliary prosthesis (P=.04).

CONCLUSIONS

Inadequate periprocedural management of antithrombotic therapy is not associated with a significant increase in the incidence of thromboembolic events in the 30days after ERCP. However, close follow-up and surveillance during the days after this is essential in those patients with a condition that significantly increases the risk of thrombosis.

Risk of post-sphincterotomy bleeding in patients with thrombocytopenia

Background

Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Objective

The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES.

Design

Retrospective observational cohort study.

Methods

Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review.

Results

A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not.

Conclusion

In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.

Endoscopic Bridge-and-Seal of Bile Leaks Using a Fully Covered Self-Expandable Metallic Stent above the Papilla

Background/Aims: Endoscopic management by endoscopic sphincterotomy with or without plastic stents or fully covered self-expandable metallic stents (FCSEMSs) is widely accepted as the current standard of care for postoperative bile leaks. Biliary stents are placed across the papilla, not above the papilla. We investigated the safety and effectiveness of the bridge-and-seal technique for bile leaks by the placement of FCSEMS above the papilla. Methods: This was a retrospective study of FCSEMS placement above the papilla for bile leaks between October 2016 and July 2021. FCSEMS was placed above the papilla to bridge and seal the leak. The main outcome measures were the resolution of bile leaks and adverse events. Results: Seven patients with postoperative bile leaks underwent FCSEMS above the papilla. The locations of bile leaks were 1 cystic duct remnant; 2 intrahepatic bile duct; 1 hepatic duct; 2 common bile duct and 1 anastomosis. The technical success rate of FCSEMS placement was 100%, and resolution of bile leaks was achieved in five patients (71.4%). All the adverse events were observed after FCSEMS removal; as follows: 1 moderate cholangitis; 2 mild post-ERCP pancreatitis; and 1 mild remnant cholecystitis. Conclusions: FCSEMS placement above the papilla can be a treatment option for postoperative bile leaks.

Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations

Background

Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but life-threatening complications. The treatment of Type-II-periampullary perforations that develop during endoscopic sphincterotomy remains a topic of discussion. This study aimed to evaluate the usefulness of fully covered self-expanding metal stenting (FCSEMS) for treating Type-II perforations.

Methods

The files of all patients who underwent the ERCP procedures between January 2015 and October 2021 were retrospectively reviewed; patients with Stapher Type-II perforation were included in the current study. Patients with FCSEMS were classified into two groups: those who underwent FCSEMS and those who were conventionally followed up. Moreover, patients with FCSEMS were classified into two subgroups: those who underwent simultaneous stenting and those who underwent late stenting. Mortality, surgical intervention, percutaneous drainage, length of hospital stay, and inflammatory markers were all compared between the groups.

Results

Of the 9253 patients undergoing ERCP during the study period, 28 patients (0.3%) were found to have Type-II perforation. The mean age of these patients was 67.7 ± 3.9 years, and 15 patients were female. FCSEMS was performed on 19 patients, whereas 9 patients were on conventional follow-up. None of the patients developed mortality. In the conventional follow-up group, one patient required percutaneous drainage and one required surgical intervention. In contrast, none of the patients in the FCSEMS group required additional intervention. At a statistically significant level, the length of hospital stay was found to be shorter in the FCSEMS group. There was no difference in inflammatory markers between the two groups. In nine patients, FCSEMS was performed simultaneously, whereas, in ten patients, FCSEMS was performed later because they required a second intervention. These two subgroups did not differ in terms of outcomes.

Conclusions

FCSEMS is a safe and effective treatment modality for patients with Type-II perforation. Moreover, it can be safely used in patients whose perforations are diagnosed during the ERCP procedure and in patients whose diagnoses are made after the procedure.

Biliary Self-Expandable Metal Stent Could Be Recommended as a First Treatment Modality for Immediate Refractory Post-Endoscopic Retrograde Cholangiopancreatography Bleeding

Background/Aims

Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding.

Methods

Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis.

Results

A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min.

Conclusions

Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

Endoscopic Treatment of Post-Cholecystectomy Biliary Leaks

Postcholecystectomy leaks may occur in 0.3-2.7% of patients. Bile leaks associated with laparoscopy are often more complex and difficult to treat than those occurring after open cholecystectomy. Furthermore, their incidence has remained unchanged despite improvements in laparoscopic training and technological developments. The management of biliary leaks has evolved from surgery into a minimally invasive endoscopic procedural approach, namely, endoscopic retrograde cholangiopancreatography (ERCP), which decreases or eliminates the pressure gradient between the bile duct and the duodenum, thus creating a preferential transpapillary bile flow and allowing the leak to seal. For simple leaks, the success rate of endotherapy is remarkably high. However, there are more severe and complex leaks that require multiple endoscopic interventions, and clear strategies for endoscopic treatment have not emerged. Therefore, there is still some debate regarding the optimal time point at which to intervene, which technique to use (sphincterotomy alone or in association with the placement of stents, whether metallic or plastic stents should be used, and, if plastic stents are used, whether they should be single or multiple), how long the stents should remain in place, and when to consider treatment failure. Here, we review the types and classification of postoperative biliary injuries, particularly leaks, as well as the evidence for endoscopic treatment of the latter.

Practical Experiences of Unsuccessful Hemostasis with Covered Self-Expandable Metal Stent Placement for Post-Endoscopic Sphincterotomy Bleeding

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Early Covered Self-Expandable Metal Stent Placement Is Effective for Massive Post-endoscopic Sphincterotomy Bleeding

BACKGROUND

Placement of covered self-expandable metallic stent (CSEMS) for post-endoscopic sphincterotomy (ES) bleeding achieves excellent hemostasis results. Although CSEMS placement is typically performed after failure of conventional endoscopic combination therapy, its excellent outcomes may justify earlier placement.

AIMS

We aimed to examine the efficacy of "early" CSEMS placement for massive post-ES bleeding.

METHODS

The medical records of 2750 patients who underwent ES between 2005 and 2019 were reviewed retrospectively, and 61 patients who developed massive post-ES bleeding were enrolled. These patients were divided into those who underwent early CSEMS placement (E-CSEMS group) and those who underwent conventional endoscopic combination therapy (Conventional group). The outcomes of hemostasis procedures were compared between the groups.

RESULTS

The primary success rates of endoscopic hemostasis were 100% (21/21) and 98% (39/40) in the E-CSEMS group and Conventional group, respectively, without significant differences (P = 1.000). However, in the E-CSEMS group, re-bleeding was significantly less frequent (5% vs. 31%; P = 0.023), the median hemostasis procedure time was significantly shorter (14 min vs. 26 min; P < 0.001), and transfusion after initial hemostasis treatment was less commonly required (10% vs. 38%; P = 0.034). Multivariate analyses showed that hemodialysis was associated with a significantly higher re-bleeding rate (P = 0.029), while CSEMS placement was associated with a significantly lower re-bleeding rate (P = 0.039).

CONCLUSIONS

Early CSEMS placement may be effective for improving the clinical outcomes of massive post-ES bleeding by decreasing re-bleeding and the extent of bleeding.

Management of Postcholecystectomy Biliary Complications: A Narrative Review

Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).

Fully Covered Self-Expandable Metal Stens eliminate surgical repair requirement in both endoscopic sphincterotomy and precut sphincterotomy-related perforation (with video)

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations occur in 0.3-0.6% of patients. The treatment of retroperitoneal paravaterian perforations (type II), which develop during endoscopic sphincterotomy or precut sphincterotomy, remains a matter of debate. We aimed to evaluate the efficacy of fully covered self expandable metal stent (Fc-SEMS) placement in the treatment of type II perforations.

METHODS

The study was conducted in a tertiary ERCP reference center of Turkey between December 2013 and June 2016. Patients with type II ERCP-related perforation constituted the study group. Type II perforations were treated by insertion of an Fc-SEMS (10 mm × 60 mm) during the ERCP procedure or intraoperatively by surgery-endoscopy rendezvous technique, if biliary cannulation could not be achieved.

RESULTS

A total of 2689 ERCPs were performed. ERCP-related perforation was observed in 12 procedures (0.4%). Eight patients had Stapfer type II perforations, which developed during endoscopic sphincterotomy in seven patients and precut sphincterotomy in one patient. Fc-SEMSs were inserted during the ERCP procedure in seven patients and intraoperatively by surgery-endoscopy rendezvous technique in one patient. None of the patients developed fever, hemodynamic instability, or peritoneal signs. Stents were removed after a median duration of 9 (3-14) days. All of the patients were uneventfully discharged after an average hospital length of stay of median 5 (1-9) days.

CONCLUSION

Fc-SEMSs are highly effective in the nonoperative treatment of type II perforations and their intraoperative insertion in patients with unsuccessful cannulation may facilitate surgery by eliminating the need for duodenum repair surgery.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Complications of endoscopic retrograde cholangiopancreatography: an imaging review

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Background/Aims

Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques.

Methods

A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult.

Results

Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists.

Conclusions

There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training.

Key Message

There is a significant gap between guidelines and routine clinical practice.

Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature<sup/>

BACKGROUND AND AIM

Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting.

PATIENTS AND METHOD

Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal.

RESULTS

Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6-10 mm, 4-8 cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2-105) days. The median hospital stay was of 10 (4-21) days. Median time to post-operative feeding was 4 days (2-15).

CONCLUSION

FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.

A Case of Unresolved and Worsening Retroperitoneal Abscess

Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset. Herein, we present a case of retroperitoneal abscess secondary to a perforation that occurred during an ERCP. A 54-year-old female patient was admitted to an outside hospital with gallstone pancreatitis and underwent ERCP with sphincterotomy followed by laparoscopic cholecystectomy. An abdominal CT scan was performed at the outside hospital 10 days later for worsening abdominal pain which showed multiple loculated pockets in the right upper and lower quadrant. Her condition improved after IV antibiotics and percutaneous drainage. Her symptoms recurred a month later and she presented to our hospital. Repeat abdominal CT scan at our hospital revealed recurrence of her abscesses. Multiple drains were placed and the abscess cavity was washed out without much improvement. EGD revealed a small mucosal defect in the distal portion of the duodenal bulb which was closed successfully using an over-the-scope clip. Repeat CT scan after 8 weeks from the endoscopic closure showed near complete resolution of the abscess. ERCP-associated perforation is a rare complication and can be challenging to diagnose and treat; prompt recognition is mandatory for favorable prognosis. Our patient was managed successfully via nonsurgical approach.

The use of fully-covered self-expanding metallic stents for intraprocedural management of post-sphincterotomy perforations: a single-center study (with video)

BACKGROUND AND STUDY AIMS

Management of post-sphincterotomy perforations is variable, with some patients managed conservatively and other requiring surgery. Fully-covered self-expanding metal stents (FCSEMs) have been used in the past, but data is limited. The aim of this study was to report the clinical characteristics and outcomes following placement of anchored FCSEMSs for the immediate management of post-sphincterotomy perforation.

PATIENTS AND METHODS

All patients undergoing an ERCP procedure between June 2011 and December 2015 at our institution were reviewed for post-sphincterotomy perforation. All intra-procedurally recognized perforations underwent placement of FCSEMs with flexible anchoring fins and were included in this study. Data extracted included patient demographics, indication, peri-procedural details, clinical course and long-term outcome following anchored FCSEMS placement.

RESULTS

A total of 15 patients (12 females, median age-66 years) with post-sphincterotomy perforation were included. Major indications included choledocholithiasis in 9 (60 %), and 5 (33.3 %) patients had intra-ampullary or periampullary diverticula. All patients underwent placement of FCSEMS without any complication and had immediate resolution of perforation as evidenced by decrease in fluoroscopic gas and lack of contrast extravasation. None of the patients became symptomatic or needed surgery with a median 2 days of hospitalization following the procedure. Stents were removed after a median of 30.5 days and no complications were noted during follow-up after stent removal.

CONCLUSIONS

Anchored FCSEMs are safe and effective for management of intra-procedurally recognized post-sphincterotomy perforations and obviates need for surgery.

Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 - 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %). Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months. 12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

Relationship between postoperative duodenal papilla hemorrhage and primary disease in patients after therapeutic endoscopic retrograde cholangiopancreatography

AIM

To investigate the relationship between postoperative duodenal papilla hemorrhage and primary disease in patients after therapeutic endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The clinical data of 661 patients treated by ERCP at our hospital were retrospectively analyzed. According to whether the patients had postoperative duodenal papilla hemorrhage or not, they were divided into a bleeding group and a non-bleeding group. The relationship between primary disease type and the risk of bleeding was then evaluated.

RESULTS

The overall bleeding rate was 6.1% (40/661). The percentage of patients with hypertension in the bleeding group was significantly higher than that in the non-bleeding group (P < 0.05). The proportions of patients with impacted stones in the ampulla of Vater, bile duct carcinoma, pancreatic carcinoma and duodenal papilla carcinoma were significantly higher in the bleeding group than that in the non-bleeding group (P < 0.05). The proportions of patients with common bile duct stones, acute suppurative cholangitis, acute biliary pancreatitis, and biliary cholangitis stricture in the two groups had no significant difference (P > 0.05).

CONCLUSION

The risk of duodenal papilla bleeding after therapeutic ERCP is greater in patients with impacted stones in the ampulla of Vater, bile duct carcinoma, pancreatic carcinoma and duodenal papilla carcinoma. Prevention of bleeding should be emphasized in these patients, and endoscopic hemostasis is safe and effective.

Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy?

PURPOSE

There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations.

METHODS

A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively.

RESULTS

Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery.

CONCLUSIONS

Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation.

Current Status of Biliary Metal Stents

Many advances have been achieved in biliary stenting over the past 30 years. Endoscopic stent placement has become the primary management therapy to relieve obstruction in patients with benign or malignant biliary tract diseases. Compared with plastic stents, a self-expandable metallic stent (SEMS) has been used for management in patients with malignant strictures because of a larger lumen and longer stent patency. Recently, SEMS has been used for various benign biliary strictures and leaks. In this article, we briefly review the characteristics of SEMS as well as complications of stent placement. We review the current guidelines for managing malignant and benign biliary obstructions. Recent developments in biliary stenting are also discussed.

Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients

BACKGROUND

Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks.

METHODS

This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy.

RESULTS

Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases.

CONCLUSIONS

Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

BACKGROUND

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear.

OBJECTIVE

To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks.

DESIGN

Prospective study.

SETTING

Two tertiary-care referral academic centers and one general district hospital.

PATIENTS

Forty consecutive patients with refractory biliary leaks who underwent endoscopic management.

INTERVENTIONS

Temporary placement of MPS (n = 20) or FCSEMSs (n = 20).

MAIN OUTCOME MEASUREMENTS

Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success.

RESULTS

Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases.

LIMITATIONS

Non-randomized design.

CONCLUSION

In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis. ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation (EPLBD) with a size of 15 mm. Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla. Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis. Therefore, we placed a 10 mm fully covered self-expandable metallic stent (SEMS) across the duodenal papilla, and the hemorrhage stopped immediately. After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct. A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct. We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.

Novel biliary self-expanding metal stents: indications and applications

Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed.

Endoscopic retrograde cholangiopancreatography-related adverse events: general overview

Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.

Emerging endoscopic therapies for nonvariceal upper gastrointestinal bleeding

Several new devices and innovative adaptations of existing modalities have emerged as primary, adjunctive, or rescue therapy in endoscopic hemostasis of gastrointestinal hemorrhage. These techniques include over-the-scope clip devices, hemostatic sprays, cryotherapy, radiofrequency ablation, endoscopic suturing, and endoscopic ultrasound-guided angiotherapy. This review highlights the technical aspects and clinical applications of these devices in the context of nonvariceal upper gastrointestinal bleeding.

Value of temporary stents for the management of perivaterian perforation during endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of treatment in hepato-pancreato-biliary disease. However, ERCP requires a high level of technical skills and experience in therapeutic endoscopy, there is always a risk of complications. Especially, the perforation per se affects the patient adversely, and the clinical course may lead to a poor prognosis, even with appropriate management. The treatments for ERCP-related perforation are diverse, depending on the location and mechanism of the bowel perforation and the time of diagnosis. Thus, we reviewed the appropriate surgical and non-surgical management options for therapeutic ERCP-related perforations, especially, evaluating metallic stenting as a treatment modality in perivaterian perforation.

[Retroperitoneal emphysema after endoscopic retrograde cholangiopancreatography]

Retroperitoneal emphysema represents a pathological situation with an abnormal amount of air in the retroperitoneal tissue. The diagnosis is made radiologically.The cause is mostly an iatrogenic complication of different diagnostic or therapeutic procedures. The most common cause is a perforation after endoscopic retrograde cholangiopancreatography (ERCP). In cases of clinically suspected complications after a procedure prompt diagnosis with computed tomography (CT) scan of the abdomen and an interdisciplinary decision on the suitable therapeutic measures is warranted, as immediate therapy reduces morbidity and mortality of patients. For selecting the ideal therapy it is essential to understand the underlying pathophysiological mechanism of retroperitoneal emphysema and to take the clinical situation of the patient into account. Thus periampullary or bile duct lesions facing the retroperitoneum can be treated conservatively in clinically stable patients, whereas in unstable patients with abscess formation, interventional radiological or endoscopic procedures are indicated. In cases of a duodenal lesion an endoscopic closure of the perforation can be performed in stable patients but if the patient shows signs of peritonism or if the clinical situation deteriorates, operative therapy is necessary.

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

Future developments in biliary stenting

Biliary stenting has evolved dramatically over the past 30 years. Advancements in stent design have led to prolonged patency and improved efficacy. However, biliary stenting is still affected by occlusion, migration, anatomical difficulties, and the need for repeat procedures. Multiple novel plastic biliary stent designs have recently been introduced with the primary goals of reduced migration and improved ease of placement. Self-expandable bioabsorbable stents are currently being investigated in animal models. Although not US Food and Drug Administration approved for benign disease, fully covered self-expandable metal stents are increasingly being used in a variety of benign biliary conditions. In malignant disease, developments are being made to improve ease of placement and stent patency for both hilar and distal biliary strictures. The purpose of this review is to describe recent developments and future directions of biliary stenting.

Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure with the potential for a variety of adverse events, including acute pancreatitis, perforation, bleeding, and cardiopulmonary complications, which are well-established risk factors. It has become standard that patients undergoing ERCP are carefully selected based on appropriate indications. Once an ERCP is undertaken, preprocedure and intraprocedure risks should be assessed and appropriate risk-reducing modalities, such as prophylactic pancreatic stent placement and rectal indomethacin, should be used if patient or procedural factors suggest an increased risk of post-ERCP pancreatitis.