Air contrastography technique for successful urgent ERCP in a high risk allergic patient

Air cholangiogram: a new technique for biliary imaging during ERCP

BACKGROUND

Palliation of patients with malignant hilar stenosis by stent insertion is fraught with risk of cholangitis because of contrast injection in the undrained segment.

OBJECTIVE

The purpose of this study was to evaluate the results of unilateral metal stenting in type II and III malignant hilar biliary obstruction by using air as a contrast medium.

DESIGN

Prospective, uncontrolled, single center pilot study.

SETTING

Tertiary care referral center.

PATIENTS

Cohort of 17 patients with malignant hilar obstruction.

INTERVENTION

A single metallic stent was inserted in type II and III malignant hilar obstruction by using air as a contrast medium. Patients were evaluated weekly up to 1 month after stent placement.

MAIN OUTCOME MEASURES

Successful implantation, successful drainage, early complications, procedure-related mortality, 30-day mortality.

RESULT

Successful stent placement and drainage was achieved in 100% of the patients (17 of 17). No patient developed cholangitis or died within 30 days of the procedure.

LIMITATIONS

Small cohort of patients.

CONCLUSION

Air cholangiography provides a safe and effective roadmap for unilateral metallic stenting in type II and III malignant hilar biliary obstruction.

Cholangitis prevention in endoscopic Klatskin tumor palliation: air cholangiography technique

INTRODUCTION

Endoscopic biliary drainage is the treatment of choice for inoperable hilar cholangiocarcinoma (so-called Klatskin tumor). Cholangitis is the main complication post-endoscopic retrograde cholangiopancreatography (ERCP) in Klatskin patients, specially when medium contrast is injected into biliary tree that could not be subsequently drained. Bacterial cholangitis is the principal cause of mortality in these patients. The aim of this study is to analyze cholangitis rate resulting from the use of air versus iodine contrast to obtain cholangiography during ERCP.

METHODS

In 9 years, 188 inoperable Klatskin patients were recruited and divided into two groups: iodine (A) or air (B) contrast cholangiography, respectively. We used air or iodine contrast to obtain cholangiography before hilar stricture stenting. We retrospectively compared these data in both groups.

RESULTS

The group B had a significant lower rate of cholangitis than group A in Bismuth type II (p < 0.05), in Bismuth type III (p < 0.05), and in the Bismuth type IV population (p < 0.05).

CONCLUSION

The air contrast cholangiography is a safe and effective method, and it appears justified as a routine procedure to prevent or reduce the risk of post-ERCP cholangitis, specially in Klatskin patients (p < 0.005).

Contrast-free endoscopic stent insertion in malignant biliary obstruction

AIM: To present a case series of MRCP-guided endoscopic biliary stent placement, performed entirely without contrast injection.

METHODS: Contrast-free endoscopic biliary drainage was attempted in 20 patients with malignant obstruction, unsuitable for resection on the basis of tumor extent or medical illness. MRCP images were used to confirm the diagnosis of tumor, to exclude other biliary diseases and to demonstrate the stenoses as well as dilation of proximal liver segments. The procedure was carried out under conscious sedation. Patients were placed in the left lateral decubitus position. The endoscope was inserted, the papilla identified and cannulated by a papillotome. A guide wire was inserted and guided deeply into the biliary tree, above the stenosis, by fluoroscopy. A papillotomy approximately 1 cm. long was performed and the papillotome was exchanged with a guiding-catheter. A 10 Fr, Amsterdam-type plastic stent, 7 to 15 cm long, was finally inserted over the guide wire/guiding catheter by a pusher tube system.

RESULTS: Successful stent insertion was achieved in all patients. There were no major complications. Successful drainage, with substantial reduction in bilirubin levels, was achieved in all patients.

CONCLUSION: This new method of contrast-free endoscopic stenting in malignant biliary obstruction is a safe and effective method of palliation. However, a larger, randomized study comparing this new approach with the standard procedure is needed to confirm the findings of the present study.