Selective embolization for post-endoscopic sphincterotomy bleeding: technical aspects and clinical efficacy

A Study on the Spectrum of Imaging Findings of Post-ERCP-Specific Complications: A Retrospective Descriptive Study

Aim  The aim of this study was to examine the imaging manifestations of post-endoscopic retrograde cholangiopancreatography (ERCP) specific complications by computed tomography to aid in its early and successful diagnosis and timely intervention. Method  Forty-one cases of imaging having post-ERCP were complications were retrospectively collected and the spectrum of complications and their key imaging features and methods to improve their detection were analyzed. Result  The most common complication detected in computed tomography (CT) post-ERCP was the presence of intra-abdominal collections seen in 21 patients (51.2%). Pancreatitis was seen in 20 of 41 patients (48.7%), while bowel perforation was present in 9 patients (21%). Pleural effusion was present in 8 patients (19.5%), liver abscess in 6 patients (14.6%), cholangitis in 4 patients (9.7%), gallbladder perforation in 4 patients (9.7%), displaced common bile duct stent in 3 patients (7.3%), possibility of main pancreatic duct cannulation in 2 patients (4.8%), vascular injury resulting in right hepatic artery pseudoaneurysm in 1 patient (2.4%), thrombosis of portal vein or its branches in 2 patients (4.8%), superior mesenteric vein thrombosis in 1 patient (2.4%), right hepatic vein thrombosis in 1 patient (2.4%), pulmonary thromboembolism in 2 patients (4.8%), duodenal inflammation in 1 patient (2.4%), bowel ileus in 4 patients (9.6%), and bowel obstruction in 1 patient (2.4%). Conclusion  Complications after ERCP can cause significant morbidity and mortality if not diagnosed early and treated appropriately. Familiarity with normal findings post-ERCP and knowledge of the imaging appearance of these complications are vital in the early management of these conditions.

Left hepatic artery pseudoaneurysm complicating endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND

Pseudoaneurysms of the hepatic artery or its branches have been reported following abdominal trauma, iatrogenic injury at the time of many operations such as percutaneous transhepatic biliary drainage and cholecystectomy. Hepatic artery pseudoaneurysms after endoscopic retrograde cholangiopancreatography (ERCP) are uncommon and potentially life threatening and should be identified and treated rapidly.

CASE SUMMARY

We report a case of intra-abdominal hemorrhage secondary to a left hepatic artery pseudoaneurysm resulting from guide wire injury at ERCP. The patient primary diagnosis was acute biliary pancreatitis with cholangitis, he underwent ERCP on the third day of admission. During ERCP, the left intrahepatic bile duct was cannulated three times. Over the sixth day, Contrast enhanced computed tomography scan demonstrated left hepatic lobe contusion and a pseudoaneurysm formation. The patient was successfully treated with the embolization of a small branch of left hepatic artery angiographically.

CONCLUSION

The common complications of ERCP are pancreatitis, bleeding and perforation. False aneurysms occur as a result of damage to the wall of an artery. As far as we know, it is rare complication has been reported following ERCP. We advise urgent referral for angiographic embolization in this situation to avoid aneurysm rupture.

Malpositioned endoscopically inserted biliary stent causing massive hematemesis managed with vascular plug and stenting

A 46-year-old man with a history of hepatitis B cirrhosis and hepatocellular carcinoma (HCC) status post liver transplantation two years ago complicated by HCC recurrence and biliary stenosis presented with hypovolemic shock and melena one month after endoscopic exchange of plastic biliary stents. During endoscopic retrograde cholangiopancreatography, patient was found to have hemobilia and developed uncontrollable bleeding after a common bile duct (CBD) sweep managed by insertion of a stent-graft across major papilla into presumed CBD. The bleeding continued with subsequent negative angiography, and a computed tomography angiography showed malpositioned stent-graft between major papilla and inferior vena cava (IVC). This was successfully managed by the deployment of a vascular plug inside the stent graft and excluding it by deploying a stent across the affected area in IVC.

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.

Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to determine the safety, efficacy, and outcomes of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) as the single embolic agent for the management of non-variceal upper and lower gastrointestinal bleeding (GIB).

MATERIALS AND METHODS

A literature search using MEDLINE/PubMed, EMBASE, and SCOPUS databases was performed for studies published from January 1980 to December 2019. Data from eligible studies were extracted and evaluated by two independent reviewers. Exclusion criteria were sample size <5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. Technical success, clinical success, 30-day rebleeding, 30-day overall and major complications, and 30-day mortality were evaluated. The estimated overall rates were calculated with their 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. Heterogeneity across studies was assessed using the Q test and I² statistic.

RESULTS

Fifteen studies with 574 patients were included. For upper GIB (331 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (328 of 331 patients) and 88.0% (237 of 300 patients), and 12.5% (69 of 314 patients) and 15.9% (68 of 331 patients), respectively. Thirty-day overall and major complications occurred in 14.3% (28 of 331 patients) and 2.7% (7 of 331 patients) of patients, respectively. For lower GIB (243 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (78 of 78 patients) and 78.0% (145 of 189 patients), and 15.7% (33 of 218 patients) and 12.7% (14 of 78 patients), respectively. Thirty-day overall and major complications occurred in 13.0% (25 of 228 patients) and 8.6% (19 of 228 patients) of patients, respectively.

CONCLUSION

TAE with NBCA is safe and effective for treating non-variceal GIB, with high clinical success and very low major complication rates.

Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States

OBJECTIVES

Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective.

METHODS

Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years.

RESULTS

Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention.

CONCLUSION

Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

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.

Transcatheter Arterial Embolization of Gastrointestinal Bleeding with N-Butyl Cyanoacrylate: A Systematic Review and Meta-Analysis of Safety and Efficacy

PURPOSE

To evaluate the safety and efficacy of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for the treatment of gastrointestinal (GI) bleeding via a meta-analysis of published studies.

MATERIALS AND METHODS

The MEDLINE/PubMed and EMBASE databases were searched for English-language studies from January 1990 to March 2016 that included patients with nonvariceal GI bleeding treated with transcatheter arterial embolization with NBCA with or without other embolic agents. The exclusion criteria were a sample size of < 5, no extractable data, or data included in subsequent articles or duplicate reports.

RESULTS

The cases of 440 patients (mean age, 63.8 y ± 14.3; 319 men [72.5%] and 121 women [27.5%]) from 15 studies were evaluated. Of these patients, 261 (59.3%) had upper GI bleeding (UGIB) and 179 (40.7%) had lower GI bleeding (LGIB). Technical success was achieved in 99.2% of patients with UGIB (259 of 261) and 97.8% of those with LGIB (175 of 179). The pooled clinical success and major complication rates in the 259 patients with UGIB in whom technical success was achieved were 82.1% (95% confidence interval [CI], 73.0%-88.6%; P = 0.058; I² = 42.7%) and 5.4% (95% CI, 2.8%-10.0%; P = 0.427; I² = 0.0%), respectively, and those in the 175 patients with LGIB in whom technical success was achieved were 86.1% (95% CI, 79.9%-90.6%; P = 0.454; I² = 0.0%) and 6.1% (95% CI, 3.1%-11.6%; P = 0.382; I² = 4.4%), respectively.

CONCLUSIONS

Transcatheter arterial embolization with NBCA is safe and effective for the treatment of GI bleeding.

Comparing endoscopic intervention against fully covered self-expanding metal stent placement for post-endoscopic sphincterotomy bleed (CEASE Study)

Background and study aims: Limited data exist for the use of fully covered self-expanding metal stent (FCSEMS) as an intervention for immediate bleeds post-endoscopic sphincterotomy (ES) after primary endoscopic intervention failure or to reduce the number of delayed bleeding events in patient with increased risk of bleeding post-ES. Patients and methods: We evaluated a retrospective cohort of individuals who had ES performed from 2011 to 2014. A total of 700 patients were identified with 67 patients having post-ES bleeding. The FCSEMS treatment group included 23 patients and the non-FCSEMS treatment group included 44 patients. The primary end point was rate of change of Hgb at 72 hours after ES in the FCSEMS group and the primary endoscopic intervention-only group. A comparison also was made between the FCSEMS and non-FCSEMS group with regards to proportion of coagulopathy and number of delayed bleeding events. Results: The FCSEMS treatment group had a lower bleeding rate at 72 hours (0.66 g/dL vs 1.98 g/dL P < 0.001), increased proportion of patients at high risk of bleeding (40 % vs 9 % P value 0.008), and increased frequency of bleeding events that were moderately severe (52 % vs 9 % P = 0.0002) compared to the non-FCSEMS treatment group. The FCSEMS group included 9 patients at increased risk of bleeding and no patients with delayed bleed compared to the non-FCSEMS group, in which all 4 patients at increased risk of bleeding developed a delayed bleed. Conclusion: FCSEMS can provide homeostasis after primary endoscopic intervention failure, thus reducing the need for high-risk procedures. FCSEMS can reduce delayed bleeding events in patients at high risk of post-ES bleeding.

Angiographic management of pseudoaneurysms of gastroduodenal artery following endoscopic sphincterotomy

Gastrointestinal bleeding follows endoscopic sphincterotomy in 1 % to 10 % of patients. We report two cases of bleeding from pseudoaneurysms of the gastroduodenal artery occurring as a complication of endoscopic sphincterotomy.

Cap-assisted hemoclip application with forward-viewing endoscope for hemorrhage induced by endoscopic sphincterotomy: a prospective case series study

Background

Endoscopic sphincterotomy (ES) is a therapeutic technique developed as an advanced application of endoscopic retrograde cholangiopancreatography (ERCP). An important adverse event associated with this procedure is hemorrhage, which may sometimes be uncontrollable. We sought to examine whether cap-assisted hemoclip application is effective in controlling ES–induced hemorrhage.

Methods

In this prospective study, we investigated the outcomes in 10 patients who had uncontrolled ES–induced hemorrhage and were treated by cap-assisted application of hemoclip with a forward-viewing endoscope.

Results

Nine of the 10 investigated patients were successfully treated using the cap-assisted hemoclip technique with forward-viewing endoscope, yielding a success rate of 90 %. The patient with hemorrhage non-responsive to hemoclipping required catheter embolization of the bleeding artery after its identification by digital subtraction angiography. One of the 10 patients developed mild pancreatitis after the procedure, but was successfully managed conservatively.

Conclusions

Cap-assisted hemoclip application with a forward-viewing endoscope appears to be an effective therapeutic modality for achieving hemostasis in cases of ES–induced hemorrhage, without the occurrence of any severe adverse events; we believe that this method should be considered as an option in the management of ES–induced hemorrhage.

Clinical research for delayed hemorrhage after endoscopic sphincterotomy

To analyze the effect of delayed hemorrhage after endoscopic sphincterotomy (EST) and compare the efficacy in improving complication between medicine treatment alone and medicine combined with endoscopic treatment. 1741 patients with EST admitted in Yijishan hospital of Wannan medical college from September 2009 to May 2014 were enrolled in this study. 32 cases suffered from delayed hemorrhage. The patients with delayed hemorrhage were evaluated through incision length of duodenal papilla, clinical manifestation, stool occult blood test and the difference of hemoglobin concentration between pre and post operation. 32 patients were divided into mild bleeding group, mild serious group and serious group through the speed and amount of bleeding. All cases in mild group accepted medicine treatment. Mild serious group were divided into medicine therapy group and medicine combined with endoscopic therapy group randomly. Serious group accepted vascular intervention therapy even traditional operation. The different treatments for delayed hemorrhage were judged by efficiency. The dates were analyzed by t-test or chi-square test. Nobody endured delayed hemorrhage who accepted small incision. Delayed hemorrhage was found in 7 patients out of 627 cases who accepted medium-large incision, 25 patients of 920 cases who accepted large incision. The patients who accepted lager EST were more dangerous than small EST (χ(2)=4.718, P=0.030) concerning delayed hemorrhage. 32 cases in 1741 patients suffered from delayed hemorrhage. 14 patients only have passed black stool after EST. Among 14 cases, 13 patients stop bleeding after medical therapy, and 1 case received endoscopic hemostasis. 15 cases with hematemesis or melena after EST, 7 patients who received combination therapy stop bleeding. 3 patients from 8 cases stop bleeding after single chemical treatment, 5 cases had to receive endoscopic hemostasis after ineffectual medical therapy. There are significant difference for concerning effect between combination therapy group and medical therapy group (P=0.026). 3 patients repeatedly vomited blood and develop to peripheral circulatory failure. Those patients all received vascular intervention therapy, 2 patients stop bleeding, 1 patient failed in vascular intervention therapy and given up emergency rescue and died. Large EST has more risks than small EST in concerning delayed hemorrhage. Delayed bleeding after EST should be treated by different levels. Adapted therapy should be recommend for patients with different levels bleeding.

Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation.

Teaching Points

• Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders.

• Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered.

• Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections.

• Diagnosis and management of complications rely on combined clinical, laboratory and imaging data.

• Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.

Embolization of post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy: technical results, clinical efficacy and predictors of outcome

PURPOSE

To retrospectively analyse the technical and clinical outcomes of embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy, and in addition, to analyse factors potentially influencing 30-day mortality.

MATERIALS AND METHODS

From November 1998 to November 2012, 34 patients underwent percutaneous embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic treatment. Demographic, laboratory, angiographic, and clinical follow-up data were collected.

RESULTS

Indication for initial endoscopic sphincterotomy was benign (n = 28) or malignant (n = 6) disease. A precut sphincterotomy followed by sphincterotomy was performed in 13 patients (38 %), whereas the remaining 21 patients (62 %), underwent only sphincterotomy. Seven patients (20.6 %) were still on antithrombotic medication at the time of sphincterotomy. Angiographic evaluation revealed contrast extravasation (n = 31), pseudoaneurysm (n = 2), or a combination of both (n = 1). Embolization was successful in 33 of 34 patients (97 %). Recurrent bleeding occurred in three patients (9 %), and 30-day mortality was 20.6 % (n = 7). Factors significantly influencing 30-day mortality were INR (P = 0.008) and aPTT (P = 0.012).

CONCLUSION

Angiographic embolization is very effective in stopping post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy. The rate of rebleeding is acceptably low, but 30-day mortality remains significant. Haemostatic disorders appear to significantly influence 30-day survival.

KEY POINTS

• Transcatheter embolization is very effective in stopping major post-biliary sphincterotomy bleeding • The rate of rebleeding is acceptably low • Haemostatic disorders appear to significantly influence 30-day survival.

Superselective arterial embolization of the superior mesenteric artery for the treatment of gastrointestinal hemorrhage following allogeneic hematopoietic stem cell transplantation

Superselective arterial embolization is a common therapeutic procedure for cases of visceral hemorrhage. However, until now, it has not been applied in the treatment of gastrointestinal (GI) hemorrhage caused by acute graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation. We describe a case presenting with persistent GI bleeding associated with acute GVHD successfully treated by superselective arterial embolization of the superior mesenteric artery with gelatin sponge after noneffective conventional management. This case will help guide hematologists to deal with a similar situation in the future.

Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach

BACKGROUND

Endoscopic sphincterotomy is an integral component of endoscopic retrograde cholangiopancreatography. Post-sphincterotomy hemorrhage is a recognized complication. First line treatment involves a variety of endoscopic techniques performed at the time of sphincterotomy. If these are not successful, transcatheter arterial embolization or open surgical vessel ligation are therapeutic considerations.

PURPOSE

To evaluate the technical and clinical success of transcatheter arterial embolization via micro coils in the management of bleeding post-endoscopic sphincterotomy (ES).

MATERIAL AND METHODS

An 8-year retrospective review of all patients referred for transcatheter arterial embolization (TAE) for management of post-ES bleeding not controlled by endoscopy was performed. We analyzed the findings at endoscopy, angiography, interventional procedure, and the technical and clinical success.

RESULTS

Twelve embolization procedures were performed in 11 patients. Technical success was achieved in 11 of 12 procedures. Branches embolized included the gastroduodenal artery (GDA) in 11 cases, the superior pancreaticoduodenal artery (SPDA) in one case, and the inferior pancreaticoduodenal artery (IPDA) in four cases. Clinical success was achieved in 10 of 11 patients. One patient was referred for surgical intervention due to rebleeding from the IPDA.

CONCLUSION

Our experience demonstrates that TAE can effectively control bleeding post-ES avoiding the need for invasive surgery in most patients.