[Difficult or Complex Bile duct stones in ERCP: Large Balloon Dilation and other stone management methods. Accumulated experience in a referral Endoscopic Center 2009- 2018.]

INTRODUCTION

Bile duct stones constitutes 20% of symptomatic gallbladder disease and difficult stones are one third of this. Endoscopic papillary large balloon dilation (EPLBD) with or without prior endoscopic sphincterotomy (EST) produces excellent outcomes for the treatment of complex or difficult common bile duct (CBD) stones, alone or combined with previous therapeutic options as mechanical lithotripsy (ML) and temporary or definitive stenting.

OBJECTIVES

Show success rate, complications and adverse events. Show that higher success rates are obtained combining ERCP techniques with no increase in complications.

MATERIALS AND METHODS

We evaluated the safety and therapeutic outcomes of EPLBD with vs. without EST and other combinations for the removal of difficult bile duct stones. We described our procedures for a decade and compare them with the previous decade without balloon dilation. Of 865 patients and procedures, 223 (25.78%) had difficult stones. Treatments where EPLBD with EST (n=183), EPLBD alone group (n=40). Additional modalities where required in 15.25% (n=34). These two groups were compared with respect to overall procedure-related adverse events, overall stone removal success rate, number of sessions required for complete stone removal, need for mechanical lithotripsy, temporal or definite stenting and total procedure time. Results Safety removal of stones was achieved in one session on 84.75% of cases with EPLBD. The incidence of adverse events was not significantly different between the groups (EPLBD alone vs. EPLBD with EST: overall adverse events 12.5% vs. 10.38% (including pain); pancreatitis 2.7% vs. 2.5%, p=0.62). Overall success similar, initial success similar, and the need for additional techniques were also similar between groups. Median total procedure time tended to be greater in the EPLBD alone group (20.5 minutes) than in the EPLBD with EST group. Conclusion DPBGD in ERCP allows bile duct stone extraction rates close to 99.65% (90% in previous decade) according to other reports of literature. Adverse events of EPLBD alone or with EST are similar between them and with classic ERCP without statistical difference and similar to other world series.

[Safety and efficacy of the use of self-expanding metal stents in the management ofunresectable malignant biliary stenosis]

BACKGROUND

In recent years there has been an increase in the use of self-expanding metallic stents (SEMS) in patients with unresectable malignant stenosis of the bile duct. However, in Peru there are no reports on the safety and efficacy of this procedure.

OBJECTIVE

To evaluate the safety and efficacy of the use of SEMS in the palliative management of malignant stenosis of the bile duct.

MATERIALS AND METHODS

Retrospective cohort. All patients referred for placement of biliary SEMS as part of a palliative treatment between January 2016 and August 2018 were included. Rates of successful placement of SEMS, adequate palliation of the obstruction, and complications associated with the procedure were obtained. The patency of the prosthesis was evaluated during follow-up. Survival was determined after placement of the prosthesis.

RESULTS

We included 32 patients with indication of palliative management due to an unresectable malignant stenosis of the bile duct. Pancreatic cancer (56.25%) followed by cholangiocarcinoma (31.25%) were the most frequent etiologies. A successful first-time placement rate of 96.97% was achieved. Adequate palliation of biliary obstruction was achieved in 100% of patients (p<0.05). Two SEMStc migrated during follow-up (6.25%) being managed with the placement of a new SEMSuc.

CONCLUSIONS

The placement of SEMS is a safe and effective therapeutic strategy in the palliative management of patients with malignant obstruction of the biliary tract.

Factors associated with complications during endoscopic esophageal dilation

BACKGROUND

endoscopic dilation is considered as the treatment of choice for esophageal strictures. However, there are no studies in our region that have assessed the safety of the procedure.

OBJECTIVE

to assess the safety of esophageal dilation and the factors associated with the development of complications.

MATERIALS AND METHODS

a retrospective cohort was studied. All patients referred for esophageal dilation between January 2015 and June 2017 were included in the study. A complication rate was obtained and the association between nonadherence to the "rule of 3" and the development of complications was determined. Other predictive factors associated with complication development were also analyzed.

RESULTS

a total of 164 patients that underwent 474 dilations were included in the study. Surgical anastomosis stricture was the most prevalent etiology. A total of six complications occurred, including three perforations (0.63%), two bleeding events (0.42%) and one episode of significant pain that required post-procedure observation (0.21%). Endoscopic esophageal dilation without adherence to the "rule of 3" was not associated with a higher risk of complications. Balloon dilation was the only predictive factor for complications.

CONCLUSIONS

esophageal dilation is a safe procedure. Nonadherence to the "rule of 3" does not appear to be associated with a higher risk of complications, including esophageal perforation.

Fasciola hepatica in the common bile duct: spyglass visualization and endoscopic extraction

We report the case of a 60-year-old Peruvian female who was admitted with abdominal pain and jaundice. Cholangioscopy revealed a leaf-like trematode, Fasciola hepatica. This trematode was extracted with a Dormia's basket via endoscopic retrograde cholangiopancreatography (ERCP).

[Large balloon dilation for removal of choledocholithiasis difficult to extract: clinical experience]

OBJECTIVE

The aim of this study was to report the initial experience of the combined use of biliary sphincterotomy plus balloon dilatation of the papilla for management of large stones.

MATERIALS AND METHODS

Design: Retrospective, descriptive. This study included 18 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2012 and April 2014. Patients had multiple large stones, tapered distal common bile duct, previous sphincterotomy, or peri/ intradiverticular papilla. CRE™ dilatation balloons with diameters ranging from 12 to 20 mm were used. Data were recorded as successful procedure, use of lithotripsy and complications during the procedure.

RESULTS

The average age was 66.1 years. There was a predominance of the female gender (66.7%). The average size of the bile duct stones was 16.7 mm. The main indications were: giant choledocholithiasis (12 patients, 66.7%) and tapered distal common bile duct (6 patients, 33.3%). The dilatation balloons diameter used were: 15 mm (8 patients, 44.4%), 18 mm (5 patients, 27.8%), 12 mm (3 patients, 16.7%) and 20 mm (2 patients, 11.1%). Complete stone clearance was achieved in 15 patients (83.3%). Lithotripsy was performed in 4 patients (22.2%). There were 3 patients in whom the removal with balloon was unsuccessful, performed surgical management. It was reported 1 case of mild acute pancreatitis (5.5%).

CONCLUSIONS

The results show that endoscopic papillary large balloon dilation after sphincterotomy is a safe and effective technique for treatment of difficult bile duct stones.

[Clinical and epidemiological profile of ulcerative colitis in a hospital in Lima]

The Non-specific Ulcerative Colitis (NUC) is an inflammatory disease of the rectum and the colon that can extend from the distal part of the rectum to the colon. Only in rare occasions is the terminal ileum compromised.

OBJECTIVE

To know the clinic and epidemiological profile of the NUC, in the Edgardo Rebagliati Martins Hospital-EsSALUD (Lima-Peru).

METHOD

Prospective and descriptive study of 43 patients diagnosed with NUC, from June, 2001 to May, 2003.

RESULTS

The patients were 27 women (62.8%) and 16 men (37.2%); 31 from previous analysis (72.1%) and 12 new patients (27.9%); the largest compromised age group was between 30 to 39 years old (23.3%). The main symptoms were diarrhea (86%), rectal bleeding (58.1%), and abdominal pain (37.2%). Follow-up showed: remission (65.1%), recurrence (28%), persistency (2.3%) and fulminant course (2.3%). One patient died (2.3%). The colon compromise was: rectosigmoid (32.6%), left (30.3%), pancolitis (20.9%), to transverse (9.3%) and distal (6.9%).

CONCLUSIONS

The incidence was of 2.1 cases per year, the average age was 45 years old (at the time of diagnosis), with a prevalence of women (62.8%). The main symptoms were diarrhea, rectal bleeding and abdominal pain. The main factor of recurrence was the interruption of the medication and anaemia was a frequent problem observed in the follow-up.