Endoscopic biliopancreatic balloon dilation

Multidisciplinary approaches for management of postcholecystectomy problems (surgery, endoscopy, and percutaneous approaches)

PURPOSE

A prospective study to evaluate the postcholecystectomy problem management.

PATIENTS AND METHODS

From March 2005 to April 2007, 210 patients were managed using surgery, endoscopy, and percutaneous approaches.

RESULTS

Endoscopy was therapeutic in 183 cases [stones (81), stricture (55), leakage (35)], and only diagnostic in 24 cases. Percutaneous approaches were carried out in 34 cases as diagnostic in 19 cases, stenting in 2 cases, and combined with endoscopy in 13 cases. Surgery was carried out in 40 cases either urgent in 10 cases (4.8%), or planned in 30 cases (14.3%), for peritoneal lavage in 7 cases, choledocholithotomy in 8 cases, undo ligation and T-tube drainage in 5 cases, common bile duct repair splinted by T tube in 3 cases, choledochoduodenostomy in 1 case, and Roux-en-Y choledochojejunostomy in 18 cases.

CONCLUSIONS

Endoscopy is effective and safe not only for diagnostic but also for therapeutic approaches, especially when combined with percutaneous approaches that help in failure cases, but surgery remains as the gold standard treatment not only for the cases, which failed to be treated by less invasive approaches, but also in cases that are mandatory to be explored as peritonitis.

Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures

BACKGROUND

Percutaneous transhepatic cholangioscopy is a nonoperative method for accessing bilio-enteric anastomotic strictures that cannot be reached via the transpapillary route. This study evaluated the immediate and long-term results of treatment via percutaneous transhepatic cholangioscopy of patients with benign bilio-enteric anastomotic strictures.

METHODS

A retrospective analysis was conducted of 21 patients who, between October 1994 and March 2001, had undergone percutaneous transhepatic cholangioscopy for bilio-enteric anastomotic strictures. Follow-up ranged from 12 to 79 months (mean 33.3 months).

RESULTS

The initial technical success rate was 100%, and the short-term morbidity and mortality rates were, respectively, 14.3% and 0%. However, strictures recurred in 8 patients (38.1%) at a mean of 17.1 months (range 2-38 months). The success rate exclusive of patients with recurrent strictures was 61.9%, and the overall success rate was 81.0% when the procedures were repeated. The long-term morbidity rate was 38.1%, but most complications resolved with conservative treatment. In 17 patients (81.0%), strictures were complicated by biliary stones, and these were successfully treated via percutaneous transhepatic cholangioscopy (stone removal rate 94.1%, recurrence rate 37.5%).

CONCLUSIONS

Percutaneous transhepatic cholangioscopy-based treatment of patients with benign bilio-enteric anastomotic strictures is safe and effective. This minimally invasive method frequently can be used as a substitute for surgery.

Pancreatic Duct Strictures

The treatment of pancreatic duct strictures is based on an accurate assessment of the etiology of the disease, and then the degree of symptomatology. Our outline for therapy is as follows: Exclude a diagnosis of malignancy by using radiologic, endoscopic, histologic, and molecular biologic modalities. Once a benign stricture has been demonstrated, we favor a trial of endoscopic dilation and stent placement For the unresectable pancreatic neoplasm, in which an obstructive etiology for pain is suspected, a trial of endoscopic dilation and stent placement also should be considered. In benign pancreatic duct strictures complicated by biliary obstruction, and where the most durable treatment modality is sought, surgical intervention merits earlier consideration. Pancreatic duct stent placement should seldom be considered definitive therapy, and the risk of stent-induced duct injury must be weighed against potential therapeutic benefit.

Endoscopic Diagnosis of Biliary Tract Lesions Using Hydrostatic Balloon Sphincter Dilation: A Preliminary Experience

We report some encouraging results of endoscopic balloon sphincter dilation (EBSD) and discuss its clinical relevance in the diagnosis of bile duct lesions by endoscopically accessing the biliary tree. Endoscopic approach to the bile duct was performed in seven patients with various biliary tract diseases (bile duct cancer in 2 cases, pancreatic cancer in 1, Caroli disease with bile duct stones in 1, gallbladder cancer in 1, and hepatocellular carcinoma in 2) after passing a baby scope through the papilla of Vater using EBSD. The instrument used was a Maxforce 5 French balloon-tipped biliary catheter for EBSD, an Olympus CHF-BP30 or Pentax FCP-9P baby fiberscope, and an Olympus TJF-M20 mother fiberscope for endoscopic examination. Using EBSD, it was possible to advance a baby fiberscope through the papilla of Vater in all cases. In 6 patients, endoscopic observation was successfully achieved. Apart from minimal self-limiting venous oozing seen following balloon deflation, there was no papillary hemorrhage or perforation observed. Pancreatitis developed in one patient and was resolved within 24 hours. Although our series is limited and several technical issues remain to be solved, this new procedure has potential for endoscopic diagnosis of biliary tract lesions. One of the major advantages may lie in the possibility of preserving sphincter function. We favor the use of EBSD for diagnostic evaluation of bile duct diseases.