Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla

BACKGROUND & AIMS

Therapeutic endoscopic retrograde cholangiopancreatography requires selective cannulation of the relevant ductal system. The aim of this study was to evaluate the efficacy and safety of 3 different precutting techniques for difficult bile duct access on the basis of the characteristics of the major duodenal papilla (MDP).

METHODS

The patients were classified into small MDP, large MDP, or swollen MDP groups on the basis of the characteristics of the MDP. The precutting technique was based on MDP characteristics: transpancreatic sphincterotomy for small MDPs, needle-knife precut sphincterotomy for large MDPs, and needle-knife fistulotomy for swollen MDPs. The success rate of bile duct cannulation and the complication rates were compared.

RESULTS

A total of 86 patients (58 men; mean age, 76 years) with difficult bile duct cannulation required precutting technique; 48 had transpancreatic sphincterotomy, 30 had needle-knife precut sphincterotomy, and 8 had needle-knife fistulotomy. With precutting, the procedure was successful in 46 of 48 (96%), 27 of 30 (90%), and 8 of 8 patients (100%), respectively. The overall success rate of biliary cannulation after 2 endoscopic retrograde cholangiopancreatography attempts was 100%. The overall complication rate was 4.7% (4 of 86) (2 mild bleeding and 2 mild pancreatitis).

CONCLUSIONS

Selection of the precutting technique on the basis of the characteristics of the MDP resulted in a high degree of success and a low complication rate in cases of difficult bile duct cannulation.

Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy

AIM: To analyze the indications, efficacy and safety of sphincteroplasty in our centre.

METHODS: A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the filling pressure.

RESULTS: The indications included intradiverticular papilla in 26 patients (49%), stenosis of a previous sphincterotomy in 19 patients (35.8%), small size of the papilla in 4 patients (7.5%), Billroth II gastrectomy in 3 patients (5.6%), and coagulopathy in one patient (1.9%). The efficacy was 97.8%, with all the calculi extracted from the common bile duct in 84.4% of the patients, even though 21 of the patients (39.6%) had calculi with a diameter equal to or greater than 10 mm. Seven patients (13.2%) presented complications: haemorrhage in 1 patient (1.9%) and mild pancreatitis in 6 patients (11.3%). The mean hospital stay in case of complications was of 3 ± 0.63 d.

CONCLUSION: Sphincteroplasty is highly effective, with a complication rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort to lithotripsy or rescue sphincterotomy.

Percutaneous transhepatic cholangioscopy for diagnosis and therapy of biliary diseases in older patients

OBJECTIVE

To describe the use of percutaneous cholangioscopy in older patients with complex diagnostic and therapeutic bile duct disorders.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS

Fourteen patients with a mean age of 74 (SD +/- 9) years (range, 60-91 years) underwent percutaneous cholangioscopy. Eleven of these patients presented with endoscopically irretrievable bile duct stones. These 11 patients represent 4.1% of a group of 342 patients (age > or = 60 years) with a mean age of 76 (SD +/- 9) years who were treated endoscopically because of common bile duct stones between January 1993 and January 1996. Three patients presented with obstructive jaundice resulting from a bile duct stricture. In these three patients, brushing cytology of the strictures had proved to be negative.

INTERVENTION

After creation and dilatation of a percutaneous transhepatic tract, cholangioscopy was carried out with a flexible cholangioscope. All procedures were performed under mild sedation and analgesia. Stone disintegration was obtained by electrohydraulic lithotripsy, applied through the working channel of the cholangioscope.

RESULTS

Complete stone disintegration and removal was obtained after one to three cholangioscopic sessions in all 11 patients with stones. A histological diagnosis of malignancy was obtained in the three patients with biliary strictures.

CONCLUSIONS

Percutaneous cholangioscopy is a well tolerated and promising technique in our diagnostic and therapeutic strategy in older patients with complex biliary disorders not responsive to peroral endoscopic diagnosis or treatment.

[Results of transduodenal papillosphincterotomy and double internal drainage of the common bile duct using the SPP-20 device]

The authors discuss the immediate and late results of operations conducted with the [symbol: see text] suturing instrument of their design. It made possible one-stage transduodenal papillosphincteroplasty by application of two rows of tantalum staple sutures with division of the tissue between them--papillosphincterotomy. The authors conducted the operation on 242 patients for benign stenosis of the common bile duct by stones incarcerated in it. In 29 patients the intervention was complemented by the formation of supraduodenal choledochoduodenoanastomosis by means of the same suturing instrument, establishing in this was double internal drainage of the bile ducts. The suturing instrument made the operation easier and atraumatic and provided reliable hemostasis. Immediate postoperative mortality as 1.9%. Transduodenal papillosphincterotomy with the [symbol: see text] suturing instrument produced g od and satisfactory results in 95.2% and poor results in 4.8% of patients; poor late results of double drainage of the choledochus by the authors' method were not registered.

Percutaneous removal of biliary stones

Since 1983 we have performed percutaneous treatment of biliary lithiasis in 97 patients. Previous retrograde endoscopic procedures were incomplete or infeasible in all patients. Immediate results were excellent resulting in complete resolution of lithiasis in 89 of 97 patients (92%). In 4 patients (4%) partial success was obtained (symptoms subsided although there were nonobstructing residual stones). Percutaneous treatment failed in 1 patient (1%). Three patients died. Complications occurred in 14 of 97 patients (14%) and mortality at 30 days was 3%. Long-term results were evaluated in 71 patients who had a least a 6-month follow-up (mean 31 months and range 6-78 months). Eight of 71 patients (11%) had recurrence of stones and 7 of these were successfully retreated transhepatically. Percutaneous removal of biliary stones is efficacious because it has a high cure rate, a low complication rate, and a mortality rate that compares favorably to that of surgery even though the patients are usually older and in poorer general condition.

Endoscopic retrograde sphincterotomy in the treatment of biliary tract disease

Endoscopic retrograde sphincterotomy (E.R.S.) is rapidly becoming popular. In the past 5 years, E.R.S. was technically successful in 124 of 130 patients (95%) in whom it was attempted. One hundred twenty four had choledocholithiasis, and six had papillary stenosis after cholecystectomy. Urgent E.R.S. was performed for septic cholangitis in 12 patients and biliary pancreatitis in four. There were six patients with choledocholithiasis in whom sphincterotomy was not possible. Of the 118 patients with successful papillotomy for choledocholithiasis, spontaneous passage of calculi after E.R.S. occurred in 28 cases (24%), and instrumental extraction of stones was possible in 81 (69%). Duct clearance failed in nine patients (8%), mostly due to the large size of the retained stones. The largest stone extracted was 26 mm in diameter. The overall success rate of removing common bile duct stones was 109 in 118 cases (88%). In patients with papillary stenosis, E.R.S. was successful in relieving symptoms and biochemical cholestasis in six of six cases (100%). Complications occurred in only two patients. The complications were pancreatitis in one and hemorrhage in one. None of these patients required surgical treatment of the complication. Endoscopic retrograde sphincterotomy is effective for the removal of stones of the common bile duct, and at relieving the symptoms of papillary stenosis. It is safe in experienced hands and has led to only rare complications.