Endoscopic biliary therapy using the combined percutaneous and endoscopic technique

Dowsett, J. F.; Vaira, Dino; Hatfield, A. R. W.; Cairns, S R; Polydorou, Andreas; Frost, Robert A.; Croker, J. R.; Cotton, P. B.; Russell, R. C. G.; Mason, Richard R.

doi:10.1016/0016-5085(89)91639-9

Cited by 281 publications

(131 citation statements)

References 19 publications

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“…MRCP has been advocated to assist in providing a guide to the ductal anatomy and formulating a plan for drainage [7]. Approximately one-fourth to one-third of the liver needs to be drained to relieve jaundice [8]. Raju et al found no difference in patency between bilateral and unilateral stenting.…”

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confidence: 99%

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Aslanian

Jamidar

2011

Dig Dis Sci

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The majority of patients with cholangiocarcinoma present with locally unresectable disease and the median survival with radiation and chemotherapy is 7-12 months. The endoscopic palliation of inoperable hilar cholangiocarcinoma remains one of the more challenging cases for the biliary endoscopist. The endoscopist must define the anatomy without injecting contrast into ducts that will not be drained, achieve guide-wire access for unilateral or bilateral stent placement and determine what type of stent-plastic or self-expanding metal (SEMS), will best serve the patient to relieve pain and jaundice and prevent cholangitis.Raju et al.[1] present a retrospective review of 100 patients who underwent endoscopic plastic or SEMS placement for inoperable hilar cholangiocarcinoma. Patients were regularly followed to death or reintervention, and stent patency and survival were examined. In 48 patients uncovered (as expected due to the hilar location of obstruction) SEMS were placed, with plastic stents (at least one of which was 10 French) in the other 52 patients. The Bismuth Classification of lesions was similar between the groups. There was however, a greater number of Type 3 and 4 cases that received plastic stents (73.1% vs. 56.3%), potentially favoring a better outcome with SEMS. The technical success rate was high in both groups (95.8% vs. 94.2%). Bilateral stenting was performed successfully in 20/23 plastic stent patients and 5/5 SEMS. The SEMS group demonstrated significantly better stent patency (5.56 vs. 1.86 months) and required fewer re-interventions for stent obstruction (1.53 vs.4.6). The complication rate was similar in both groups (8.3% SEMS and 7.7% plastic) and there was a non-significant trend towards greater survival in the SEMS group (9.08 vs. 8.22 months). During the study time period, routine stent changes in patients with plastic stents were not performed; however, the median patency was only 1.5 months. No difference between the patency of straight and pigtail plastic stents was seen, nor was there a difference between unilateral and bilateral plastic stents or SEMS. All re-interventions were performed endoscopically, nine patients with plastic stents were converted to SEMS and plastic stents were placed within SEMS in four patients.The results of Raju et al. are similar to those of prior studies identifying less stent failure with the use of SEMS versus plastic stents for hilar tumors [2,3]. There is scant information in the way of randomized comparisons between plastic and metal stents. A study by Wagner et al.[2] is the only prospective, randomized study. Twenty patients were randomized between metal stents placed percutaneously or endoscopic stents placed by a combination of endoscopic-percutaneous technique. Perdue et al.[3] reviewed a multicenter database of 62 consecutivelyreported endoscopically-placed metal or plastic stents for hilar obstruction. Outcomes in favor of metals stents were reported in both studies.

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Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

Aslanian

Jamidar

2011

Dig Dis Sci

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“…The patient was having acute pancreatitis which is, in the opinion of some authors, a relative contraindication to ERCP; however, if the episode of pancreatitis is due to a calculus impacted in the ampulla of Vater, then ERCP and sphincterotomy may be a lifesaving procedure [8]. Cannulation of the papilla within the diverticulum has been considered to be a cause of technical difficulties [9,10] and to perform sphincterotomy within a duodenal diverticulum is also another difficulty with a significantly increased risk of perforation and bleeding [8,11,12].…”

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confidence: 99%

“…The failure rate of ERCP with and without diverticulum has been a matter of controversy with some reports suggesting a higher failure rate in the presence of periampullary diverticulum [6][7][8][9]11,12] but a recent study is suggesting no difference [13].…”

Section: Discussionmentioning

confidence: 99%

“…They may cause some difficulties in endoscopic cannulation, especially when the papilla is situated inside or on the ridge of a diverticulum [5]. In the literature, different impressions and controversial views are expressed on the success rate for cannulation and endoscopic sphincterotomy of the papilla in the presence of diverticula (L) [6][7][8][9][10][11][12][13]. This is a case report of acute biliary pancreatitis due to gallstones with a papilla situated inside a large diverticulum.…”

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Endoscopic Sphincterotomy of Intradiverticular Papilla in a Patient with Acute Pancreatitis and Obstructive Jaundice

Al-Karawi

Al-Mandeel

1993

Ann Saudi Med

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Diverticula of the duodenum are found on up to 5% of barium meals [1], 22% of autopsies [2], and approximately 10% to 15% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) [3]. Duodenal diverticula are a mucosal outpouching that most often arise from the medial wall of the second part of the duodenum and the majority are juxtapapillary [4]. They may cause some difficulties in endoscopic cannulation, especially when the papilla is situated inside or on the ridge of a diverticulum [5]. In the literature, different impressions and controversial views are expressed on the success rate for cannulation and endoscopic sphincterotomy of the papilla in the presence of diverticula (L) [6][7][8][9][10][11][12][13]. This is a case report of acute biliary pancreatitis due to gallstones with a papilla situated inside a large diverticulum. Case ReportAn 81-year-old Saudi female presented to the Accident and Emergency Room complaining of right upper quadrant and epigastric pain, recurrent vomiting and loss of appetite. Her family noticed her to be jaundiced for one day. She complained of constipation, but had no history of fever or chills, hematemesis or melena. She has a past history of myocardial infarction three years ago and trauma to the lumbar spine one year ago.On examination, this was an elderly thin female who looked ill, was in pain, mildly dehydrated, jaundiced and in distress. Temperature was 35.5°C, pulse 84/min and blood pressure 114/50 with no lymphadenopathy, no thyroid enlargement; chest and central nervous system were within normal limits. The cardiovascular system showed S1 and S2 and a pansystolic murmur. The abdomen was not distended; guarding with tenderness was present in the right upper quadrant. There were no masses or organomegaly. She has kyphoscoliosis. InvestigationsOn admission, WBC was 12.2x10 9 /L, Hb 12.5 g/L, platelets 253x10 9 /L, total protein 66 g/L, albumin 34 g/L, total bilirubin 116 (μmol/L, bilirubin 95 μmol/L, aspartate transaminase 178 u/L, amylase 7,820 u/L, urea 8.6 μmol/L, Na 140 μmol/L, bicarbonate 24 μmol/L, creatinine 81 μmol/L, calcium 2.18 μmol/L, phosphate 1.32 μmol/L. Arterial blood gases showed a pH of 7.45 Kpa, PCO 2 5.03 Kpa, PO 2 11.09, O 2 saturation 0.96, PT 16/16, PTT 21/32, HbsAg +ve, HbcAb +ve, and mid stream urinalysis was negative.On the first day after admission, the patient had an ultrasound which showed dilatation of the common bile duct (1.1 cm) and shadowing in the distal common duct suggestive of a stone. The pancreas was not significantly enlarged or edematous, though there was slight dilatation of the pancreatic duct. The gallbladder wall was thickened and there were echoes within the gallbladder with some shadowing distally suggestive of calculi. The kidneys appeared normal. Abdominal x-ray showed no obvious abnormality apart from lumbar scoliosis. Chest x-ray showed slightly hyperinflated lungs, otherwise no active disease. X-ray of the lumbar spine showed severe scoliosis of the lumbar spine convex to the left. There were moder...

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“…Firstly, endoscopic palliative drainage for malignant biliary obstruction is preferred; however, careful reviewing of the clinical presentation, anatomy, and location is necessary. Higher-grade strictures such as Bismuth type >2 can be a challenge, and management depends on the expertise and available radiological backup as a combination of percutaneous and endoscopic approach may be required in certain cases [11]. Secondly, preprocedural strategic planning with adequate imaging is important before any attempted endoscopic treatment.…”

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confidence: 99%