Bahattin Çiçek

Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy

Background and Aim:  Endoscopic retrograde cholangiopancreatography (ERCP) is more complicated in patients with Billroth II gastroenterostomy (B II GE) especially in those associated with Braun anastomosis (BA). The aim of the present study was to review experience of ERCP in patients with B II GE.

Endoscopic treatment of pancreatic fistulas.

BackgroundPancreatic fistulas are managed primarily by conservative treatment. Surgery is performed in cases of conservative treatment failure. Endoscopic treatment is reported to be both effective and safe as an alternative treatment method.MethodsA total of 26 patients underwent endoscopic treatment after failure of conservative treatment between January 2002 and November 2004. The mean time between the onset of fistula and the endoscopic retrograde cholangiopancreatography (ERCP) procedure was 95 days. The mean fistula output volume was 400 ml per day. Four patients had pancreatic ascites. The aim of the endoscopic treatment was to bypass the ductal disruption by placing stents or drains where the origin of fistulous tract could be identified, and to lower the pancreatic duct pressure by performing pancreatic sphincterotomy or by placing stents where the site of the leak could not be identified.ResultsPancreatography could be performed in all the patients except one. Partial duct disruption occurred in 16 patients. All of the fistulas closed after the ductal disruption was bypassed. Pancreatic sphincterotomy or endoprothesis placement was effective for eight of the remaining nine patients in whom the ductal disruption originated from the tail of the pancreas and hence could not be bypassed. The overall success rate was 94% for the patients with partial duct disruption. Four patients had side branch leaks. All of them closed after placement of an endoprothesis. Fistulas closed in only one (20%) of the five patients with complete duct disruption. Pancreatic ascites resolved in two of the four patients after endoscopic treatment. No serious complications resulted from endoscopic treatment other than proximally migrated stents in two patients.ConclusionsEndoscopic treatment is an effective and safe method for patients with pancreatic fistulas unresponsive to conservative treatment. The success rate is very high, especially for patients with partial and side branch duct disruption.

Early Decision for Precut Sphincterotomy: Is It a Risky Preference?

The aim of this prospective study was to evaluate the results and the complications at a tertiary referral center which frequently uses precutting techniques for biliary cannulation. Four hundred seventy patients with naive papilla for whom biliary intervention was planned were included in the study. If the selective cannulation was not achieved after a few trials, precutting sphincterotomy was performed. The results were evaluated for the frequency, success, and complication rates of precutting. Precutting was performed on 238 (50.6%; 117 male, 121 female; mean age, 58.5±16.2 years) of 470 patients. Total success rate of endoscopic retrograde cholangiopancreatography (ERCP) was 99.2% (236/238). The rate of complications in patients with versus without precutting was 7 (2.9%) versus 3 (1.3%) for pancreatitis, 2 (0.8%) versus 1 (0.4%) for perforation, and 7 (2.9%) versus 3 (1.3%) for bleeding. The differences between the rates were not significant. Early precutting can be preferable in prolonged cannulation trials of therapeutic ERCP.

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

BackgroundAnomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.MethodsThe data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.ResultsA total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).ConclusionThe opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Accuracy of endoscopic ultrasound-guided fine needle aspiration cytology on the differentiation of malignant and benign pancreatic cystic lesions: a single-center experience.

The aim was to compare the use of endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) in cytology and the biochemical analysis of cyst fluid, together with the size of the lesion in the differentiation between benign and malignant pancreatic cystic lesions.

Endoscopic Therapy of Hepatic Hydatid Cyst Disease in Preoperative and Postoperative Settings

The most common and serious complication of hepatic hydatid cyst disease is the communication between the cyst and the biliary tree. The diagnosis and treatment of this condition poses various difficulties. Data from patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for hydatid cysts communicating with the bile ducts either in the preoperative or postoperative setting over a 2-year period have been analyzed. In the preoperative group (n=41), jaundice (n=18), biliary colic (n=11), and cholangitis (n=10) were the most common presentations. On the other hand, the most common indication for ERCP in the postoperative group (n=69) was biliocutaneous leaks (n=60) and cholangitis (n=9). All but 2 patients in the preoperative group were treated by endoscopic sphincterotomy and/or extraction of hydatid cyst remnants followed by the placement of nasobiliary drainage catheter for the patients who had filling defects on cholangiogram. Subsequently, these patients were referred for surgery. ERCP was a definitive treatment for the remaining 2 patients. Endotherapy was successful for the patients who developed leak or had cyst remnants following surgery, whereas long-term biliary stenting was required for those who developed bile duct stenosis. There was no ERCP-associated complication, except mild pancreatitis in a single patient and self-limited hemorrhage in 2 patients. ERCP is an efficacious and safe method for the diagnosis and management of biliary complications associated with hydatid cyst disease.

Endosonographic evaluation of patients with suspected extraluminal compression or subepithelial lesions during upper gastrointestinal endoscopy

Background The aim of this study was to evaluate the endosonographic ultrasound (EUS) findings of patients with suspected extraluminal compression or subepithelial intramural lesions observed during upper gastrointestinal endoscopy. Methods EUS findings were grouped as follows; compression by an extramural pathologic lesion, compression by an adjacent vascular structure, compression by adjacent organs, subepithelial intramural lesion, and normal EUS. Results The data of 211 patients referred to the EUS unit between February 2004 and January 2010 for further evaluation of suspected extraluminal compression or subepithelial intramural lesions after upper gastrointestinal endoscopy were retrospectively analyzed. Mean age of the patients was 51.0±15.2 years, 124 (58.9%) of which were female. EUS examination was normal in 48 (22.7%) patients. EUS confirmed the presence of a pathological finding in the esophagus in 38 (92.6%) out of 41 patients when compared with abnormal findings in 122 (73.4%) of 166 patients who were evaluated for suspected lesions of the stomach (P=0.009). Suspected extraluminal compression of the esophagus (n=41) was due to a vascular structure in 17 (41.4% ) patients, an adjacent organ in four (9.7%) patients, an extramural pathological lesion in two (4.9%) patients, and a subepithelial intramural lesions in 15 (36.6%) patients, whereas in three patients (7.4%) EUS findings were normal. Of the 166 patients referred for evaluation of gastric lesions EUS findings were normal in 44 (26.5%) patients, whereas compression due to an adjacent organ was observed in 66 (39.7%) patients followed by compression by an adjacent vascular structure in 34 (20.4%) patients. An extramural pathologic lesion was discovered in 14 (8.6%) patients, whereas suspected compression was due to a subepithelial intramural lesion in eight (4.8%) patients. Conclusion Accurate diagnosis of suspected extraluminal compression or subepithelial intramural lesions, particularly in the stomach, requires meticulous evaluation. EUS provides an invasive but effective option. In one-third of cases, suspected extraluminal compression of the esophagus is actually due to a subepithelial intramural lesion.

The long-term effects of lamivudine treatment in patients with HBeAg-negative liver cirrhosis

IntroductionIn hepatitis B virus (HBV)-related liver cirrhosis, patients with HBV replication show a higher mortality rate than those without. We aimed to investigate the long-term effects of lamivudine on HBV DNA suppression, Child-Pugh score, and survival in patients with hepatitis Be antigen (HBeAg)-negative liver cirrhosis.MethodsSixty-eight patients (51 male, 17 female) diagnosed with HBV-positive liver cirrhosis, who were monitored by the hepatology and liver transplantation outpatient clinics of our hospital between June 1999 and May 2007, were included in the study. Lamivudine (100 mg/day) was administered orally. Follow-up visits were scheduled monthly during the first 3 months, and every 3 months thereafter. Complete blood count, haemostasis, biochemistry (aspartate aminotransferase [AST], alanine aminotransferase [ALT], amylase, urea, creatinine, total bilirubin, direct bilirubin, total protein, albumin), and alpha-foetoprotein were recorded every 3 months. HBV DNA levels, abdominal ultrasound and the Child-Pugh score were evaluated every 6 months.ResultsSixty-eight patients (mean age, 52.05±12.6 years) were monitored for 49.51±18.51 months. Basal ALT, HBV DNA levels and Child-Pugh scores were 103.9±73.9 IU/ml, 4133±121,94 IU/ml, and 7.6±2.4, respectively. The ALT normalisation was 59.7% during the first year, 68.2% during the second year and 44.4% during the fifth year. There was a significant decrease in Child-Pugh scores in the first 3 follow-up years when compared with the baseline score (P<0.05). During the treatment, HBV DNA positivity and YMDD mutations were determined in 20 of 68 (29.4%) patients at 46±17.9 months. Nine patients (13.2%) developed hepatocellular carcinoma at 44.8±21.5 months. Thirteen patients (19.1%) died during the treatment due to liver failure or variceal bleeding.ConclusionLamivudine is beneficial in patients with HBeAg-negative liver cirrhosis in terms of improvement in liver function and enhancement of survival and quality of life. An HBV DNA suppressive effect and improvement in Child-Pugh score were seen especially in the first years. It is important to be aware of YMDD mutation early, as addition of new antivirals is necessary to overcome unwanted results of the mutation.

Diverticulum With Papillae: Does Position of Papilla Affect Technical Success?

Basis and Purpose: The presence of peripapillary diverticulum (PPD) can cause some biliary diseases, especially common bile duct stones, and also, literally, can change the technique of endoscopic retrograde cholangiopancreatography (ERCP) and affect the complication ratio of this procedure. In this study, we investigate the effect of localization and position of the papilla according to the diverticulum on the success of therapeutic ERCP procedures. Materials and Methods: The study was conducted prospectively in the patients with naive papillae, who underwent ERCP for a period of 16 months. In all patients, the position of papillae according to the diverticulum (the periphery of the diverticulum is thought as the clock circumference, and the position of papillae is defined as the dials of clock), the success rate of biliary cannulation, total procedure time, overall treatment success rate of ERCP, and the complications are investigated. Results: During this period, 222 (18.5%) of the 1205 enrolled patients who underwent ERCP had PPD. Of the patients with PPD, 123 (55.4%) were female and 99 (44.6%) were male, and the median age was 68.9±10.1 years. According to the position of the papilla by the diverticulum, 90 (40.5%) patients have it on 7 o’clock position, 64 (28.8%) patients have on 6 o’clock position, 63 (28.3%) patients have on 5 o’clock position, and 5 (2.3%) patients have on 1 o’clock position. In the cases of the papilla on 1 o’clock position according to the diverticulum, cannulation procedures were found to be more difficult than other patients (P<0.05). The presence of the diverticulum did not affect the success of therapeutic procedures and did not increase the ratio of complications. Conclusions: In the presence of PPD, additional cannulation techniques may be required for the procedure. Particularly, the aid of percutaneous techniques may be needed for the papilla on 1 o’clock position.

Demonstration of retraction of the main papilla toward the biliary system in patients with primary sclerosing cholangitis with magnetic resonance cholangiopancreatography

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, which leads to the formation of multifocal bile duct strictures. In a previous study we found that the main papilla was retracted toward the biliary system in 7 of 10 patients (70%) with PSC. Retraction of the papilla was defined as the embedding of the papilla into the duodenum wall and peripapillary duodenal convergence (i.e. tent-like appearance). It was suggested by our team that the presence of the main papillary retraction may be a useful sign in the diagnosis of PSC.Herein, two patients in whom this finding could be detected on magnetic resonance cholangiopancreatography (MRCP) are presented. Patient 1: A 43-year-old man with Crohn’s disease was diagnosed as having PSC in January 1998 and underwent endoscopic sphincterotomy. In May 2004, endoscopy showed retraction of the main papilla. MRCP was performed in May 2008 in order to search for the presence of dominant stricture or cholangiocarcinoma because of increasing pruritus and liver enzyme levels. The papilla was seen to be retracted toward the biliary system (Fig. 1), which was confirmed on endoscopy. Patient 2: A 47-year-old man with a history of asymptomatic increase in liver enzymes underwent MRCP in October 2006. At that time, a diagnosis of PSC was made, but there was no retraction of the main papilla. Endoscopic cholangiography was not performed because the patient was asymptomatic. In May 2009, the patient presented with itching and cholangitis. MRCP at this time showed retraction of the main papilla toward the biliary system (Fig. 2). The capacity of MRCP to show retraction of the main papilla provides a valuable alternative to endoscopy. The air that is introduced into the gastrointestinal lumen during endoscopy inflates the duodenum. As a result, the retracted position of the main papilla becomes less apparent. Another benefit of MRCP is that it avoids the possibility of the papilla being pushed artificially into a retracted position by the endoscopic catheter. In our opinion, retraction of the main papilla in patients with PSC can be included among the criteria for diagnosing this disease via MRCP.