Burhan Şahin

Endoscopic Management of Biliary Obstruction Caused by Cavernous Transformation of the Portal Vein

BACKGROUND Symptomatic biliary obstruction caused by cavernous transformation of the portal vein is an extremely rare disorder for which there is no consensus as to optimal treatment. The results of endoscopic treatments in a small group of patients is reviewed. METHODS A total of 10 patients (5 men, 5 women; mean age 36.1 years, range 17-48 years) with severe biliary strictures were treated between 1995 and 2001. Biliary sphincterotomy was performed in all patients. Four patients also underwent balloon dilation, nasobiliary drainage, and stone or sludge extraction by using a balloon. All patients had stent insertion. OBSERVATIONS The mean duration of therapy was 3.3 years (range 1-7 years). There was no complication directly related to the endoscopic procedures except for hemobilia that occurred in one patient during stent removal. Cholangitis developed in 5 patients during the therapy period and was treated endoscopically. In 4 patients, significant improvement in the biliary stricture was observed and stents were removed in 3. These patients were followed without stent insertion for one year. CONCLUSIONS Endoscopic management of biliary stricture caused by cavernous transformation of the portal vein appears to be effective and safe.

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.

ERCP subsequent to retroperitoneal perforation caused by endoscopic sphincterotomy.

BACKGROUND Perforation occurs after endoscopic sphincterotomy in 0.4% of cases. With recognition of a perforation, the procedure usually is aborted and further attempts at ERCP are thought to be precluded by the complication. The aim of this study was to determine the timing and the outcome of ERCP after retroperitoneal perforation caused by endoscopic sphincterotomy when the initial ERCP was incomplete. METHODS A total of 1787 patients underwent endoscopic sphincterotomy during a period of 29 months. A type II duodenal perforation was recognized in 15 patients, whereupon the ERCP, including further intervention, was halted. Eight patients agreed to undergo a second therapeutic ERCP to complete the treatment of the primary disease. OBSERVATIONS Therapeutic ERCP was repeated in all patients from 11 to 15 days after the perforation. Treatment was successfully completed in all patients without complication. CONCLUSIONS Therapeutic ERCP may be repeated and has a high success rate in patients who sustain a perforation caused by endoscopic sphincterotomy.

Comparison of endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and fecal elastase 1 in chronic pancreatitis and clinical correlation.

Objectives: In this study, we prospectively compared the use of endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), and fecal elastase 1 in patients with chronic pancreatitis and searched for correlation with symptoms, clinical findings, and elastase 1 levels. Methods: Twenty-four consecutive patients (19 were male, and 5 were female) with chronic pancreatitis who had already undergone ERCP within the last 2 years and 19 healthy control subjects (10 were male, and 9 were female) are studied prospectively. Clinical and laboratory parameters of the patients were recorded, and all underwent EUS and fecal elastase 1 testing. Fecal elastase 1 was measured in healthy control subjects. Results: The ERCP and EUS severity scores were 1 in 0 to 2 patients, 2 in 6 to 8 patients, and 3 in 18 to 14 patients. Sensitivity and specificity of fecal elastase for chronic pancreatitis were 75% and 100%, respectively. There was a negative correlation between disease duration and fecal elastase 1 levels. Patients with dyspepsia or those who use pancreatic enzyme preparations had significantly lower fecal elastase 1 levels than others. Conclusions: Endoscopic retrograde cholangiopancreatography and EUS are nearly equal in staging chronic pancreatitis. Fecal elastase 1 correlates well with these tests. Fecal elastase 1 also correlates well with some clinical symptoms such as dyspepsia and disease history.

ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP), besides reducing the need for surgery in a wide spectrum of biliary disease, is increasingly be used for the treatment of biliary complications of surgery. In this paper, we review our experience with postoperative ERCPs required after biliary surgery with a special focus on side-to-side choledochoduodenostomy (CD).MethodsThe records of 70 patients with a history of CD who underwent ERCP from May 2000 to February 2006 were analyzed.ResultsThere were 70 patients, 32 (45.7%) women and 38 (35.6%) men, with a mean age of 56 (range, 21–80) years. Indications for ERCP were cholangitis in 46 (65.7%), abnormal liver function tests with abdominal pain and abnormal USG in 22 (31.4%), and abnormal liver function tests and abnormal USG in 2 (2.9%). Overall 133 ERCP were performed. Anastomotic stenosis was found in 14 (20%), benign biliary stricture above the anastomosis in 13 (18.6%), sump syndrome in 11 (15.7%), common bile duct stone in 8 (11.4%), malignancy in 4 (5.7%), hepatolithiasis in 1 (1.4%), and secondary sclerosing cholangitis in 1 (1.4%). ERCP was normal in 18 (25.8%). Patients were managed by stone extraction in 8 (11%), stent insertion in 22 (36%), balloon dilatation in 15 (21%), nasobiliary drainage in 11 (16%), and bougie dilatation in 2 (3%) patients.ConclusionsWe have reported one of the largest groups of patients with CD in the literature and showed that ERCP is a very important diagnostic and therapeutic tool for the management of biliary problems after CD.

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.

Factors affecting the success of endoscopic treatment of sphincterotomy bleeding

BACKGROUND AND AIM Endoscopic methods are effective in the control of endoscopic sphincterotomy (ES) bleeding. Initial failure or recurrent bleeding may develop in some patients, which may require angiographic or surgical interventions. We aimed to determine the factors leading to failure of endoscopic treatment methods. METHODS Forty-six patients (1.37%) had endoscopic and/or clinically significant bleeding among a total of 3354 ESs (2998 primary, 356 re-ES) performed within 3 years. Forty-one patients (21 immediate, 20 late onset bleeding) underwent endoscopic treatment. Nineteen patients were treated initially by epinephrine injection and 22 with heat probe. The relation between demographic, laboratory parameters, presence of comorbidity, cholangitis, coagulopathy, and juxtapapillary diverticula, pre-cutting, type of ES, time and pattern of bleeding, treatment modality, the success and relapse of endoscopic treatment were evaluated. RESULTS The first method was successful in the treatment of bleeding in 18 patients with heat probe and epinephrine injection, each. Presence of cholangitis, coagulopathy and increased international normalized ratio (INR) levels were found to determine the success of first treatment method. Bleeding could be stopped in all of the patients either with initially preferred or combined methods. Five patients developed recurrent bleeding. Presence of cholangitis, coagulopathy, increased INR levels, low thrombocyte counts and performance of precutting were factors predicting recurrence. Both of the treatment methods were 100% effective in patients without coagulopathy and none of the patients developed recurrent bleeding. CONCLUSIONS Treatment of ES bleeding in patients with high risks such as coagulopathy require new effective methods. Patients with coagulopathy must be carefully followed for the development of recurrent bleeding.

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.

Endoscopic treatment of biliary fistulas developing after liver resections.

Bile leaks are a major cause of mortality and morbidity after liver resections. We prospectively evaluated the safety and efficacy of endoscopic treatment of biliary fistulas developing after liver resections in 15 patients. Fistulas developed after extended right hepatectomy in 4, extended left hepatectomy in 8, and segmentectomy in 3 patients. Median time interval between surgery and endoscopic intervention was 10 days (range, 7 to 35 d). Endoscopic sphincterotomy followed by a nasobiliary drain insertion was the initial treatment. If the fistula persisted after 2 weeks, nasobiliary drain was replaced by a plastic stent. The effect of output (low in 10 and high in 5 patients) and the origin of fistula (stump in 10 and resection surface of the liver in 5 patients) on the time for closure were evaluated. Bile leakage ceased by only nasobiliary drainage catheter placement in 11 patients (73.3%). Plastic stents were inserted in 4 patients. There was a significant correlation between the output of bile leakage and the time needed for fistula closure. Endoscopic treatment methods are effective in patients with bile leaks due to liver resections.

What to Do If a Transesophageal Echocardiography Probe Buckled in Esophagus

A 65‐year‐old man was consulted because of buckling of transesophageal echocardiography (TEE) probe in the esophagus. A forward‐viewing endoscope was inserted to the esophagus alongside the TEE probe. TEE probe was pushed to the stomach while the retroflexed tip portion was pushed by the endoscope in order to prevent retroflexion. The TEE probe was advanced into the stomach by this method where the buckled part was unfolded and then withdrawn. Cardiologists performing TEE and the referred gastroenterologists could perform such a method of solution in case of buckling of TEE probe in the esophagus. (Echocardiography 2012;29:E85‐E86)