E. A. J. Rauws

Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction

Self-expanding metal stents are claimed to prolong biliary-stent patency, although no formal comparative trial between plastic and expandable stents has been done. In a prospective randomised trial, we assigned 105 patients with irresectable distal bile-duct malignancy to receive either a metal stent (49) or a straight polyethylene stent (56). Median patency of the first stent was significantly prolonged in patients with a metal stent compared with those with a polyethylene stent (273 vs 126 days; p = 0.006). The major cause of stent dysfunction was tumour ingrowth in the metal-stent group and sludge deposition in the polyethylene-stent group. Treatment after any occlusion included placement of a polyethylene stent. In the metal-stent group none of 14 second stents occluded, whereas 11 of 23 (48%) second stents clogged in the polyethylene-stent group (p = 0.002). Overall median survival was 149 days and did not differ significantly between treatment groups. Incremental cost-effectiveness analysis showed that initial placement of a metal stent results in a 28% decrease of endoscopic procedures. Self-expanding metal stents have a longer patency than polyethylene stents and offer adequate palliation in patients with irresectable malignant distal bile-duct obstruction.

Acute upper GI bleeding: did anything change?: Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000

OBJECTIVES:The aim of this study was to examine recent time trends in incidence and outcome of upper GI bleeding.METHODS:Prospective data collection on all patients presenting with acute upper GI bleeding from a defined geographical area in the period 1993/1994 and 2000.RESULTS:Incidence decreased from 61.7/100,000 in 1993/94 to 47.7/100,000 persons annually in 2000, corresponding to a 23% decrease in incidence after age adjustment (95% CI = 15–30%). The incidence was higher among patients of more advanced age. Rebleeding (16% vs 15%) and mortality (14% vs 13%) did not differ between the two time periods. Ulcer bleeding was the most frequent cause of bleeding, at 40% (1993/94) and 46% (2000). Incidence remained stable for both duodenal and gastric ulcer bleeding. Almost one half of all patients with peptic ulcer bleeding were using nonsteroidal anti-inflammatory drugs or aspirin. Also, among patients with ulcer bleeding, rebleeding (22% vs 20%) and mortality (15% vs 14%) did not differ between the two time periods. Increasing age, presence of severe and life-threatening comorbidity, and rebleeding were associated with higher mortality.CONCLUSIONS:Between 1993/1994 and 2000, among patients with acute upper GI bleeding, the incidence rate of upper GI bleeding significantly decreased, but no improvement was seen in the risk of rebleeding or mortality in these patients. The incidence rate of ulcer bleeding remained stable. Prevention of ulcer bleeding is important.

Treatment of bile duct lesions after laparoscopic cholecystectomy.

From January 1990 to June 1994, 53 patients who sustained bile duct injuries during laparoscopic cholecystectomy were treated at the Amsterdam Academic Medical Centre. There were 16 men and 37 women with a mean age of 47 years. Follow up was established in all patients for a median of 17 months. Four types of ductal injury were identified. Type A (18 patients) had leakage from cystic ducts or peripheral hepatic radicles, type B (11 patients) had major bile duct leakage, type C (nine patients) had an isolated ductal stricture, and type D (15 patients) had complete transection of the bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) established the diagnosis in all type A, B, and C lesions. In type D lesions percutaneous cholangiography was required to delineate the proximal extent of the injury. Initial treatment (until resolution of symptoms and discharge from hospital) comprised endoscopy in 36 patients and surgery in 26 patients. Endoscopic treatment was possible and successful in 16 of 18 of type A lesions, five of seven of type B lesions, and three of nine of type C lesions. Most failures resulted from inability to pass strictures or leaks at the initial endoscopy. During initial treatment additional surgery was required in seven patients. Fourteen patients underwent percutaneous or surgical drainage of bile collections, or both. After endoscopic treatment early complications occurred in three patients, with a fatal outcome in two (not related to the endoscopic therapy). During follow up six patients developed late complications. All 15 patients with complete transection and four patients with major bile duct leakage were initially treated surgically. During initial treatment additional endoscopy was required in two patients. Early complications occurred in eight patients. During follow up seven patients developed stenosis of the anastomosis or bile duct. Reconstructive surgery in the early postoperative phase was associated with more complications than elective reconstructive surgery. Most type A and B bile duct injuries after laparoscopic cholecystectomy (80%) can be treated endoscopically. In patients with more severe ductal injury (type C and D) reconstructive surgery is eventually required in 70%. Multidisciplinary approach to these lesions is advocated and algorithms for treatment are proposed.

Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age

BACKGROUND Little is known about the long-term effects of endoscopic biliary sphincterotomy. METHODS We retrospectively evaluated the rate of late complications after endoscopic sphincterotomy (EST) for bile duct stones. Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years old or younger at the time of ERCP. A total of 100 patients were identified. Information was obtained from general practitioners and patients by telephone. Patients completed a postal questionnaire and a blood sample was obtained for liver function tests. RESULTS Information was obtained for 94 patients (in the majority of cases [87%] from multiple sources). There were 26 men and 68 women with a mean age of 51 years at the time of ERCP (range, 23 to 60 years). Early complications (< 30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation secondary to EST. During a median period of 15 years (range, 3 to 18 years), 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and one patient with biliary pancreatitis. Other late complications, such as recurrent ascending cholangitis or malignant degeneration, were not observed. An ERCP was performed in 20 of the 22 patients with late complications and demonstrated bile duct stones in 13, combined with stenosis of the EST opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and one patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. CONCLUSIONS After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem, but can in general be managed endoscopically.

Benign biliary strictures. Surgery or endoscopy

OBJECTIVE This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. SUMMARY BACKGROUND DATA Surgery is considered the treatment of choice, offering more than 80% long-term success. Endoscopic stenting has been reported to yield similar results and might be a useful alternative. METHODS In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Thirty-five patients were treated surgically and 66 by endoscopic stenting. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. RESULTS Mean length of follow-up was 50 +/- 3.8 and 42 +/- 4.2 months for surgery and endoscopy, respectively. Early complications occurred more frequently in the surgically treated group (p < 0.03). Late complications during therapy, occurred only in the endoscopically treated group. In 46 patients, the endoprostheses were eventually removed. Recurrent stricturing occurred in 17% in both surgical and endoscopic patients. CONCLUSIONS Surgery and endoscopy for benign biliary strictures have similar long-term success rates. Indications for surgery are complete transections, failed previous repairs, and failures of endoscopic therapy. All other patients are candidates for endoscopic stenting as the initial treatment.

Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones: Report on 117 patients

BACKGROUND Endoscopic sphincterotomy and stone extraction can clear the bile ducts in 85% to 90% of patients. In case endoscopic stone extraction fails, insertion of a biliary endoprosthesis is an alternative. METHODS Biliary endoprostheses were inserted in 117 patients (73 women and 44 men, median age 80 years). Follow-up was achieved by contacting referring physicians and general practitioners. RESULTS Biliary drainage was established in all patients. Early complications occurred in 10 patients (9%) with a fatal outcome in 1. In 59 patients the endoprosthesis was a temporary measure before elective surgery or repeat endoscopy. Further treatment in these 59 patients caused only mild complications and there were no deaths. Endoprostheses were inserted as permanent therapy in 58 patients. Median follow-up in these 58 patients was 36 months (range, 1 to 117 months). A total of 34 complications occurred in 23 patients (40%), cholangitis being the most frequent. During follow-up, 44 patients died, 9 as a result of a biliary-related cause. CONCLUSIONS These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy.

Postoperative bile leakage: endoscopic management.

Bile leakage is an infrequent but serious complication after biliary tract surgery. This non-randomised single centre study evaluated the endoscopic management of this problem in 55 consecutive cases. Treatment consisted of standard sphincterotomy and, if needed, subsequent stone extraction with or without endoprosthesis placement. The aim of all treatments was to facilitate bile flow into the duodenum. The biliary tract and the site of the leakage were visualised during endoscopic retrograde cholangiopancreatography (ERCP) in 98%. There was distal obstruction in 33--caused by retained gall stones in 15 patients and concomitant strictures in 18. Overall, 48 of 55 patients were treated endoscopically. An excellent outcome (clinical and radiological resolution of the bile leak) was achieved in 43 patients (90%). Five patients (10%) had continuing sepsis from which they died. Postoperative bile leakage can be diagnosed safely and effectively by ERCP and subsequent endoscopic management is successful in most cases.

Endoscopic stenting for post-operative biliary strictures.

This study evaluates the efficacy of endoscopic stenting in 70 patients with noncomplete post-operative biliary strictures. The treatment consisted of placement of two 10 F gauge straight endoprostheses with elective exchange trimonthly, for a 1-year period. Successful endoprosthesis placement was accomplished in 66 of 70 patients (94%). In all 66 patients jaundice subsided. During the stenting period six patients had an operation and six died. In 46 patients the endoprostheses were removed. The mean period of follow-up was 42 months (range, 4 to 99 months). Excellent (asymptomatic, normal, or stable liver enzymes) and good (only one episode of cholangitis) responses were achieved in 83%; restricturing occurred after stent removal in 17%. Prolonged biliary stenting appears to be a safe and effective treatment modality for benign post-operative strictures and a valid alternative to surgery.

Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method

Background: Surgery is the treatment of choice in echinococcal cysts with cystobiliary fistulas. PAIR (puncture, aspiration, injection, and reaspiration of scolecidals) is contraindicated in these cases. Aim: To evaluate a modified PAIR method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material. Patients: Twelve patients were treated: 10 patients with multivesicular cysts which contained non-drainable material and were complicated by spontaneous intrabiliary rupture, secondary cystobiliary fistulas, cyst infection, or obstructed portal or hepatic veins; and two patients with large univesicular cysts and a ruptured laminated membrane, one obstructing the portal and hepatic veins and one a suspected cystobiliary fistula. Methods: The methods used, termed PEVAC (percutaneous evacuation of cyst content), involved the following steps: ultrasound guided cyst puncture and aspiration of cyst fluid to release intracystic pressure and thereby to avoid leakage; insertion of a large bore catheter; aspiration and evacuation of daughter cysts and endocyst by injection and reaspiration of isotonic saline; cystography; injection of scolecidals only if no cystobiliary fistula was present; external drainage of cystobiliary fistulas combined with endoprosthesis or sphincterotomy; catheter removal after complete cyst collapse and closure of the cystobiliary fistula. Results: In all 12 patients initial cyst size was 13.1 (6–20) cm (mean (range)). At follow up 17.9 (4–30) months after PEVAC, seven cysts had disappeared and five cysts had decreased to 2.4 (1–4) cm (p=0.002). In eight patients with multivesicular cysts, a cystobiliary fistula, and infection, cyst size was 12.5 (6–20) cm, catheter time 72.3 (28–128) days, and hospital stay 38.1 (20–55) days. At 17.3 (4–28) months of follow up, six cysts had disappeared and in two cysts residual size was 1 and 2.9 cm, respectively (p=0.012). In four patients without a cystobiliary fistula, cyst size was 14.4 (12.7–16) cm, catheter time 8.8 (3–13) days, and hospital stay 11.5 (8–14) days. At 19.3 (9–30) months of follow up, one cyst had disappeared and three cysts were 85 (69–94)% smaller (2.2 (1–4) cm) (p=0.068). Conclusion: PEVAC is a safe and effective method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material.

Immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed malignant bile duct strictures†

Immunoglobulin (Ig) G4‐related lymphoplasmacytic sclerosing pancreatitis has been described in the context of autoimmune pancreatitis mimicking distal cholangiocarcinoma. The aim of this study was to assess the occurrence of this entity in benign bile duct strictures in patients resected for presumed hilar cholangiocarcinoma.