Sang Woo Cha

The Detection of Bile Duct Stones in Suspected Biliary Pancreatitis: Comparison of MRCP, ERCP, and Intraductal US

OBJECTIVES:Early ERCP and endoscopic sphincterotomy for stone extraction can benefit the prognosis in patients with severe biliary pancreatitis, but are associated with complications. The ability to identify choledocholithiasis by noninvasive means in biliary pancreatitis is limited. The aim of this study was evaluation of the ability of MRCP to detect choledocholithiasis in patients with acute biliary pancreatitis. In addition, we investigated whether intraductal US (IDUS) could help manage these patients.METHODS:Thirty-two patients with suspected biliary pancreatitis were studied prospectively. MRCP was performed immediately before ERCP by separate blinded examiners within 24 h of admission. Wire-guided IDUS was performed during ERCP within 72 h of admission, regardless of the results of MRCP. Using endoscopic extraction of a stone as the reference standard, the diagnostic yield of MRCP was compared with transabdominal US, CT, ERCP, and IDUS.RESULTS:The sensitivity of US, CT, MRCP, ERCP, and IDUS for identifying choledocholithiasis was 20.0%, 40.0%, 80.0%, 90.0%, and 95.0%, respectively. The overall agreement between MRCP and ERCP was 90.6% for choledocholithiasis (κ = 0.808, p < 0.01). The sensitivity of MRCP for detecting choledocholithiasis decreased with dilated bile ducts (bile duct diameter > 10 mm, 72.7% vs 88.9%). The combination of ERCP and IDUS improved accuracy in the diagnosis of choledocholithiasis.CONCLUSIONS:MRCP can be used to select patients with biliary pancreatitis who require ERCP. IDUS may be applied in the management of biliary pancreatitis if ERCP is performed.

Factors predictive of adverse events following endoscopic papillary large balloon dilation: Results from a multicenter series

BackgroundLack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones.AimsWe sought to identify factors predictive of adverse events (AEs) following EPLBD.MethodsThis multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12–20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan.ResultsNinety-five (10.0xa0%) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7xa0%) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, pxa0=xa00.003), length of EST (full-EST: OR 6.22, pxa0<xa00.001) and stone size (≥16xa0mm: OR 4.00, pxa0<xa00.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, pxa0<xa00.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14xa0mm: OR 0.27, pxa0=xa00.015).ConclusionsEPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

BACKGROUNDnEndoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis.nnnMETHODSnSix patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire.nnnRESULTSnEn bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically.nnnCONCLUSIONSnWire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.

A Randomized Controlled Comparative Study of Covered Versus Uncovered Self-Expandable Metal Stent for Malignant Biliary Obstruction

A Randomized Controlled Comparative Study of Covered Versus Uncovered Self-Expandable Metal Stent for Malignant Biliary Obstruction S. H. Lee, Sang Woo Cha, Young Koog Cheon, Y. Kim, J. H. Moon, Y. D. Cho, Y. S. Kim, J. S. Lee, M. S. Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: Self-expandable metal stents (SEMS) with various designs have been developed to improve clinical efficacy for treatment of malignant biliary obstruction. However, a lot of articles previously published for SEMS study reported a variety of efficacy of covered SEMS.Weperformed this study to compare the safety and clinical efficacy of membrane-covered SEMS (Shim-Hanarostent, M.I.Tech, Seoul, Korea) and uncovered SEMS (Hanarostent, M.I.Tech, Seoul, Korea) in a prospective randomized controlled trial. METHODS: There were 43 consequent patients, including 26men and 17 women, with a mean age of 70 years (range, 49-87) who were diagnosed as malignant biliary obstruction. The etiology of the strictures included pancreatic cancer (17), cholangiocarcinoma (17), ampullary cancer (4), and gall bladder cancer (5). Patients were randomly assigned to covered or uncovered stent. After insertion of the stent, we followed up symptoms, LFT and abdominal US. We performed ERCP & mother-baby scopy in occluded cases. In case of stent malfunction, we inserted plastic stent into the metal stent. The survival rates of the patient and the stent’s patency rates were calculated using Kaplan-Meier survival analysis. Serum bilirubin, amylase and lipase levels were evaluated in regular interval, and the mean differences of these data before and after stenting were evaluated using a Wilcoxon signed-rank test. The average follow-up duration was median 5.3 months (range, 0.8-29 months). RESULTS: Endoscopic procedures were successful (including complete relief of jaundice) in all cases. Late complications such as tumor ingrowth etc. occurred in 11 of 21 patients with uncovered stents, as compared with 4 of 22 patients in the covered group (p < 0.05). Median stent patency of covered and uncovered stent were 216 days (range 76 to 760 days) and 127 days (range 25 to 447 days), respectively (p< 0.05). Life table analysis showed similar survival in both groups. CONCLUSION: Membrane-covered selfexpandable biliary metal stents have a significantly better palliation than uncovered metal stents in the treatment of patients with malignant biliary obstruction.

A Survey of the Radiation Exposure Protection of Health Care Providers during Endoscopic Retrograde Cholangiopancreatography in Korea

Background/Aims During endoscopic retrograde cholangiopancreatography (ERCP), all efforts should be made to be aware of radiation hazards and to reduce radiation exposure. The aim of this study was to investigate the status of radiation protective equipment and the awareness of radiation exposure in health care providers performing ERCP in Korean hospitals. Methods A survey with a total of 42 questions was sent to each respondent via mail or e-mail between October 2010 and March 2011. The survey targeted nurses and radiation technicians who participated in ERCP in secondary or tertiary referral centers. Results A total of 78 providers from 38 hospitals responded to the surveys (response rate, 52%). The preparation and actual utilization rates of protective equipment were 55.3% and 61.9% for lead shields, 100% and 98.7% for lead aprons, 47.4% and 37.8% for lead glasses, 97.4% and 94.7% for thyroid shields, and 57.7% and 68.9% for radiation dosimeters, respectively. The common reason for not wearing protective equipment was that the equipment was bothersome, according to 45.7% of the respondents. Conclusions More protective equipment, such as lead shields and lead glasses, should be provided to health care providers involved in ERCP. In particular, the actual utilization rate for lead glasses was very low.

Wire-Guided Endoscopic Snare Retrieval of Proximally Migrated Pancreatic Stents after Endoscopic Papillectomy for Ampullary Adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.

New Technique of Endoscopic Sphincterotomy with Iso-Tome® to Incise the Distal Papillary Roof in Patients with Choledocholiths and Choledochoduodenal Fistula

Background/Aims It is sometimes difficult to incise the distal papillary roof (PR) completely in patients with choledocholiths and choledochoduodenal fistula (CDF). The Iso-Tome® (MTW-Endoskopie W. Haag KG), which is helpful in preventing electrical leakage, has good orientation capabilities and can be easily placed at the orifice of the CDF or ampulla of Vater (AV). We aimed to evaluate the efficacy of endoscopic sphincterotomy (ES) with the Iso-Tome® for cutting the distal PR. Methods Between May 2003 and July 2012, 35 patients were analyzed retrospectively. The distal PR was cut downward and/or upward using the Iso-tome® until the pink intrapapillary mucosa was fully exposed. Downward incisions were performed from the opening of the CDF to the orifice of the AV; upward incisions were performed in reverse. Results Spontaneous or artificial CDF occurred in four and 31 patients, respectively. The technical and therapeutic success rates were 94.3% (33/35) and 94.3% (33/35), respectively. There was no case of electrical damage to the pink intrapapillary mucosa. Adverse events occurred in 2.9% (1/35; 1, mild bleeding) of patients. Conclusions The new technique of ES with the Iso-tome® is feasible and useful for effectively incising the distal PR in patients with CDF and choledocholiths.

Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management

Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.