The treatment of intrahepatic stones: the case for extracorporeal shockwave lithotripsy.
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Bile Ducts, Intrahepatic↗
Biomedical subjects
K Huibregtse
Publications and source records attributed to K Huibregtse.
The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures.
During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.
Cholestasis↗
Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones.
BACKGROUND: Endoscopic sphincterotomy (EST) for the removal of bileduct stones is associated with acute complications and a permanent loss of biliary-sphincter function. Endoscopic balloon dilation (EBD) causes less trauma to the biliary sphincter, but may be less effective in allowing stone removal. METHODS: 218 consecutive patients with bileduct stones on endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. 202 who met all eligibility criteria were randomly assigned EST or EBD. The patients were observed in hospital for at least 24 h and followed up at 1 month and 6 months. Complications were classified by an expert panel unaware of treatment allocation and outcome. Analysis was done by intention to treat. FINDINGS: After a single ERCP, all stones were removed from 92 (91%) of 101 patients assigned EST and 90 (89%) of 101 assigned EBD (p = 0.81); in nine of the latter, successful removal required additional EST. Mechanical lithotripsy was used to fragment stones in 31 EBD procedures and 13 EST procedures (p < 0.005). Early complications (before 15 days) occurred in 24 EST patients and 17 EBD patients (p = 0.29). One patient died of retroperitoneal perforation after EBD. Four patients had bleeding after EST. Seven patients in each group had pancreatitis. Complications during follow-up occurred in 23 EST patients and 18 EBD patients (p = 0.48). Acute cholecystitis was observed in seven EST patients and one EBD patient (p < 0.05). INTERPRETATION: The success rate of EBD was similar to that of EST. We found there is no evidence of the previously suggested higher risk of pancreatitis with EBD and suggest that EBD is preferred in patients at risk of bleeding after EST. Preservation of biliary-sphincter function after EBD may prevent long-term complications and reduce the risk of acute cholecystitis during follow-up. This procedure is a valuable alternative to EST in patients with bileduct stones.
Adult↗
Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones.
BACKGROUND: Traditionally, a cholecystectomy is performed after successful endoscopic sphincterotomy and removal of common bile duct (CBD) stones, except in patients of advanced age or with substantial comorbidity. In practice, however, the gallbladder is left in situ more frequently now in patients without contraindications for surgery. The criteria by which patients are selected for an elective cholecystectomy are unclear. The aim of the present study was to establish the proportion of patients for whom a "wait-and-see" strategy was advised and to determine which, if any, patient characteristics had influenced this decision. METHODS: This study included 71 patients, all younger than 80 years of age, with both CBD stones and a gallbladder containing stones in whom endoscopic clearance of bile duct stones was achieved. RESULTS: Three patients underwent a cholecystectomy within 1 week because of acute cholecystitis. Among the remaining 68 patients, cholecystectomy was recommended for 42 patients and a wait-and-see strategy was advised for 26 patients. Patient characteristics were identical in both groups except for the American Society of Anesthesiologists Physical Status (ASA) score. The ASA score was higher in the wait-and-see group, but 69% of the patients in this group had an ASA score of I or II. Six patients in the wait-and-see group had symptoms; five patients underwent cholecystectomy. The outcome of surgery was no worse in this group than in the cholecystectomy group. CONCLUSIONS: Selection of patients for either elective cholecystectomy or wait-and-see was not based on established criteria but mainly dependent on preference of the specialist. The outcome of surgery, indicated in 23% of the patients in the wait-and-see group was comparable with elective cholecystectomy. A controlled trial comparing both treatment options in patients younger than 80 years of age should be performed.
Acute Disease↗
Endosonographic imaging of pancreatic pseudocysts before endoscopic transmural drainage.
BACKGROUND: Endoscopic drainage of pancreatic pseudocysts has become an established alternative to surgery. We performed endosonography before endoscopic drainage to find out whether detailed anatomic information would help in the selection of appropriate candidates and result in a reduction of complications. PATIENTS AND METHODS: Between April 1992 and July 1995 endosonography was performed in 32 patients, referred for endoscopic pseudocyst drainage, to determine the minimal distance between the pseudocyst and the gut, to identify interposed vascular structures, and to determine the optimal site for drainage. RESULTS: Endosonography failed to identify a pseudocyst in 3 patients and in 2 patients the lesion was inconsistent with a pseudocyst. In 7 patients transmural drainage was considered inappropriate: in 4 the distance between the gut and the cyst was too large, in 2 varices were present between the cyst and the gut, and in 1 patient normal pancreatic parenchyma was present between the cyst and the gut. In 20 patients endosonography was followed by ERCP, and in 19 endoscopic drainage was attempted. Transmural drainage was successful in 16 patients. Endosonography changed management in 37.5% of the patients. CONCLUSION: Endosonography provides essential information prior to endoscopic drainage of pseudocysts, leading to a change in therapy in one third of patients.
Adult↗
Lack of complications following short-term stent therapy for extrahepatic bile duct strictures in primary sclerosing cholangitis.
BACKGROUND: In 10% to 20% of patients with primary sclerosing cholangitis, a dominant stricture of an extrahepatic bile duct is responsible for symptoms and an exacerbation of cholestasis. The complications of a dominant stricture can usually be relieved by endoscopic placement of a stent through the stricture. The conventional policy of leaving stents in situ for 2 to 3 months is associated with a high incidence (e.g., 50%) of clinical deterioration due to stent occlusion. We have attempted to overcome this problem by substantially reducing the duration of stent placement. METHODS: Sixteen patients with symptomatic primary sclerosing cholangitis and dominant extrahepatic bile duct strictures were treated by stent placement for a median interval of only 9 days. RESULTS: In all patients endoscopic stent therapy was technically successful with a 7% incidence of transient procedure-related complications. During median follow-up of 19 months (range 7 to 27 months) serum biochemical evidence of cholestasis decreased substantially and 13 (81%) of the 16 patients became asymptomatic. No patient had a recurrence or exacerbation of either symptoms or biochemical evidence of cholestasis that could be attributed to stent occlusion. CONCLUSIONS: Short-term endoscopic stent therapy is a safe and effective treatment for symptomatic dominant extrahepatic bile duct strictures in patients with primary sclerosing cholangitis.
Adolescent↗
Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy.
AIM: To evaluate the function of the biliary sphincter 15 to 17 years after endoscopic sphincterotomy and to investigate if loss of sphincter function is associated with bacterial colonization, changes in bile composition, or inflammation of the biliary system. METHODS: Eight patients who had undergone endoscopic sphincterotomy for bile duct stones 15 to 17 years previously underwent ERCP with biliary manometry, bile sampling, and biopsy. Manometry was performed using a perfused triple-lumen manometry catheter and a station pull-through technique. Bile samples were cultured and analyzed for biliary lipids, bile salts, bacterial beta-glucuronidase, and phospholipase A2. Biopsy specimens were taken from the proximal common heptic duct for histologic examination. RESULTS: Manometry demonstrated absent basal sphincter pressure and no choledochoduodenal pressure gradient in all patients. Phasic contractions were observed in two patients. Cholangiography showed stones in one patient. Positive cultures were obtained in three patients, including the patient with stones. All bile samples showed a high content of biliary lipids and cholesterol. Some samples contained considerable amounts of hydrophobic bile salts. Five samples contained very high levels of phospholipase A2 activity. Significant bacterial beta-glucuronidase activity was found in one patient, the patient with stones. Biopsy specimens of the proximal common hepatic duct in three patients showed chronic inflammation with fibrosis and reactive epithelial changes. CONCLUSIONS: After endoscopic sphincterotomy for bile duct stones, the function of the biliary sphincter is permanently lost. This is associated with bacterial colonization, presence of cytotoxic components in the bile, and chronic inflammation of the biliary system.
Adult↗
Analysis of occluded pancreatic stents and juices in patients with chronic pancreatitis.
BACKGROUND: Pancreatic stents may occlude with time, and there is little information available on the nature of the clogging process. METHODS: We analyzed the contents of occluded pancreatic polyethylene stents in nine patients with chronic pancreatitis. In the same patients, the protein patterns in the corresponding pancreatic juices were analyzed. The stents had been in place for a mean of 9 weeks (range 2 to 17). RESULTS: All stents were occluded at both ends, especially around side holes, with thick creamy-white precipitate. The average dry weight of occluding debris was 3 mg per 3.25 cm 10F stent. Total protein content was 50% (SD 16.3) and total calcium 0.8% of dry weight (SD 0.6). Light microscopy showed that proteinaceous material completely filled the stent lumen. Yeasts and plant material were seen in two stents. A variable number of bacteria of mixed species, sometimes in clumps, were patchily scattered in the protein matrix. Cultures of stent contents grew several species of Gram-positive and negative bacteria. Scanning and transmission electron microscopy showed an amorphous protein matrix in all stents, arranged as a network in some areas, but in layers in other areas. Sodium dodecylsulfate polyacrimide gel electrophoresis showed that protein patterns of stent contents were remarkably different from the protein patterns of the juice samples of the same patient. A 66 kD band, identified as albumin, appeared in the protein patterns of stent content, whereas it was lacking in most juice samples. CONCLUSIONS: Adherence of protein, especially albumin, plays an important role in the process of pancreatic stent clogging. Other factors, such as bacteria, refluxed duodenal contents, and calcium seem to be of less importance.
Albumins↗
Complications of endoscopic sphincterotomy and their prevention.
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Cholangiopancreatography, Endoscopic Retrograde↗
Piperacillin to prevent cholangitis after endoscopic retrograde cholangiopancreatography. A randomized, controlled trial.
BACKGROUND: Cholangitis does not often occur after endoscopic retrograde cholangiopancreatography (ERCP), but it can be a serious complication of this procedure. Antibiotic prophylaxis is therefore frequently used in patients having ERCP, but existing data are insufficient to allow evaluation of the effectiveness of this practice. OBJECTIVE: To determine the efficacy of single-dose antibiotic prophylaxis with piperacillin for ERCP-induced cholangitis. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Tertiary referral center for ERCP. PATIENTS: Patients who had ERCP for suspected biliary tract stones or distal common bile duct stricture were eligible. Major exclusion criteria were previous ERCP within 7 days, biliary endoprosthesis in situ, and use of antimicrobial agents or presence of fever within 7 days before the procedure. INTERVENTION: Piperacillin, 4 g, or placebo was given intravenously approximately 30 minutes before ERCP. MEASUREMENTS: Duration of follow-up was 1 week. Acute cholangitis was diagnosed if a patient had a body temperature greater than 38 degrees C, a clinically apparent need for antibiotic treatment, and no symptoms indicating infection outside of the biliary tree. RESULTS: 551 consecutive patients were enrolled. During ERCP, stones were found in 147 patients, malignant distal strictures were found in 203 patients, other pathologic findings were seen in 88 patients, and normal biliary tracts were seen in 113 patients. Seventeen of the 281 patients who received placebo (6.0%) and 12 of the 270 patients who received piperacillin (4.4%) developed acute cholangitis (relative risk, 0.73 [95% CI, 0.36 to 1.51]). The absolute risk reduction was 1.6% (CI, -5.3% to 2.1%). All cases of cholangitis (with the exception of one case seen in a patient in the piperacillin group) were mild or moderate in severity. CONCLUSION: Single-dose prophylaxis with piperacillin is not associated with a clinically significant reduction in the incidence of acute cholangitis after ERCP in patients suspected of having biliary tract stones or distal common bile duct stricture.
Adult↗
Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis.
A retrospective evaluation was made of the long-term results of endoscopic stenting in 58 patients with benign biliary stricture due to chronic pancreatitis. Immediate relief of jaundice and cholestasis was achieved in all patients after endoscopic stent insertion. Median follow-up was 49 months. Five (9 per cent) of the 58 patients had complications following therapeutic endoscopic retrograde cholangiopancreatography. Late stent-related complications occurred in 37 (64 per cent) of 58 patients. There were no deaths. Sixteen (28 per cent) of the 58 patients had regression of the biliary stricture and permanent removal of the stent. Forty-two patients had persistent biliary stricture: 26 had continued stenting and 16 underwent surgical procedures. Early morbidity after surgery was found in six of 16 patients, with no deaths. Postoperative relief of jaundice was achieved in 15 of the 16 patients. In conclusion, endoscopic stenting and surgery are both effective treatments for biliary stricture in patients with chronic pancreatitis. Endoscopic stenting is associated with fewer early complications. However, late stent-related complications remain a major limitation. Endoscopic stenting offers definitive treatment in more than one-quarter of patients (28 per cent).
Adult↗
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.
Age Factors↗
Staging of ampullary and pancreatic carcinoma: comparison between endosonography and surgery.
BACKGROUND: The aim of the study was to update our previously published data on the clinical TNM staging of ampullary and pancreatic carcinoma by endosonography. METHODS: Endosonography was performed in 70 patients with pancreatic cancer and in 32 patients with ampullary carcinoma. TNM staging was carried out before surgery and compared with findings of histology and/or surgery. RESULTS: Endosonography was accurate in staging the depth of tumor invasion. Early-stage carcinomas could be distinguished from advanced cancers. Nonresectability was accurately assessed on the basis of vascular involvement using real-time ultrasound. Tumor compression due to peritumoral pancreatitis and direct tumor invasion into the base of the mesocolon could not be diagnosed by endosonography. The overall accuracy in tumor staging for pancreatic and ampullary carcinomas was 83.6% and 84.4%, respectively. Endosonography was accurate in diagnosing regional lymph node metastases but not accurate in defining nonmetastatic lymphadenopathy and distant metastases. CONCLUSION: Endosonography was accurate in staging tumor stage and lymph node metastases. Minimally invasive methods of resection for superficial ampullary cancers should be based on endosonography staging.
Ampulla of Vater↗
Endoscopic stent therapy for dominant extrahepatic bile duct strictures in primary sclerosing cholangitis.
BACKGROUND: In 15% to 20% of patients with primary sclerosing cholangitis, a dominant stricture of the extrahepatic bile ducts may be responsible for declining results of serum biochemical liver tests and may contribute to symptoms such as jaundice, cholangitis, pruritus, and right upper quadrant pain. METHODS: Retrospectively, over the period 1985 to 1994, we evaluated 25 patients who had been treated by endoscopic stent therapy after declining results of serum biochemical liver tests and symptoms attributable to dominant extrahepatic bile duct strictures. Serum biochemical liver test results and symptoms were compared before and after treatment. RESULTS: Endoscopic therapy was technically successful in 21 patients (84%). In these 21 patients results of all serum biochemical liver tests improved significantly (p < 0.001) within 6 months of stent therapy. During median follow-up of 29 (2 to 120) months after stent removal, 12 patients (57%) remained asymptomatic with stable serum biochemical liver tests and 4 (19%) had clinical and biochemical relapse of disease that responded favourably to additional endoscopic therapy. Early procedure-related complications occurred in 14% of therapeutic endoscopic biliary procedures. CONCLUSIONS: Endoscopic stent therapy is a safe and effective treatment modality for an acute exacerbation of disease caused by dominant extrahepatic bile duct strictures in patients with primary sclerosing cholangitis.
Adult↗
Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.
BACKGROUND: The aim of our study was to evaluate the long-term results of endoscopic pancreatic stone removal in patients with chronic pancreatitis. METHODS: We retrospectively included 53 patients with chronic pancreatitis, in whom an attempt was made at endoscopic stone removal between 1984 and 1993. Patients presented with pain (30) or an exacerbation of pancreatitis (23). A sphincterotomy was performed in 41 patients. A nasopancreatic drain was left in situ for saline flushing in 6 patients. A pancreatic stent was inserted beyond the stones in 28 patients. Fragmentation of stones was performed by mechanical lithotripsy in 4 patients or by extracorporeal shock wave lithotripsy in 8 patients. RESULTS: All patients had pancreatic stones (multiple 33, single 20) with proximal dilatation of the pancreatic duct. Median follow-up was 33 months (range 4 to 131). Stone removal was successful in 42 patients (79%) (complete 39, partial 3) with relief of symptoms in 38 of 42 (90%). The remaining 4 patients had pancreatic surgery. Stone removal failed in 11 patients and 3 of 11 patients had symptomatic improvement. The remaining 8 patients needed either pancreatic surgery (4) or continued conservative treatment (4). Thirteen of the 53 patients (25%) had recurrent stones, which could be removed endoscopically in 10 of 13. Procedure-related complications occurred in 5 of 53 patients (9%). Mortality was 0%. Seven of the 28 stented patients (25%) had stent-related complications. CONCLUSIONS: Endoscopic treatment of pancreatic stones is a valid approach in patients with pancreatic lithiasis with an acceptable risk profile.
Adolescent↗
Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications.
BACKGROUND AND STUDY AIMS: Precut sphincterotomy remains a controversial means of gaining biliary access during endoscopic retrograde cholangiopancreatography (ERCP). This report is a retrospective evaluation of the use of needle-knife sphincterotomy as a precut procedure to achieve biliary access during ERCP. PATIENTS AND METHODS: From November 1992 to August 1993, a total of 1071 ERCPs were performed at our institution. During this time, precut sphincterotomy was carried out in 180 patients, with complete follow-up obtained in 178 patients. The follow-up concentrated on the efficacy of the procedure and short-term complications. RESULTS: Cannulation of the common bile duct was achieved immediately after precut sphincterotomy in 88% of the patients, and during a second ERCP in an additional 11% of patients (total success rate 99%). There were no precut-related deaths. The complication rate of precut sphincterotomy was 21 in 178 (12%). Complications included bleeding in ten patients (5.5%), perforation in four patients (3%), pancreatitis in one patient (0.5%), and fever of unknown origin in six (3%) patients. All complications were managed conservatively. CONCLUSIONS: Precut sphincterotomy is a safe and highly effective method of gaining biliary access in patients in whom deep cannulation proves difficult or impossible and biliary access is considered essential.
Adult↗
Endoscopic biliopancreatic balloon dilation.
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Bile Duct Diseases↗
Wallstents for metastatic biliary obstruction.
BACKGROUND AND STUDY AIMS: In patients with obstruction of the common bile duct caused by primary pancreaticoblliary tumors, Wallstents have been shown to remain patent for a median duration of 273 days (range: 14-363). However, in one study that included both patients with primary pancreaticobillary malignancies and patients with metastatic malignant disease, the reported median Wallstent patency was found to be significantly shorter. We have studied the patency of Wall-stents in patients with metastatic billary obstruction. PATIENTS AND METHODS: All patients who had received a Wallstent for metastatic biliary obstruction between January 1990 and August 1994 were analyzed retrospectively. Follow-up was achieved by contacting referring physicians and general practitioners, and lasted up to the end of the study period (November 1994) or death of the patient. Follow-up was discontinued if a polyethylene stent was inserted through the Wallstent for treatment of stent dysfunction. RESULTS: 28 patients were identified, including 14 men and 14 women, with a mean age of 61.3 years (range 24-87). Long-term follow-up was possible in 27 patients (96%), for a median duration of 140 days (range 29- 561). Eleven patients died during the study period, and there were three deaths related to Wallstent dysfunction. The median duration of Wallstent patency was 265 days (range 11-519). Wallstent obstruction occurred in 13 patients; seven patients presented with cholangitis, six patients had jaundice. The cause of obstruction was established at endoscopic retrograde cholangiopancreatography in ten patients: seven had tumor ingrowth, and three had tumor overgrowth. Treatment consisted of insertion of a polyethylene stent in seven and placement of a second Wallstent in three patients. CONCLUSION: In patients with metastatic obstruction of the common bile duct, the duration of patency of Wallstents is comparable to that reported in series of Wallstents for primary pancreaticobiliary malignancies.
Adult↗