Abstracts

S1383

Removable Fully Covered Biliary Metal Stents in Benign Biliary

DiseaseDonna M. Varela, Sofiya Reicher, David S. Chung, Binh V. Pham, ViktorE. EysseleinBackground and Aims: Traditionally, benign biliary diseases, such as bile leaks andbiliary strictures, are managed with plastic stents. However, plastic stents are ofteninadequate for large leaks and require frequent replacements due to limited long-term patency. Recently, fully covered metal stents have been increasingly used inbenign biliary diseases. The aim of our study was to evaluate the safety and efficacyof removable fully covered biliary metal stents for benign indications. Methods:Fully covered biliary metal stents (Viabil, ConMed) were placed in 8 patients (sizes:10 mm diameter, 6-10 cm length). Indications were bile leaks (nZ3) and biliarystrictures (nZ5). Prior to placement, patients with bile leaks failed standardtherapy (biliary sphincterotomy and plastic stents) and were poor surgicalcandidates. Biliary strictures were anastomotic (nZ1) or due to benign stonedisease (nZ4). These strictures were refractory to prolong multiple plasticstenting. All strictures were located in the distal bile duct; leaks were from cysticduct take off. Removal of the fully covered metal stents was done with a snaredevice or grasping forceps. Clinical success was resolution of bile leak or stricturewith normalization of laboratory values. Results: All stent placements weretechnically successful. The duration of stenting was 12 to 18 weeks. To date, 7patients had stents removed with resolution of bile leak (nZ2) and stricture(nZ5). One patient with bile leak is awaiting stent removal. There were noprocedure-related complications. In 1 patient, cholangioscopic evaluation of bileduct at the time of stent removal via choledochoscopy showed some mucosalirregularity, which completely resolved on repeat examination. Conclusion: Fullycovered biliary metal stents offer a new approach to the management of benignbiliary diseases, such as bile leaks and strictures, and are easy to use with anacceptable complication rate. Long term effects of extended fully covered metalstenting on bile duct mucosa should be further evaluated.

Follow Up Time

Patient

www.gi

IndicationFor Stent

ejournal.org

StentDuration

Since StentRemoval

SymptomsPost Procedure

1

Anastomotic biliarystricture

12 Weeks

10 Months No complaints,no jaundice

2

Persistent bile leak 14 Weeks 7 Months No complaints, nojaundice

3

Persistent bile leak 13 Weeks 5 Months No complaints, nojaundice

4

Benign biliary stricture 13 Weeks 2 Months No complaints, nojaundice

5

Benign biliary stricture 12 Weeks 2 Months No complaints, nojaundice

6

Benign biliary stricture 16 Weeks 1 Months No complaints, nojaundice

7

Benign biliary stricture 18 Weeks 1 Months No complaints, nojaundice

8

Persistent bile leak 16 Weeks Stent in place

S1384

Common Bile Duct Stones Associated with Pancreatobiliary

Reflux and Disproportionate Bile Duct DilatationSe-Joon Lee, Hyeyeon Park, Yonghan Paik, Dongki Lee, Kwan Sik LeeIntroduction: The diameter of common bile duct (CBD) in CBD stone patients isusually increased more than 10mm, but peripheral bile duct dilatation is notcommonly observed. In contrast, CBD and peripheral bile duct diameters showproportionate dilatation pattern in malignant CBD obstruction patients. Thisdifference is frequently observed in radiologic findings, but the exact mechanism isnot yet clear. Meanwhile, the theory that pancreatobiliary reflux could damage thebile duct and cause CBD dilatation is well accepted in choledochal cyst patients. Wesuggest that not only elevated hydrostatic pressure in CBD but also chemicalirritation produced by pancreatobiliary reflux are responsible for thisdisproportionate bile duct dilatation. Aim: The aim of this study was toprospectively compare the dilatation pattern of bile duct and the degree ofpancreatobiliary reflux in CBD stones patients (Group A) versus malignant CBDobstruction patients (Group B). Method: From November 2007 to August 2008,endoscopic retrograde cholangiopancreatography (ERCP) was performed in 33patients of calculous cholangitis and 12 patients of malignant CBD obstruction.Before contrast dye injection, bile juice was aspirated at CHD level then sent for bileamylase and lipase measure. CBD and peripheral bile duct diameter werecalculated after contrast injection. Patients with pancreatobiliary maljunction andgallstone pancreatitis were excluded. Result: In group A (15 males, 18 females,mean age 52.09 years, range 29-80), thirty patients (90.9%) showeddisproportionate dilatation (i.e. peripheral duct not dilate) but in group B (4 males,8 females, mean age 63.67 years, range 45-82), only four patients (33%) showed

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disproportionate dilatation pattern. Mean value of bile amylse and lipase level ingroup A were 1387 IU/L and 6737 IU/L respectively, which were significantly higherlevel than in group B 32 IU/L and 138 IU/L (p!0.05, both). Mean value of serumamylase and lipase showed no difference between both groups. Conclusion: Thisstudy suggests that patients with CBD stones exhibit pancreatobiliary reflux, whichcan cause disproportionate bile duct dilatation.

S1385

The Early Use of the Double-Wire Technique to Facilitate

Difficult Biliary Cannulation and Its Impact On Post-ERCP

PancreatitisSandeep Patel, Victor J. Torres, Glenn W. GrossBackground: Common bile duct (CBD) cannulation can be difficult in up to 15% ofERCPs performed by experienced endoscopists. This situation leads to increasedincidence of both unsuccessful procedures and post-ERCP pancreatitis. We reportour outcomes using the double-wire technique early in accessing difficult biliarysystems and the complication rates associated with this technique. Methods: 882patients underwent ERCP at our institution from October 2006 to September 2008.Charts were reviewed retrospectively. During ERCP, the double-wire technique wasinstituted upon the third inadvertent passage of the guidewire into the pancreaticduct (PD). Upon leaving the guidewire in the PD, one of three scenarios ensued: (i)successful cannulation of the CBD with respective therapies; (ii) successfulcannulation of the CBD with respective therapies and the placement of a modifiedPD stent; (iii) unsuccessful initial CBD cannulation with subsequent placement ofa PD stent followed by a pre-cut papillotomy. 69 patients requiring this techniquewere identified and assessed for successful cannulation and complication rates.Success was characterized as selective CBD cannulation regardless of the number ofERCP attempts. The incidence of post-ERCP pancreatitis was then compared in allthree groups. Results: The double-wire technique was utilized in 69 pts (35M, 34 F;mean age 51.8 years): 36 pts in (group i); 15 pts in (group ii); and 18 pts in (groupiii). These 69 pts underwent a total of 78 ERCPs (mZ1.1). Indications included:biliary stricture in 28 pts (40.6%); choledocholithiasis in 24 pts (34.8%); bile leak in12 pts (17.4%); and suspected sphincter of Oddi dysfunction in 5 pts (7.2%). CBDcannulation was achieved in 68/69 pts (98.5%) with 61 pts (88.4%) requiring onlyone ERCP session. Post-ERCP pancreatitis occurred in 5 pts (7.2%). The pancreatitisrates within the groups were as follows: 3/36 (8.3%) in group i; 2/15 (13.3%) ingroup ii; and 0/18 pts (0%) in group 3. Pancreatitis was mild in all cases with noprocedure-related deaths. Conclusion: Early use of the double-wire technique iseffective in achieving difficult biliary cannulation and does not appear to increasethe risk of post-ERCP pancreatitis.

S1386

The Usefulness of Multiple Double Pigtail Stents and Oral

Ursodeoxycholic Acid in the Treatment of Difficult Bile Duct

StonesTae Hoon Lee, Sang-Heum Park, Ji-Young Park, Chang Kyun Lee, IlKwun Chung, Sun-Joo KimBackground: Large common bile duct (CBD) stones accompanied with risk factorscan be difficult to extract by conventional techniques. When the extractiontechniques have failed, temporary stenting is a technically easy and feasiblemethod. Aim: Our study was to investigate the efficacy of combination therapy withmultiple double pigtail stents and ursodeoxycholic acid (UDCA) as a prospectiveclinical trial. Materials and Methods: From September 2005 to September 2008,a total of 895 patients underwent attempted removal of CBD stones at our hospital.ERCP was performed using a video duodenoscope (TJF 240; Olympus, Japan).Difficult CBD stones were defined as those which could not be removed aftersphincterotomy and/or balloon plasty by basket or balloon extraction, because ofmultiple or large stone (O 20 mm in diameter) accompanying with/without riskfactors. Two or three double pigtail stents (7 or 10 Fr) were inserted into the bileduct over a guidewire with the proximal end above the stone and the distal end inthe duodenum. The stents were left in place until endoscopic removal duringa second attempt. All patients received oral UDCA (600 mg/day) during follow-up.Follow-up was performed every one or two months. Results: In 21 patients(2.34%), complete clearance was not achieved by the conventional method. Therewere 9 men and 12 women with a mean age of 73.8 years (range 38-88). Large (sizeO 20 mm, nZ11) and multiple (nO3 and size O 10mm; nZ16) stones, thepresence of periampullary diverticulum limiting sphincterotomy (5), narrowing orstricture of distal CBD (3), and severe cardiopulmonary diseases (8) were found aslimiting factors for stone removal in this study. Two stents were inserted in 13patients and 3 stents in 8 patients. Complete endoscopic clearance was achieved in12 patients (57.1%) and there was a statistically significant reduction in stone size(17.65 � 4.20 mm vs. 13.04 � 3.16 mm; p Z 0.002). The mean duration (�SD) ofstenting and medication was 73.9 (� 35.3) days. The outcomes for the remaining 9patients were spontaneous migration of the stent with the stone (1), surgicaloperation (2), exchange of occluded stents (3), and remaining well with stents (3).There was no immediate complication related to the insertion of biliary stents.Conclusion: Our results suggest that combination therapy with multiple pigtail

lume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB159