The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla’s orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.
Endoscopic retrograde cholangiopancreatography; Intrahepatic bile duct; Rendezvous technique
Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication, but it has a relatively high mortality risk. Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation. The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma. However, the current standard treatment for duodenal free wall perforation is surgical repair. Recently, several case reports of endoscopic closure techniques using endoclips, endoloops, or fully covered metal stents have been described. We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers. All the cases were simply managed by endoclips under transparent cap-assisted endoscopy. Based on the available evidence and our experience, endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations. Our results suggest that endoscopists may be more willing to use this treatment.
Duodenal perforation; Endoscopic retrograde cholangiopancreatography; Endoscopic therapy; Endoclip
AIM: To compare small sphincterotomy combined with endoscopic papillary large balloon dilation (SES + ELBD) and endoscopic sphincterotomy (EST) for large bile duct stones.
METHODS: We compared prospectively SES + ELBD (group A, n = 27) with conventional EST (group B, n = 28) for the treatment of large bile duct stones (≥ 15 mm). When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy.
RESULTS: No significant differences were observed in the mean largest stone size (A: 20.8 mm, B: 21.3 mm), bile duct diameter (A: 21.4 mm, B: 20.5 mm), number of stones (A: 2.2, B: 2.3), or procedure time (A: 18 min, B: 19 min) between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B (P = 0.473). Mechanical lithotripsy was required for stone removal in nine of 27 patients (33%) in group A and nine of 28 patients (32%, P = 0.527) in group B.
CONCLUSION: SES + ELBD did not show significant benefits compared to conventional EST, especially for the removal of large (≥ 15 mm) bile duct stones.
Sphincterotomy; Endoscopic; Balloon dilatation; Cholelithiasis; Lithotripsy
Gallbladder diverticula have the appearance of hernia-like protrusions of the gallbladder wall. This disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases. Gallbladder pseudodiverticula have an acquired cause, multiple fundal lesions, an association with gallstones, internal saccular lesions without external hernia-like protrusions, and little to no smooth muscle in the gallbladder wall. We report a unique anomaly of multiple pseudodiverticula presenting with calculous cholecystitis, which was pathologically different from true diverticula and had a unique shape similar to a bunch of grapes and a septation infilling pattern on endoscopic retrograde cholangiography.
Chemical ablation of the gallbladder is effective in patients at high risk of complications after surgery. Percutaneous gallbladder drainage is an effective treatment for cholecystitis; however, when the drain tube cannot be removed because of recurrent symptoms, retaining it can cause problems. An 82-year-old woman presented with cholecystitis and cholangitis caused by biliary stent occlusion and suspected tumor invasion of the cystic duct. We present successful chemical ablation of the gallbladder using pure alcohol, through a percutaneous gallbladder drainage tube, in a patient who developed intractable cholecystitis with obstruction of the cystic duct after receiving a biliary stent. Our results suggest that chemical ablation therapy is an effective alternative to surgical therapy for intractable cholecystitis.
Percutaneous cholecystostomy; Cholecystitis; Biliary stenting; Alcohol; Chemical therapy
AIM: To investigate the relationship between post-endoscopic resection (ER) scars on magnifying endoscopy (ME) and the pathological diagnosis in order to validate the clinical significance of ME.
METHODS: From January, 2007 to June, 2008, 124 patients with 129 post-ER scar lesions were enrolled. Mucosal pit patterns on ME were compared with conventional endoscopy (CE) findings and histological results obtained from targeted biopsies.
RESULTS: CE findings showed nodular scars (53/129), erythematous scars (85/129), and ulcerative scars (4/129). The post-ER scars were classified into four pit patterns of sulci and ridges on ME: (I) 47 round; (II) 54 short rod or tubular; (III) 19 branched or gyrus-like; and (IV) 9 destroyed pits. Sensitivity and specificity were 88.9% and 62.5%, respectively, by the presence of nodularity on CE. Erythematous lesions were high sensitivity (100%), but specificity was as low as 36.7%. The range of the positive predictive value (PPV) on CE was as low as 10.6%-25%. Nine type IV pit patterns were diagnosed as tumor lesions, and 120 cases of type I-III pit patterns revealed non-neoplastic lesions. Thus, the sensitivity, specificity, and the PPV of ME were 100%.
CONCLUSION: ME findings can detect the presence of tumor in post-ER scar lesions, and make evident the biopsy target site in short-term follow-up. Further large-scale and long-term studies are needed to determine whether ME can replace endoscopic biopsy.
Endoscopic mucosal resection; Endoscopic submucosal dissection; Magnifying endoscopy; Pit pattern; Scar
A Killian-Jamieson diverticulum (KJD) is an unfamiliar and rare cervical esophageal diverticulum. This diverticulum originates on the anterolateral wall of the proximal cervical esophagus through a muscular gap (the Killian-Jamieson space) below the cricopharyngeal muscle and lateral to the longitudinal muscle of the esophagus. To date, only surgical treatment has been recommended for a symptomatic KJD due to its close proximity to the recurrent laryngeal nerve and the concern of possible nerve injury. Recently, traditional open surgery for a symptomatic KJD is being challenged by the development of new endoscopic techniques and devices. We present here a case of a symptomatic KJD that was successfully treated with the flexible endoscopic diverticulotomy using two new devices. An isolated-tip needle-knife papillotome (Iso-Tome) was used for the dissection of the tissue bridge of the diverticulum. And a flexible overtube with a modified distal end (a fitted overtube) was used for adequate visualization of the tissue bridge of the diverticulum and protection of the surrounding tissue during dissection of the tissue bridge. Our successful experience suggests that the flexible endoscopic diverticulotomy with the use of appropriate endoscopic devices can be a safe and effective method for the treatment of a symptomatic KJD.
Esophagus; Diverticulum; Killian-Jamieson diverticulum; Endoscopy; Diverticulotomy
Duodenal perforations caused by biliary prostheses are not uncommon, and they are potentially life threatening and require immediate treatment. We describe an unusual case of aortic aneurysm and rupture which occurred after retroperitoneal aortoduodenal fistula formation as a rare complication caused by biliary metallic stent-related duodenal perforation. To our knowledge, this is the first report describing a lethal complication of a bleeding, aortoduodenal fistula and caused by biliary metallic stent-induced perforation.
Stents; Retroperitoneal perforation; Aortic aneurysm; Fistula
Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.
Cholangiopancreatography, endoscopic retrograde; Perforation; Duodenum; Therapeutics
Brunner's gland hamartoma is a rare benign small bowel neoplasm and most lesions are small and asymptomatic. However, large hamartoma-related obstructive symptoms and hemorrhage related to tumor ulceration manifest as hematemesis or melena. The exact pathogenesis if these lesions is not well known, but they are thought to be frequently associated with Helicobacter pylori infections and chronic pancreatitis. We report the case of a 45-year-old man who presented with melena due to a large pedunculated Brunner's gland hamartoma arising from the pylorus. It was successfully removed by endoscopic mucosal resection with piecemeal technique because of too large tumor size for application of a conventional snare.
Brunner's gland hamartoma; Hematemesis; Melena; Endoscopic mucosal resection
Placement of a self-expanding metal stent (SEMS) is an effective method for palliation of a malignant biliary obstruction. However, metal stents can cause various complications, including stent migration. Distally migrated metal stents, particularly covered SEMS, can be removed successfully in most cases. Stent trimming using argon plasma coagulation may be helpful in difficult cases despite conventional methods. However, no serious complications related to the trimming or remnant stent removal method have been reported due to the limited number of cases. In particular, proximal migration of a remnant fragmented metal stent after stent trimming followed by balloon sweeping has not been reported. We report an unusual case of proximal migration of a remnant metal stent during balloon sweeping following stent trimming by argon plasma coagulation. The remnant metal stent was successfully removed with rotation technique using a basket and revised endoscopically.
Pancreatic neoplasms; Stents; Cholangiopancreatography, endoscopic retrograde; Argon plasma coagulation
Choledochal cysts are congenital anomalies of the biliary tract manifested by cystic dilatation of the extrahepatic and intrahepatic bile ducts. Choledochal cyst is not rare in far-East Asian countries. Type II choledochal cysts account for 2% of all such cysts. They are true diverticula of the extrahepatic bile duct and communicate with the bile duct through a narrow stalk. This condition is associated with significant complications, such as ductal strictures, stone formation, cholangitis, rupture and secondary biliary cirrhosis. We describe a case of a huge impacted stone in a diverticular choledochal cyst which masqueraded as an unusual cystic duct stone causing Mirizzi's syndrome.
Choledochal cyst; Mirizzi's syndrome; Cholangitis
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.
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.
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.
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.
Endoscopic retrograde cholangiopancreatography; Radiation exposure; Protective equipment
In this study, we examined the efficacy and toxicity of S-1 with cisplatin as a second-line palliative chemotherapy for gemcitabine-refractory pancreatic cancer patients. Patients who had been previously treated with gemcitabine-based chemotherapy as palliative first-line chemotherapy received S-1/cisplatin [body surface area (BSA) <1.25 m2, S-1 40 mg/day; BSA ≤1.25 to <1.5 m2, 50 mg/day; BSA ≥1.5 m2 60 mg/day, orally, bid, daily on days 1–14 followed by a 7-day washout and cisplatin 60 mg/m2/day intravenously on day 1] every three weeks. The enrollment of 32 patients was planned, but the study was terminated early, prior to the first stage, following the enrollment of 11 patients. The median age of the patients was 56 (range, 42–74) years. Nine patients had a performance status (PS) of one. In total, there were 21 chemotherapy cycles and the median treatment duration was 21 (range, 7–96) days. Of the 11 patients, five could not be evaluated due to discontinuation prior to the response evaluation. One of the six evaluable patients achieved stable disease (9.1% in intention to treat analysis and 16.7% in per-protocol analysis), while five had progressive disease. Grade 3–4 hematological toxicities were anemia in one, neutropenia in one and thrombocytopenia in one cycle. Grade 3–4 nonhematological toxicities were fatigue in three, nausea in four, anorexia in two, diarrhea in one and peripheral neuropathy in two cycles. With a median follow-up period of 8.9 (range, 3.2–11.3) months, the median time to progression was 44 days [95% confidence interval (CI) 25.4–62.6] and the median overall survival was 81 days (95% CI 9.3–152.7). Combination chemotherapy with S-1 and cisplatin as applied in this study did not result in promising antitumor activity, a high degree of toxicity and poor compliance.
pancreatic cancer; S-1; cisplatin; gemcitabine-refractory
The placement of self expandable metal stent (SEMS) is one of the palliative therapeutic options for patients with unresectable malignant biliary obstruction. The aim of this study was to compare the effectiveness of a covered SEMS versus the conventional plastic stent.
We retrospectively evaluated 44 patients with unresectable malignant biliary obstruction who were treated with a covered SEMS (21 patients) or a plastic stent (10 Fr, 23 patients). We analyzed the technical success rate, functional success rate, early complications, late complications, stent patency and survival rate.
There was one case in the covered SEMS group that had failed technically, but was corrected successfully using lasso. Functional success rates were 90.5% in the covered SEMS group and 91.3% in the plastic stent group. There was no difference in early complications between the two groups. Median patency of the stent was significantly prolonged in patients who had a covered SEMS (233.6 days) compared with those who had a plastic stent (94.6 days) (p=0.006). During the follow-up period, stent occlusion occurred in 11 patients of the covered SEMS group. Mean survival showed no significant difference between the two groups (covered SEMS group, 236.9 days; plastic stent group, 222.3 days; p=0.182).
The patency of the covered SEMS was longer than that of the plastic stent and the lasso of the covered SEMS was available for repositioning of the stent.
Malignant biliary obstruction; Self-expandable metal stent; Plastic stent
Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.
Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.
Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.
Without preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.
Endoscopic balloon dilation; Common bile duct; Stone; Billroth II gastrectomy; Cap-fitted endoscopy
Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.
Early bile duct cancer; Direct peroral cholangioscopy; Narrow band imaging
A 70-year-old man had undergone pancreaticoduodenectomy due to a distal common bile duct malignancy. After the operation, serous fluid discharge decreased from two drain tubes in the retroperitoneum. Over four weeks, the appearance of the serous fluid changed to a greenish bile color and the patient persistently drained over 300 ml/day. Viewed as bile leak at the choledochojejunostomy, treatment called for endoscopic diagnosis and therapy. Cap-fitted forward-viewing endoscopy demonstrated that the distal tip of a pancreatic drain catheter inserted at the pancreaticojejunostomy site had penetrated the opposite jejunum wall. One of the drain tubes primarily placed in the retroperitoneum had also penetrated the jejunum wall, with the distal tip positioned near the choledochojejunostomy site. No leak of contrast appeared beyond the jejunum or anastomosis site. Following repositioning of a penetrating catheter of the pancreaticojejunostomy, four days later, the patient underwent removal of two drain tubes without additional complications. In conclusion, the distal tip of the catheter, placed to drain pancreatic juice, penetrated the jejunum wall and may have caused localized perijejunal inflammation. The other drain tube, placed in the retroperitoneal space, might then have penetrated the inflamed wall of the jejunum, allowing persistent bile drainage via the drain tube. The results masqueraded as bile leakage following pancreaticoduodenectomy.
Whipple's operation; Bile leak; Drain tube; Intestinal penetration
The aim of this study was to evaluate whether the mucosa-tracking technique is effective for improving precutting-related pancreatitis and the sustained failure of bile duct cannulation in precut papillotomy (PP) with the Iso-Tome (MTW Endoskopie).
From September 2004 to June 2006, PP was performed with the Iso-Tome if biliary cannulation failed by conventional methods for approximately 5 minutes. The pink intrapapillary mucosa (PIPM) exposed by PP was tracked and classified into four groups: fully exposed and oriented to the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), or unexposed (group D). The success rate of bile duct cannulation (SRBC), the procedure time required for successful bile duct cannulation (PTBC), and the complications in the first session were compared between the mucosa-exposed groups (MEGs; group A, B, and C) and the mucosa-unexposed group (MUEG; group D).
A total of 59 patients (25 females, 34 males) with a mean age of 65.2 years were enrolled. The MEGs and MUEG comprised 52 (88.1%) and 7 (11.9%) patients, respectively. SRBC in the first session was 86.4% (51/59) in total and 92.3% (48/52) in the MEGs, compared to only 42.9% (3/7) in the MUEG (p=0.005). The mean PTBC in the MEGs and MUEG was 8.7 minutes and 16.3 minutes, respectively (p=0.23). Complications occurred in 6.8% of the patients (4/59; all pancreatitis); there were no differences between the MEGs (5.8%, 3/52) and MUEG (14.3%, 1/7; p=0.41). All four patients with pancreatitis were managed medically.
The mucosa-tracking technique in PP with the Iso-Tome is a feasible and useful method of enhancing SRBC. PIPM is an important endoscopic landmark for successful PP.
Precut papillotomy; Iso-Tome; Mucosatracking technique; Pink intrapapillary mucosa
Biliary stent-related enteric perforations are very rare complications that are caused by the sharp end of a metallic stent, stent migration, or tumor invasion. Moreover, the choledochoduodenal fistula resulting from metallic biliary stent-induced perforation is extremely rare. Here, we report a case in which a spontaneous choledochoduodenal fistula occurred after biliary metallic stent placement in a patient with an Ampulla of Vater carcinoma but was successfully managed by supportive treatments, including nasobiliary drainage. This case might have occurred as the result of a rupture of the bile duct following pressure necrosis and inflammation caused by impacted calculi and food materials over the tumor ingrowth in the uncovered biliary stent.
Choledochoduodenal fistula; Stents; Ampulla of Vater
We report here on an extremely rare case of duplicated extrahepatic bile ducts that was associated with choledocholithiasis, and this malady was visualized by employing the minimum intensity projection images with using multi-detector row CT. The presence of duplicated extrahepatic bile ducts with a proximal communication, and the ducts were joined distally and they subsequently formed a single common bile duct, has not been previously reported.
Bile ducts, abnormalities; Bile ducts, calculi; Computed tomography (CT), minimum intensity projection
Tissue plasminogen activator (t-PA) and plasminogen activator inhibitor type 1 (PAI-1) may be involved in the pathogenesis of peptic ulcers through suppression of fibrinolysis. This study was designed to investigate associations of t-PA and PAI-1 genes with clinical features of the patients with bleeding gastric ulcers. Eighty-four patients with peptic ulcers and 100 controls were studied between January 1998 and April 2000. We used polymerase chain reaction and endonuclease digestion to genotype for 4G/5G polymorphism in the promoter region of the PAI-1 gene and the Alurepeat insertion/deletion (I/D) polymorphism in intron h of the t-PA gene. Various clinical features, including lesion site, bleeding event, recurrence of ulcer, and rebleeding, were assessed using a multiple logistic regression model. The genotype distributions of both the t-PA and PAI-1 genes did not differ between the patient and control groups. The occurrence of the I/D or D/D genotype of t-PA was significantly higher in cases of duodenal ulcer (adjusted OR=4.39, 95% CI=1.12-17.21). When a dominant effect (i.e., 4G/4G or 4G/5G versus 5G/5G) of the 4G allele was assumed, the PAI-1 4G/4G genotype was independently associated with rebleeding after hemostasis (adjusted OR=5.07, 95% CI=1.03-24.87). Our data suggest that t-PA gene polymorphism is associated with duodenal ulcers, and that the PAI-1 gene may be a risk factor leading to recurrent bleeding after initial hemostasis.