A Case of Sigmoid Colonic Perforation due to Migration of a Plastic Stent for Endoscopic Retrograde Biliary Drainage / 대한소화기내시경학회지

Placement of an endoprosthesis for billiary obstruction has been advocated as an effective alternative for internal-external drainage catheters or surgical procedure. Endoscopic retrograde biliary drainage (ERBD) is a method of transpapillary insertion and placement of drainage tube in the billiary tree under the direct view of endoscope. Early complications following ERBD that develop within 4 weeks include obstruction of the stent, cholangitis, hemorrhage, acute pancreatitis, and bile duct or duodenal perforation. Late complications include obstruction of the stent and cholangitis, migration of the stent, and intestinal perforation. We expierenced a case of sigmoid colonic perforation following ERBD in a patient with multiple biliary tract stone and cholangitis. Thus we report this case with a brief review of the literature.

Percutaneous Endoscopic Biliary Stenting (PEBS) Using the Percutaneous Fine Needle Puncture Method in Malignant Complete Biliary Obstruction / 대한소화기내시경학회지

Nonsurgical drainage of malignant obstructive jaundice is an interesting alternative to surgical drainage in the palliative treatment of pancreaticobiliary neoplasms. Biliary drainage by endoprosthesis is as effective and better supported than percutaneous external drainage, but more difficult to control. Endoscopic retograde biliary drainage (ERBD) is a safe and effective biliary drainage procedure, and is indicated with malignant obstructive jaundice in patients on whom endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) can be performed. A nonoperative method of palliation was used in patients with malignant obstructive jaundice, in whom a biliary endoprosthesis could not be placed endoscopically due to complete obstruction of the bile duct. A guide wire was manipulated through the lesion by a percutaneous transhepatic route, after puncturing the tumor by a fine needle, and retrieved from the duodenum through an endoscope. A stent was then passed through the endoscope over the guide wire across the stricture.

Long-Term Effect of Permanent Biliary Stenting for Endoscopically Unextractable Common Bile Duct Stone (s) / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic sphincterotomy (EST) has become a well-established therapeutic modality for common bile duct stone (s). EST and subsequent stone extraction, including mechanical lithotripsy, can clear bile duct in 85% to 95% of patients. Other therapeutic modalities which have been developed to enhance bile duct clearance including extracorporeal shock-wave lithotripsy, electrohydraulic or laser lithotripsy, and chemical dissolution are high cost, not yet widely available especially in community hospital, yet to be perfected, or still under clinical evaluation. The use of biliary stenting has been proposed as an alternative therapy for patients at high risk for surgery. We carried out this prospective, controlled study to evaluate the long-term effect of biliary stenting for endoscopically unextractable common bile duct stone (s). METHODS: Of the 233 patients with common bile duct stone (s) admitted at Gil Hospital from Jan. 1995 to Dec. 1996, the stent group were 14 patients with retained comrnon bile duct stone (s) in which 7Fr polyethylene biliary stent was placed with the proximal end above the stone and the distal end in the duodenum. The control group were 6 patients with common bile duct stone (s) not treated, because of patients refusal of surgical or endoscopic management. Follow-up was achieved by direct interview and telephone, and consisted of prospective analysis of all complications that occured during long-term follow-up period. Complication rates in the both groups were compared using chi-square test and cumulative complication-free rates were calculated by Kaplan-Meier analysis.

Biliary Stenting as an Altermative to Endoscopic Nasobiliary Drainage in Patients with Acute Calculous Suppurative Cholangitis / 대한소화기내시경학회지

BACKGROUND/AIMS: Acute calculous suppurative cholangitis(ACSC) is the most severe complication of bile duct stone(s) and carries 100% mortality if left untreated, and emergent decompression is a life-saving procedure. Endoscopic therapy such as endoscopic sphincterotomy(EST) or endoscopic nasobiliary drainage(ENBD) are well-mtablished treatment of choice instead of emergent surgieal or percutaneous drainages which have a high mortality or morbity, respectively. However, EST and subsequent stone removal is operator-dependent, time consuming, associated with complication rate of 6~12%, and may be inadequeate in many critically ill patients. Recently, endoscopic retrograde biliary drainage(ERBD) is suggested to be as effective in temporary biliary drainage for retained common duct stone and acute cholangitis as ENBD is, and preferred to ENBD in some reports, because ENBD can be pulled out occasionally by confused patient, more time consuming, unpleasant, a hindrance for the patient, and does not seem to be any more effective than ERBD. So, we performed this study to evaluate the role of ERBD in patient with ACSC. METHODS: In Gil Hospital from March 1995 to April 1997, 35 patients were diagnosed as ACSC among the 289 patients with common bile duct stone(s). Of those with ACSC, "the emergent group" were 19 patients with common bile duct stone(s) in which polyethylene biliary stent was placed with the proximal end above the stone and the distal end in the duodenum within 1 days after admission, and "the delayed group" were 9 patients with common bile duct(CBD) stone(s) in which biliary stenting was delayed for 1 days or longer after admission. In both groups, diagnosis rate according to the endoscopic retrograde cholangiopancreatography(ERCP) timing, clinical manifestations at admission, clinical and laboratory effectiveness of ERBD, and mortalities were analyzed and compared by the unpaired t-test. RESULTS: 1. The mean ages and male to female ratio in the emergent group were 65.1, 11:8, respectively and 61.4, 5:4 in the delayed group. On admission, hypotension and confused mentality were more frequent in the emergent group than in the delayed group, but there were no difference in the frequency of medical disease, cholecystectomy history between the two groups. 2. In laboratory findings, anemia, leukocytosis, and thrombocytopenia were more severe in the emergent group than in the delayed group, but there were no difference in the liver function test between the two groups. 3. The diagnosis rate of ACSC according to the ERCP timing was 90.9% by the emergent ERCP, whereas 1.9% by delayed ERCP, and among the 33 procedures of emergent ERCPs, 5 ERCPs were performed without aid of fluoroscopy. 4. In endoscopic findings of papilla, the incidence of gross pus, impacted stone, choledochoduodenal fistula, and papillary hyperemia was 100%, 53.6%, 46.4%, and 21.4%, respectively. In ERCP findings, single CBD stone was most common(53.6%), followed by multiple CBD stone(46.4%), IHD stone(s)(21.4%), and GB stone(14.2%). There were no differences in endoscopic and ERCP findings between the two groups. 5. After ERBD, abdominal pain and fever, and the level of total bilirubin and GOT were subsided or normalized more rapidly in the emergent group than in the delayed group, but there were no differences in the duration of hypotension and the level of GPT, ALP, and creatinine between the two groups. 6. The success rate of ERBD were 100% in the emergent group and 77.8% in the delayed group, so overal l success rate was 92.3%. After ERBD, the effectiveness determined by clinical and laboratory findings were 94.7% in the emergent group and 100% in the delayed group, so overall effectiveness was 96.2%. 7. Definite treatment consisted of endoscopic management in 23 patients(82.1%), elective operation for gallbladder or IHD stone(s) in 3(10.7%) after endoscopic removal of CBD stone(s), permanent biliary stenting due to the patient's refusal of further endoscopic or surgical management after recovery from sepsis in 3 patients(10.7%), and urgent operation in 1 patient(3.6%) in the emergent group. One patient in the delayed group died of sepsis in spite of successful biliary drainage, so overall mortality rate was 3.6%. CONCLUSIONS: ERBD is an effective alternative method of decompressing the bile duct in patient with ACSC due to CBD stone(s), and high index of suspicion of the diagnosis is necessary because failure of diagnosis can result in delaye ddrainage and may be associated corresponding increase in mortality.