Inflammatory pseudotumor of the common bile duct.

An exceptional cause of obstructive jaundice is reported in the present case. A 51-year-old woman progressively developed jaundice with pruritus, and abdominal ultrasonography revealed dilated intra- and extrahepatic bile ducts. Endoscopic retrograde cholangiography and endoscopic ultrasonography showed a tumor in the distal common bile duct, but failed to determine the nature of the lesion, and the patient underwent a pancreaticoduodenectomy. The final diagnosis was an inflammatory pseudotumor of the common bile duct. Inflammatory pseudotumors are uncommon, without evident pathogenesis, and are described in many organs. The localization in the common bile duct is exceptional. The prognosis is good, and a more conservative approach is possible if the diagnosis is certain before surgery.

Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study.

BACKGROUND AND STUDY AIMS: Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction. PATIENTS AND METHODS: Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively. RESULTS: Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks). CONCLUSIONS: Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.

[Radiation-induced stricture of the papilla and the common bile duct: successful treatment with balloon dilation]. / Sténose radique de la papille et du cholédoque: succès de la dilatation au ballonnet.

Radiation-induced lesions of the bile ducts rarely occur and may be difficult to manage. We report the case of a 59-year old woman who developed radiation-induced stenosis of the papilla and the common bile duct 25 years after abdominal radiation therapy for abdominal non-Hodgkin's lymphoma. She presented with recurrent cholangitis and chronic cholestasis. Endoscopic results showed dilation of the intrahepatic bile ducts, radiation-induced inflammation and narrowing of the antrum and the duodenum, and stricture of the papilla and the last few millimeters of the common bile duct. The patient was treated with endoscopic balloon dilation. Forty-two months after endoscopic dilation, the patient remained asymptomatic with normal liver tests and no biliary dilation at ultrasound.

[Late biliary complications after endoscopic sphincterotomy for common bile duct stones in patients older than 65 years of age with gallbladder in situ]. / Complications biliaires à long terme après sphinctérotomie endoscopique pour lithiase de la voie biliaire principale chez les malades de plus de 65 ans avec vésicule biliaire en place.

UNLABELLED: The aim of this retrospective study was to evaluate the nature and the frequency of biliary complications after endoscopic retrograde cholangiography for common bile duct stones in elderly patients with gallbladder in situ. METHODS: Between 1991 and 1993, 169 consecutive patients with gallbladder in situ, older than 65 years (79 +/- 8) had an endoscopic retrograde cholangiography with sphincterotomy for choledocholithiasis. Information on the early (<1 month) and late biliary complications, treatment and mortality were obtained by mail or phone calls from patients and general practitioners. Long-term data were obtained for 139 patients (82%). Mean follow-up was 56.5 months (80 months for patients still alive at the end of the study). RESULTS: Early complications occurred in 13 patients (10.8%). Seven patients had acute cholecystitis, present before the procedure in all cases; all were treated by surgery. Other early complications included cholangitis (n =7), mild acute pancreatitis (n =3), bleeding (n =1), perforation (n =1), biliary colic (n =1), pneumopathy (n =1) and bradycardia (n =1), all treated medically. Forty patients underwent early cholecystectomy, and 5 died during the first month without biliary disease. Late complications were thus assessed in 94 patients and occurred in 13 (14%), i.e around 2% per year. Complications were acute cholangitis (n=4), biliary pain (n =4), cholecystitis (n =2), abdominal pain (n =2) and jaundice due to sphincterotomy stenosis (n =1). Five patients had cholecystectomy, 1 a radiological drainage and 7 were treated medically. No death due to a biliary complication was observed. The presence of gallstones, the absence of gallbladder opacification at cholangiography were not prognostic factors for the recurrence of biliary symptoms. 65 patients (50%) died without biliary disease during the follow-up (actuarial death rate 10.5% per year). CONCLUSION: Late biliary complications after endoscopic retrograde cholangiography for choledocholithiasis in patients with gallbladder in situ are rare (2% per year). Prophylactic cholecystectomy after sphincterotomy does not seem warranted in elderly patients, because of rare recurrent biliary symptoms, low mortality rate, and limited life expectancy.

[Endoscopic sphincteroclasy for choledocholithiasis of the principal bile duct. Short-term results and follow-up]. / La sphinctéroclasie endoscopique pour lithiase de la voie biliaire principale. Résultats immédiats et à distance.

AIMS: The hydrostatic dilatation of the papilla of Vater, or sphincteroclasy, has been recently proposed as an alternative to endoscopic sphincterotomy. Our aim was to assess short term results and follow-up after sphincteroclasy for choledocholithiasis. METHODS: From August, 1994 to December, 1996, 52 patients were included for endoscopic therapy of choledocholithiasis (mean age 66 +/- 17 years). Patients were prospectively followed on the short term-period (24 h, 48 h and 30 days) and longer term after treatment (every 6 months) by clinical and biological controls. MAIN RESULTS: Forty-eight sphincteroclasies were performed successfully (92.3%). Thirty seven patients had a choledocolithiasis. Eleven were stone-free. Eight had undergone former gastric surgery and 8 had impaired coagulation test. Complete stone clearance was achieved in 98% of patients. Mild pancreatitis were observed in three patients (6.25%). Thirty-day mortality was nil. Long term follow-up (mean 21.4 +/- 7 months) revealed: 2 patients with cholecystitis 6 and 13 months after treatment, one of which was followed 8 months later by a fatal septic shock, and 3 patients with cholangitis, 2 of which in the same patient, 9, 12 and 24 months after sphincteroclasy. The global long term biliary complication rate was 8.4%, 4.2% of which were potentially related to the endoscopic procedure. CONCLUSION: Sphincteroclasy is an efficient procedure for the treatment of choledocholithiasis. Its short term results are similar to those of endoscopic sphincterotomy. Complications after 2 years appear to be scarce, but longer follow-up is required before routinely performing sphincteroclasy.

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method.

BACKGROUND: Magnetic resonance cholangiography (MRC) is a new technique for non-invasive imaging of the biliary tract. AIM: To assess the results of MRC in patients with suspected bile duct stones as compared with those obtained with reference imaging methods. PATIENTS/METHODS: 70 patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median 75) with suspected bile duct stones were included (cholangitis, 33; pancreatitis, three; suspected post-cholecystectomy choledocholithiasis, nine; cholestasis, six; stones suspected on ultrasound or computed tomography scan, 19). MR cholangiograms with two dimensional turbo spin echo sequences were acquired. Endoscopic retrograde cholangiography with or without sphincterotomy (n = 63), endosonography (n = 5), or intraoperative cholangiography (n = 2) were the reference imaging techniques used for the study and were performed within 12 hours of MRC. Radiologists were blinded to the results of endoscopic retrograde cholangiography and previous investigations. RESULTS: 49 patients (70%) had bile duct stones on reference imaging (common bile duct, 44, six of which impacted in the papilla; intrahepatic, four; cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smaller than 6 mm. MRC diagnostic accuracy for bile duct lithiasis was: sensitivity, 57.1%; specificity, 100%; positive predictive value, 100%; negative predictive value, 50%. CONCLUSIONS: Stones smaller than 6 mm are still often missed by MRC when standard equipment is used. The general introduction of new technical improvements is needed before this method can be considered reliable for the diagnosis of bile duct stones.

Predictive factors for survival of patients with inoperable malignant distal biliary strictures: a practical management guideline.

BACKGROUND: Stenting is the treatment of choice for inoperable malignant strictures of the common bile duct. Criteria for the choice of stents (plastic versus metallic) remain controversial because predicting survival is difficult. AIMS: To define prognostic factors in order to improve the cost effectiveness of endoscopic palliation. PATIENTS: One hundred and one patients were included in a prospective trial. Seven prognostic variables for survival were analysed (age, sex, bilirubinaemia, weight loss, presence of liver metastases, and tumour histology and size). All patients were followed until death or at least one year after inclusion. By the end of the study, 81 (80.2%) patients had died. RESULTS: In univariate analysis, the variables associated with survival were weight loss (p < 0.05) and tumour size (p < 0.01). By multivariate analysis, tumour size was the only independent prognostic factor (p < 0.05). A threshold of 30 mm at diagnosis distinguished two survival profiles: the median survival of patients with a tumour greater than 30 mm was 3.2 months, whereas it was 6.6 months for patients with a tumour less than 30 mm (p < 0.001). CONCLUSIONS: A practical strategy could be based on tumour size at diagnosis: a metal stent should be systematically chosen for patients with an inoperable tumour smaller than 30 mm, while larger tumours are efficiently palliated by a plastic stent.

A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.

BACKGROUND: Although metallic stents remain patent longer than plastic stents, the optimal palliation of inoperable malignant biliary strictures remains controversial because of the high cost of metallic stents and short patient survival. METHODS: A total of 101 patients (mean age 72.5+/-12.9 years) with malignant strictures of the common bile duct were included in this study, after three exclusions for technical failure (n = 3) and one for noncompliance with study design. The etiology of the strictures included pancreatic cancer (65), cholangiocarcinoma (21), ampullary tumor (3), and metastatic lymph nodes (12). Patients were randomized to receive either an 11.5F polyethylene stent to be exchanged in case of dysfunction (group 1, n = 33), an 11.5F stent to be exchanged every 3 months (group 2, n = 34), or a self-expanding metallic Wallstent (group 3, n = 34). RESULTS: Endoscopic procedures were successful (including complete relief of jaundice) in 97.1 % of cases. Procedure-related morbidity was 11.9%, and mortality was 2.9%. Bilirubinemia after 48 hours (37.2%+/-21.7% decrease from the preoperative level) did not differ between groups. Patients were followed for a mean of 166 days (median 143, range 0 to 596 days). Overall survivals were not different between groups, but complication-free survival for groups 2 and 3 was longer than that of group 1 (p < 0.05). Cumulated hospital days were 7.4+/-1.5, 10.6+/-1.7, and 5.5+/-1.4 (groups 1, 2, and 3, respectively) (p < 0.05; analysis of variance). Cost analysis showed that metallic stents were advantageous in patients surviving more than 6 months, whereas a plastic stent was advantageous in patients surviving 6 months or less. CONCLUSIONS: Metallic stents and plastic stents exchanged every 3 months are valuable alternatives for increasing complication-free survival in patients with malignant strictures of the common bile duct. Metal stents are advantageous in patients with the longest life expectancy.

Endoscopic sphincteroclasy: a useful therapeutic tool for biliary endoscopy in Billroth II gastrectomy patients.

BACKGROUND AND STUDY AIMS: Endoscopic exploration of the common bile duct is generally more difficult and hazardous in patients with a Billroth II gastrectomy than in patients with normal anatomy. Hydrostatic dilation of the papilla, which we term "endoscopic sphincteroclasy", provides a useful alternative to sphincterotomy in such patients. PATIENTS AND METHODS: Endoscopic sphincteroclasy was carried out in five patients with a Billroth II anastomosis. There were four men and one woman, aged 58 to 90 years. One patients was cirrhotic, with impaired coagulation. Four presented with typical cholangitis, and one had pain and jaundice. The common bile duct was dilated in all five patients. Four had choledocholithiasis and one had a cholangiocarcinoma. RESULTS: Sphincteroclasy was carried out with balloon dilators mounted on 0.035-inch guide wires. Immediate extraction of stones was achieved in three of the four patients with choledocholithiasis. In one case, a control endoscopic retrograde cholangiopancreatography was necessary to remove residual stones, without additional dilation. Insertion of the endoprosthesis was possible without difficulty in the patient with a malignant stricture. None of the patients required a sphincterotomy. No complications were observed up to six months after the sphincteroclasy. CONCLUSIONS: We recommend the use of endoscopic sphincteroclasy in patients with a Billroth II gastrectomy who require endoscopic therapy, as well as in patients in need of emergency bile duct decompression who have impaired coagulation.

[Intra-corporeal shockwave lithotripsy in the treatment of complex lithiasis of the bile ducts. Comparison of endoscopic techniques and long-term results]. / Lithotritie intra-corporelle par ondes de choc dans le traitement des lithiases complexes des voies biliaires. Comparaison des techniques endoscopiques et résultat à distance.

OBJECTIVES: About 2% of common bile duct stones and most intra-hepatic stones cannot be removed by conventional endoscopy. Intra-corporeal lithotripsy is an alternative technique for these patients. Contact lithotripsy can be obtained by a pulsed dye laser or by electro-hydraulic shockwaves. We compared and assessed the results of these two methods. METHODS: Thirty-seven patients (79 +/- 9.8 years, 25 women and 12 men) underwent laser lithotripsy (n = 21), electro-hydraulic lithotripsy (n = 9) or both methods consecutively (n = 7) for common bile duct stones (n = 31), intra-hepatic stones (n = 3) or diffuse lithiasis (n = 3). The mean diameter of the largest stone was 23 +/- 12 mm. Lithotripsy was performed by a retrograde approach in 35 cases and a combined, retrograde and transhepatic approach in 2 cases. RESULTS: The mean number of lithotripsy sessions was 1.5 +/- 0.65. The overall success rate (free bile ducts with patent drainage) was 95%. In 2 patients, stones were not fully extracted: one underwent surgery, the other one was treated conservatively with antibiotics. The duration of the hospital stay was 9.3 +/- 4.5 days. Morbidity at 30 days was 27% and only one case of major morbidity (hemorrhage after sphincterotomy, 2.7%) was observed. There were no procedure-related mortality. Electro-hydraulic and laser groups did not differ significantly for success rate, morbidity and time spent at hospital. Follow-up information was obtained in 34 patients (91.8%) a median of 17 months after lithotripsy (range: 4.52 months). Ten patients died of non-biliary diseases. Two patients (5.8%) developed biliary symptoms 24 and 34 months after lithotripsy, one after unsuccessful lithotripsy. CONCLUSION: Intra-corporeal lithotripsy is a valuable tool for the most complex cases of duct stones, and with an acceptable morbidity. The results of the two techniques are similar. Late biliary complications after intra-corporeal lithotripsy appear to be rare.

Biliary symptoms and complications more than 8 years after endoscopic sphincterotomy for choledocholithiasis.

BACKGROUND & AIMS: Although long-term results of endoscopic sphincterotomy (ES) have been poorly estimated, extended indications of ES have been proposed, especially in young patients. The aim of this study was to assess late biliary complications of ES. METHODS: Between 1981 and 1986, 169 patients younger than age 70 (55+/-11.8 years; range, 24-70 years; male-female sex ration, 0.55) underwent ES for choledocholithiasis. One hundred fifteen patients (68%) underwent cholecystectomy. Long-term data were obtained retrospectively from the patients and general practitioners. RESULTS: Information was obtained for 156 patients, 2 of whom died within 1 month (one ES-related death). The mean follow-up for 154 patients was 9.6+/-3.3 years (range 8-13 years); 138 patients had no biliary symptoms. During follow-up, 16 patients experienced biliary symptoms; 2 of these patients underwent elective cholecystectomy, 3 had malignant strictures, 1 had a complicated cirrhosis, and 1 had a benign stricture related to the previous cholecystectomy. Nine patients developed potentially ES-related biliary symptoms. Second endoscopic exploration showed papillary stenosis in 3 patients (with stones in 2 patients) and recurrent bile duct stones in 3 others. Two patients had sine materia cholangitis, and 1 patient developed liver abscesses. CONCLUSIONS: Long-term ES-related complications seem to be rare, ES could reasonably be included in management strategies of choledocholithiasis, even in young patients.

Endoscopic sphincterotomy in patients with liver cirrhosis.

BACKGROUND: Nonsurgical alternatives in biliary diseases have not been studied in large series of patients with cirrhosis. Our aim was to determine the indications and results of endoscopic treatment in this subset of patients. METHODS: Fifty-two patients (36 men, 16 women-Child-Pugh Class A, 18; B, 22; C, 12) aged 63 +/- 18 years underwent endoscopic sphincterotomy (ES) between 1988 and 1993. Antibiotic prophylaxis was routinely carried out and coagulopathy was corrected before ES when required. The data were collected retrospectively up to 30 days after ES. RESULTS: ES succeeded in 98% of the patients (12 cases of needle-knife papillotomy). Twenty-nine patients (55.7%) had choledocholithiasis, 18 had biliary strictures (12 malignant), and 5 had pancreatic or other biliary diseases. Five days after ES, morbidity was 13.5% and mortality was 7.7%. At 1 month, morbidity was 22.9% and mortality 12.5%. Only endoscopic procedures and Ineffective drainage were seen to be significant risk factors or morbidity. The results of the subgroup of cirrhotic patients with choledocholithiasis (n = 29) were compared with those of matched noncirrhotic patients (n = 58). The cirrhotic and noncirrhotic patients treated for choledocholithiasis showed similar results for stone clearance, morbidity, and mortality. CONCLUSION: ES is a safe and effective procedure for treating choledocholithiasis in cirrhotic patients. ES can therefore be considered as an alternative to surgery in Child class A and B patients and must be preferred for Child class C patients with life-threatening biliary complications.

Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bileduct lithiasis.

BACKGROUND: Endoscopic sphincterotomy is sometimes done unnecessarily in patients with suspected choledocholithiasis. Our aims were to assess the diagnostic accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography (ERC) and to find out whether endoscopic ultrasonography may help to prevent unnecessary sphincterotomy or surgical explorations. METHODS: We recruited 119 patients aged 70.4 (SD 16.1) years with strongly suspected choledocholithiasis who presented to our endoscopy unit between January, 1994, and January, 1995. During the same spell of sedation or within 2 h of each other, endoscopic ultrasonography and ERC were carried out by investigators unaware of the patient's history. Endoscopic sphincterotomy with instrumental exploration was then done as the gold standard for the presence or the absence of stones. FINDINGS: 78 (66%) patients had choledocholithiasis; 17 (14%) had other bileduct diseases; 24 (20%) had a clear bileduct or did not require an invasive endoscopic procedure. The sensitivity of endoscopic ultrasonography was 93%, specificity 97%, positive predictive value 98%, and negative predictive value 88%. The corresponding values for ERC were 89%, 100%, 100%, and 83%. There were five false-negative cases by endoscopic ultrasonography (of which three were also negative with ERC) and one false-positive. The morbidity rate was 4.1%. INTERPRETATION: We conclude that endoscopic ultrasonography is at least as sensitive as ERC. Endoscopic ultrasonography may prevent inappropriate invasive explorations of the common bileduct.

Endoscopic sphincterotomy for suspected choledocholithiasis in patients with and without stones.

OBJECTIVE: To characterize a subgroup of patients treated with endoscopic sphincterotomy (ES) for a suspected common bile duct lithiasis (CBDL) that was not confirmed and to compare it with the subgroup with confirmed CBDL. METHODS AND RESULTS: Over 18 months, ES was successful in 245 consecutive patients (age 23-97, mean 75 yr, SE 17 yr) with suspected CBDL; 159 patients had CBDL (group 1), and 86 did not (group 2), as confirmed by CBD exploration. Fifty-nine percent of the patients in group 1 and 76.7% of the patients in group 2 had gallbladder in situ. Both groups were different for age (p < 0.001), prevalence of chronic alcoholism (p < 0.001), gallbladder in situ (p < 0.01), and gallbladder stones (p < 0.05). Patients from group 1 had two or more presenting symptoms suggestive of CBDL more often than patients from group 2 (p < 0.05), and pancreatitis was a more frequent presenting manifestation in group 2 (p < 0.0001). Overall morbidity and mortality were not different between groups, but acute cholecystitis developed in six patients from group 2 and in one patient from group 1 (p < 0.01). In a univariate analysis, only elevated alkaline phosphatase and a dilated common bile duct were positively discriminant for the diagnosis of CBDL; chronic alcoholism was negatively discriminant for the diagnosis of CBDL. In a multivariate analysis, only chronic alcoholism and a dilated bile duct were found to be independently discriminant. CONCLUSION: The risk of ES-related complications in the group without CBDL suggests that the selection of patients should be improved by a better use of preoperative criteria.

Laser lithotripsy of difficult biliary stones.

From June 1991 to September 1992, 16 patients (mean age, 72 +/- 5 years) were treated with intra-corporeal laser lithotripsy (ICL). Thirteen patients had choledocholithiasis with at least one stone larger than 20 mm; 3 patients had intra-hepatic lithiasis. All other methods, including mechanical lithotripsy, extra-corporeal lithotripsy (1 case), and intra-corporeal electrohydraulic lithotripsy (1 case), had failed to clear the bile ducts. Approaches for ICL were choledochoscopy with a "baby" endoscope via an existing sphincterotomy (8 cases), retrograde cholangioscopy with a gastroscope through a choledochoduodenal anastomosis or a sphincterotomy in patients with a gastrojejunal anastomosis (5 cases), and trans-hepatic cholangioscopy with a fibercholangioscope (3 cases, in 1 of which retrograde and trans-hepatic approaches were combined). Free bile ducts were obtained in 14/16 (87.5%) patients after a mean of 1.66 ICL sessions per patient. Mortality and laser-related morbidity did not occur; endoscopy-related morbidity was 12.5% for minor complications (1 transitory fever, 1 mild and transitory hemobilia) and 6.25% for major complications (1 post-sphincterotomy hemorrhage). Mean length of hospital stay was 11.5 +/- 2.5 days. We conclude that although it is rarely indicated and is expensive, ICL does offer a limited treatment option in selected patients. It allows the complete relief of complex biliary lithiasis. Morbidity is related to maneuvers preceding ICL, not to ICL itself.

[Psoas abscess exteriorized in the groin revealed late after acute pancreatitis]. / Abcès du psoas extériorisé au creux inguinal se révélant tardivement après une pancréatite aiguë.

Two cases of psoas abscess complicating acute necrotizing pancreatitis are reported. These cases were particular because the abscesses exteriorized in the groin and symptoms were misleading. The abscesses were detected late, three and five months after the beginning of the pancreatitis respectively. The difficulties in diagnosis and the long delay to diagnosis are emphasized as possible sources of superinfection.