Usefulness of slimmer and open-cell-design stents for endoscopic bilateral stenting and endoscopic revision in patients with hilar cholangiocarcinoma (with video).

BACKGROUND: Although endoscopic bilateral metal stenting using a "stent-in-stent" method is currently used to treat patients with unresectable hilar cholangiocarcinoma, this method has limited application in cases of tight strictures or endoscopic revision in case of tumor recurrence, especially on the first stent (initial Y stent placed) side. OBJECTIVE: To evaluate the clinical efficacy of bilateral metal stenting with the use of a slimmer (7F), open-cell-design stent. DESIGN: Prospective, uncontrolled, single center. SETTING: Tertiary referral university hospital. PATIENTS: This study involved 34 patients with unresectable hilar cholangiocarcinoma (Bismuth type II-IV). INTERVENTION: Endoscopic bilateral metal stenting using a stent-in-stent method was performed. First, a Y stent with a central, wide-open mesh was inserted, then a Zilver stent, with a preloaded delivery system that is slimmer (7F) than those (7.5-8.5F) of conventional stents, was placed into the contralateral hepatic duct through the central portion of the Y stent. The Zilver stent has an open-cell design, and it can be dilated easily. Thus, revision with bilateral plastic stents was tried in cases of stent obstruction. MAIN OUTCOME MEASUREMENTS: Technical success, functional success, complications, and revision method. RESULTS: Technical success (bilateral stenting using Y and Zilver stents) was achieved in 29 of 34 (85.3%) patients. Functional success was noted in 29 of the 29 (100.0%) patients who received bilateral stenting. Early complications such as pancreatitis and cholecystitis occurred in 3 (10.3%) patients. Late complications occurred in 11 (37.9%) patients. Cholecystitis, which occurred in 2 patients, was managed by percutaneous transhepatic gallbladder drainage. Stent obstruction by tumor ingrowth or overgrowth occurred in 9 of 29 (31.0%) patients. These patients were managed by placement of bilateral plastic stents (4 of 9), percutaneous transhepatic biliary drainage (4 of 9), and a combined method (1 of 9). Of the 5 patients in whom endoscopic revision was attempted, 4 (80%) were managed endoscopically with bilateral plastic stents. LIMITATIONS: Small number of patients, uncontrolled study. CONCLUSION: A slimmer (7F), open-cell-design stent is effective in endoscopic bilateral stenting for advanced hilar cholangiocarcinoma and endoscopic revision in case of tumor recurrence.

Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is more difficult and dangerous in patients with Billroth II (B II) gastrectomy than those with normal anatomy. OBJECTIVES: To evaluate the clinical efficacy of percutaneous transhepatic choledochoscopic lithotomy (PTCSL) for removing common bile duct stones in B II gastrectomy patients who are difficult to perform ERCP. METHODS: This study was designed as prospectively uncontrolled in a large tertiary referral center. In 20 patients, mostly men, with bile duct stones and an earlier B II gastrectomy, PTCSL was tried because of failed ERCP and high risk. The PTCSL was performed using electrohydraulic lithotripsy or papillary balloon dilation. Successful stone removal and complications were measured. RESULTS: Stone removal was achieved in all 20 patients. The mean number of procedures and session time were 4.5 and 45 min, respectively. Minor PTCSL-related complications, such as fever, hemobilia, hyperamylasemia, and wound pain, occurred in five patients (25%). There were no major procedure-related complications, including perforation or mortality. CONCLUSION: The PTCSL procedure is an effective and safe rescue therapy for common bile duct stones in B II gastrectomy patients with failed ERCP and high risk.

Nafamostat mesylate in the prevention of post-ERCP pancreatitis and risk factors for post-ERCP pancreatitis.

BACKGROUND: Pancreatitis is a major complication of ERCP. OBJECTIVE: To determine whether nafamostat mesylate prophylaxis decreases the incidence of post-ERCP pancreatitis (PEP). DESIGN: A single-center, randomized, double-blinded, controlled trial. SETTING: A large tertiary-referral center. PATIENTS: From January 2005 to December 2007, a total of 704 patients who underwent ERCP were analyzed. INTERVENTION: Patients received continuous infusion of 500 mL of 5% dextrose solution with 20 mg of nafamostat mesylate (354 patients) or without 20 mg of nafamostat mesylate (350 patients). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. MAIN OUTCOME MEASUREMENTS: The incidence of PEP and risk factors associated with the development of PEP. RESULTS: The incidence of acute pancreatitis was 5.4%. There was a significant difference in the incidence of PEP between the nafamostat mesylate and control groups (3.3% vs 7.4%, respectively; P = .018). Univariate analysis identified history of acute pancreatitis (P < .001), difficult cannulation (P = .023), periampullary diverticulum (P = .004), age younger than 40 years (P = .009), and >/=5 pancreatic-duct contrast injections (odds ratio [OR] 2.736, P = .012) as statistically significant risk factors. LIMITATIONS: A single-center study. CONCLUSIONS: Nafamostat mesylate prophylaxis is partially effective in preventing post-ERCP pancreatitis. Independent risk factors for PEP are a history of acute pancreatitis and multiple pancreatic-duct contrast injections.