Radiological intervention in pancreatic cancer.

Pancreatic carcinoma is increasing in its incidence, and despite advances in surgical treatment and chemotherapy, its prognosis remains extremely poor. Realistic therapy is targeted primarily at the relief of obstruction of the biliary tract and the duodenum, as well as the relief of pain. This paper discusses the indications and techniques for palliation and illustrates the critical team approach between radiologist, endoscopist and surgeon.

Day-case transfer of inpatients for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography.

BACKGROUND: To use facilities flexibly and efficiently, a diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) service was offered to inpatients from referring hospitals on a day-case basis. METHODS: Patients were transferred by ambulance with a nurse escort and returned to the parent hospital after a short period of recovery. The activity of this service was audited. RESULTS: A total of 188 patients (70 men and 118 women of mean age 63.5 (range 22-94) years) were referred, 55 by physicians or geriatricians and 133 by surgeons from 19 hospitals up to 100 miles distant. Some 109 (58 per cent) had jaundice, 12 (6 per cent) cholangitis, seven (4 per cent) acute pancreatitis and 41 (22 per cent) abdominal pain. All patients arrived between 08:30 and 12:00 hours, all but 16 between 09:30 and 11:00 hours, and all but one with an escort; 129 patients travelled less than 10 miles. The mean time spent in the authors' hospital was 5.9 (range 2.2-9.5) h. The mean time spent away from the parent hospital by patient and escort was 7.0 (range 3.5-10) h. Cannulation failed in 12 patients (6 per cent), two with duodenal tumours. Sphincterotomy was performed in 70 cases, mechanical lithotripsy in seven and stents were inserted in 67. Nine patients were admitted, four for percutaneous stent insertion after failed ERCP and three for abdominal pain (one acute pancreatitis); two patients with sepsis and malignancy died after admission to this hospital. After return to the parent hospital, a further patient died following laparotomy for malignancy and five patients developed abdominal pain (three acute pancreatitis). CONCLUSION: These findings show that short-stay ERCP can be undertaken on transferred inpatients safely and efficiently without adverse effect on success or complication rates.

Stenting for choledocholithiasis: temporizing or therapeutic?

Maxton and colleagues report their experience using biliary endoprostheses for treatment of failed common bile duct stone clearance after sphincterotomy. Of 283 patients with choledocholithiasis referred to their tertiary facility, 85 failed to have their ducts cleared with the first ERCP. There were 21 male and 64 female subjects; mean age was 77.5 yr. Clinical presentations were jaundice (39), cholangitis (23), and biliary colic and/or abnormal liver blood tests in the remainder. The patients were characterized as "elderly and ill with either jaundice or cholangitis present in almost 75%." Follow-up data were obtained for all patients. ERCP was first performed using a duodenoscope with a 3.2-mm instrument channel. A 7-French double pigtail stent was placed in each of the 85 patients with retained stones. Subsequent ERCP were performed at 2- to 3-month intervals using a therapeutic duodenoscope (4.2-mm instrument channel). A second stent was placed if stones remained in the bile duct after repeated extraction attempts. Patients deemed too frail and elderly for frequent ERCP had their first stent left in place, with stent exchanges and attempts at stone extraction every 6-12 months. Mechanical lithotripsy was used in 23 patients, extracorporeal shock wave lithotripsy (ESWL) in 11, and dissolution therapy via nasobiliary catheter in 10. Acute illnesses resolved in 84 of 85 patients, with significant decreases in bilirubin and alkaline phosphatase levels by the second ERCP. Six patients died with temporary stents in situ, one form a respiratory arrest the day of ERCP; the other deaths were unrelated to ERCP or choledocholithiasis. Fifty of the remaining 79 patients had successful stone clearance; 68% of these required two ERCP, 20% three ERCP, 6% four ERCP, and, in another 6%, a total of five ERCP were required before their ducts were free of stones. Seven cases of cholangitis among these 50 patients were treated successfully with i.v. antibiotics, fluids, and "early" stent replacement. Twenty-six patients had long term biliary drainage with the original stents in situ over 12 months. Four of these patients were among the six deaths, all unrelated to biliary stones or ERCP. Three patients were referred for surgical stone removal. The authors conclude that placement of a single 7-French stent after failure to clear common duct stones is safe, provides affective biliary drainage, can prevent the need for urgent surgical intervention, and allows for transfer of sick patients to centers of expertise. Further attempts at bile duct clearance were successful in most cases.

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.

Oxygen saturation during endoscopic retrograde cholangiopancreatography: a comparison of two protocols of oxygen administration.

Patients having endoscopic retrograde cholangiopancreatography (ERCP) are generally elderly and require sedation while in the prone position. These factors may be expected to aggravate any risk of arterial hypoxia. This study evaluated two protocols of oxygen administration, one with and one without pre-oxygenation. In 25 patients in whom pre-oxygenation with 4 litres/minute for five minutes before sedation was used, followed by continuous oxygen administration, arterial oxygen saturation did not fall below 90% at any stage during the procedure. By contrast, in 25 patients who were not pre-oxygenated oxygen saturation fell below 90% in nine (36%). As expected, hypoxia occurred most frequently during the early stages of sedation and endoscope insertion. Hypoxia did not occur in association with operations such as sphincterotomy, stone extraction or stent insertion. This study confirms that arterial hypoxia is a common event during ERCP and can be completely prevented by pre-oxygenation with four litres of oxygen given intranasally for five minutes before sedation.

Relief of metastatic biliary obstruction by stent placement: is it worthwhile?

Twenty-one patients undergoing stent placement for extra-hepatic biliary obstruction by metastatic disease were reviewed. Primary tumours (colorectal 8, stomach 4, breast 2, ovary 2, others 5) had been diagnosed 13 months (median) before presentation with bile duct obstruction, which was at the porta hepatis or common hepatic duct in 14 patients and in the common bile duct in seven. Endoscopic stent placement was achieved in 14 out of 20 patients in whom it was attempted. A percutaneous trans-hepatic procedure was necessary in five patients. Two patients could not be stented. Median survival was 5 months (range 1 month to 6 years) in patients stented successfully but only 1 month (2 weeks to 3 months) in unsuccessful cases (P < 0.01). Nine patients survived more than 4 months. Patients with proximal obstruction fared less well than those with distal obstruction; they required more procedures and survived for shorter periods (median 1 month versus 5 months, P < 0.05). Worthwhile palliation is afforded to almost half these patients by endoscopic stent placement and individual patients may achieve prolonged, symptom-free survival.

Common bile duct diameter and complications of endoscopic sphincterotomy.

To assess the relationship between distal common bile duct (CBD) diameter and the incidence of an immediate complication following endoscopic sphincterotomy (ES), all patients undergoing ES between January 1986 and October 1990 were studied. The overall risk of an immediate complication following ES in 655 patients was 5.6 per cent (37 patients). Patients with calculi were at greater risk if the distal CBD was dilated (P < 0.001); the complication in those with stones was most likely to be haemorrhage (81 per cent). The relative risk of a complication increased ten times if the distal bile duct diameter was > 0.8 cm. Patients with stricture of the distal CBD did not have a significantly greater risk of complication than those with stones (9.7 versus 4.9 per cent). There was no significant difference between the mean distal CBD diameter of those with stricture and controls (0.61 versus 0.44 cm).

Management of common bile duct stones using a second-generation extracorporeal shockwave lithotriptor.

Fifty-four patients with common bile duct stones (8-36 mm in diameter) that could not be removed after endoscopic sphincterotomy, even with the use of mechanical lithotripsy, underwent extracorporeal shockwave lithotripsy (ESWL) using a Siemens Lithostar. Their median age was 75.5 (range 34-89) years. Patients received 4000-6000 shocks per session over approximately 60 min. Seventeen underwent two sessions and two patients three or more. Thirty-seven patients had one stone, ten had two, and seven had three or more. Spontaneous clearance of fragments occurred in only three patients before further endoscopic retrograde cholangiopancreatography was performed to remove fragments. Stones were removed and ducts cleared endoscopically in 35 patients, giving a total of 38 of 54 patients (70 per cent) with complete duct clearance. Fragmentation in response to lithotripsy was dependent on stone size; the number of stones had little effect. ESWL was well tolerated without any haematological or biochemical abnormality. Computed tomography in the first 20 patients showed no hepatic or pancreatic change after treatment. ESWL combined with endoscopic extraction of fragments is an alternative to surgery when preliminary endoscopic extraction and mechanical lithotripsy have failed.

Pancreaticojejunostomy for severe symptomatic chronic pancreatitis.

The role of operation, particularly pancreaticojejunostomy, in the treatment of abdominal pain from chronic pancreatitis is controversial, but relief of pancreatic duct obstruction may decrease the rate of pancreatic organ failure. Our results over 6 years in 13 carefully selected patients suggest that pancreatic drainage does relieve pain but is less effective in preventing pancreatic exocrine failure. Pain was the indication for operation in all patients.

Needle knife papillotomy for endoscopic sphincterotomy and cholangiography.

Needle knife papillotomy (NKP) was used to achieve diagnostic endoscopic cholangiography in 39 patients and endoscopic sphincterotomy in 24 patients when conventional endoscopic methods had failed. These patients represent 2.2% (cholangiography) and 4.2% (sphincterotomy) of the total number of patients undergoing these procedures during the same period. Cholangiography was achieved in 37 of 39 patients and sphincterotomy was successfully accomplished in all 24 patients with the assistance of NKP. Complication rates of 2.5% for cholangiography and 12% for sphincterotomy are higher than our own rates for non-NKP-assisted procedures, but the clinical benefits obtained were considered to outweigh these increases or the risks of alternative procedures. NKP is an effective endoscopic tool, allowing endoscopic sphincterotomy to be performed when conventional techniques fail. In addition, in carefully selected cases, NKP is helpful in allowing diagnostic cholangiography when other endoscopic methods fail.

Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.

There is controversy concerning the subsequent clinical course of patients whose gallbladder is left in situ following successful endoscopic removal of stones from their common bile ducts. A total of 191 patients (median age 76 years) were reviewed between 12 and 100 months (mean 38 months) after endoscopic sphincterotomy. Ten patients (5.2 per cent) had symptoms requiring cholecystectomy which was uneventful, nine in the first year. Cholangitis at presentation or failure to fill the gallbladder by endoscopic retrograde cholangiography were not helpful in identifying these patients. Forty-nine (25.6 per cent) patients died during the review period from non-biliary pathology (usually cardiovascular). Elective cholecystectomy is not required in elderly patients with symptomatic bile duct stones if the common bile duct can be cleared of stones after endoscopic sphincterotomy.

Endoscopic sphincterotomy: the whole truth.

An 8 year experience of 602 patients (median age 76 years) referred for endoscopic management of common bile stones is reported. No patient referred for treatment has been excluded. A diagnostic cholangiogram was achieved in 94 per cent and sphincterotomy was accomplished in 91.5 per cent. The bile ducts were demonstrated to be completely cleared of stones in 491 (81.6 per cent) of 602 patients. A mean number of 1.9 endoscopic retrograde cholangiopancreatography examinations per patient were necessary to achieve this result. Complications of endoscopic sphincterotomy, which were strictly defined, occurred in 10.5 per cent of patients although five patients had two complications (total complication rate 11.3 per cent). The 30-day mortality rate was 2.2 per cent, seven of 13 deaths (1.2 per cent) occurring as a direct result of sphincterotomy. There have been statistically significant improvements in bile duct clearance and complication rates with increasing experience of endoscopists.

Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management.

Eleven patients with retroperitoneal perforation complicating endoscopic management of bile duct obstruction were seen over a seven-year period. In nine patients endoscopic sphincterotomy or pre-cut papillotomy had been performed, but in two who had not undergone sphincterotomy perforation occurred because of the penetration of a guidewire during attempts to negotiate a malignant bile duct stricture. Eight out of eleven patients remained asymptomatic, and all recovered with conservative management. Asymptomatic retroperitoneal perforation can complicate therapeutic ERCP even when sphincterotomy is not performed, but conservative management is usually effective if the complications is recognized immediately.

The pharmacokinetics of the biliary excretion of ciprofloxacin.

The pharmacokinetics of ciprofloxacin excretion have been studied in 54 patients undergoing biliary and pancreatic operations with and without obstruction of the common bile duct. High concentrations were achieved in common duct bile within 20 minutes of intravenous injection and persisted for over 3 hours after 100 mg and for over 8 hours after 200 mg. The concentration of ciprofloxacin in the bile of functioning gall bladders was much greater than that in the common duct bile. Remarkably, it was identified in therapeutic concentrations in the bile of obstructed ducts. This and the rapid fall from initially high venous concentrations probably reflect diffusion from the circulation as a result of the exceptional tissue penetration. A unique feature of this study was the finding of clinically significant concentrations in the bile of obstructed ducts. Two patients developed wound infection and no side effects were observed. The broad spectrum antibiotic ciprofloxacin has potential as a useful agent for prophylaxis in biliary surgery maintaining biliary and venous concentrations in excess of the MIC90 for most biliary pathogens for more than 8 hours.