[Classification and treatment of bile duct injuries after laparoscopic cholecystectomy]. / Einteilung und Behandlung von Gallengangverletzungen nach laparoskopischer Cholecystektomie.

Iatrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury. The incidence of biliary lesions following laparoscopic cholecystectomy is up to threefold higher than that of the open procedure. A total of 108 patients with bile duct lesions after laparoscopic cholecystectomy were treated at our institution. Endoscopic treatment was successful in 68 cases, 6 patients were treated by external drainage, and 34 patients required surgical therapy. Selection criteria for the type of treatment included the etiology, anatomical situation, and diagnostic interval of the biliary lesion. We suggest a classification of bile duct injury and a proposal for diagnosis and treatment of these complications.

[Endoscopic therapy of ischemia-type biliary lesions in patients following orthotopic liver transplantation]. / Endoskopische Therapie ischämietypischer biliärer Läsionen (ITBL) bei Patienten nach orthotoper Lebertransplantation.

Ischemic-type biliary lesions (ITBL) mainly induce stenoses in liver transplants causing cholestasis thus endangering the allograft. ERC enables distinction of ITBL from other differential diagnosis. From 1988 to 1998, 1,026 liver transplantations had been carried out at our clinic. 2.4% (25 out of 1,026) of liver transplanted patients were afflicted from ITBL. 60% (15 out of 25) of patients were endoscopically treated by means of sphincterotomy and balloon dilation. Furthermore, some patients needed extraction of calculi (n = 3), bile duct sequester (n = 6) or stenting (n = 4), respectively. Three patients suffered from ITBL type 1 (= only extrahepatic lesions) and five other patients were afflicted from ITBL type 2 (= circumscript intrahepatic lesions). 90% of those patients revealed long-term benefit from endoscopic therapy (follow-up to seven years). Another 15 patients elicited ITBL type 3 (= multiple intra- and extrahepatic lesions). Therefrom, nine patients had to be retransplanted directly while eight others were assigned to endoscopic treatment. Follow-up investigations revealed that retransplantation could be avoided in 50% of ITBL patients by means of endoscopic therapy for at least three years. In contrast, only 27% of ITBL patients could survive for more than three years without endoscopic therapy. Endoscopic success depends on localization and severity of ITBL complications in the biliary tract of the liver allograft. Therefore, benefit of endoscopic therapy depends on proper diagnosis as early as possible guiding further therapeutic strategy. Conclusively, endoscopic success enables maintenance of liver function in ITBL afflicted liver grafts and avoids or at least, delays retransplantation.

Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP).

BACKGROUND AND STUDY AIMS: The clinical importance of magnetic resonance cholangiopancreatography (MRCP) as a noninvasive diagnostic modality for investigation of the biliary tree and pancreatic duct system is under debate. Using endoscopic retrograde cholangiopancreatography (ERCP) as the gold standard, this study determined in a prospective, blinded fashion the sensitivity and further statistic values of MRCP findings for evaluation of the biliary and pancreatic tract. PATIENTS AND METHODS: Seventy-eight patients referred for ERCP were studied prospectively with MRCP and ERCP during a 12-month period. All images were interpreted on a blinded basis by two radiologists. Any dilations, strictures, and intraductal abnormalities were recorded and correlated with the clinical diagnoses. RESULTS: MRCP images of diagnostic quality were obtained in 76 of the 78 patients (97%). Magnetic resonance cholangiography (MRC) showed sensitivities (and positive predictive values) of 71% (62%) for recognition of normal bile ducts, 83% (91%) for recognition of dilation, 85% (100%) for recognition of strictures, 77% (91%) for correct stricture location, and 80% (100%) for diagnosing bile duct calculi. In addition, the sensitivity of MRC in classifying benign and malignant strictures was 50% and 80%, respectively. The statistical values (sensitivity and positive predictive value) for magnetic resonance pancreatography findings were determined for the recognition of normal pancreatic ducts (33% and 50%), recognition of dilation (62% and 100%), recognition of strictures (76% and 87%) and correct location (66% and 100%), diagnosis of benign strictures (87% and 87%) and malignant strictures (60% and 75%), and for diagnosing pancreatic duct stones (60% and 100%). CONCLUSIONS: MRCP is capable of providing diagnostic information equivalent to ERCP in many patients, and should be applied whenever established techniques provide no results, or inadequate results.

Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is an established modality for the diagnosis and treatment of pancreaticobiliary disorders. In contrast to ERCP in patients who have not undergone gastrectomy, ERCP in patients with a Billroth II gastrojejunostomy or a Roux-en-Y anastomosis is considerably more difficult. It was nevertheless considered that ERCP might be possible in most patients with gastrectomies, and this hypothesis was tested. PATIENTS AND METHODS: A total of 2256 patients were admitted to our hospital for ERCP from 1990 to 1994. Of these, 65 (3%) had gastrojejunostomies, either with Billroth II reconstructions or with the Roux-en-Y procedure. ERCP was always performed with a conventional side-viewing endoscope. RESULTS: We examined the 65 patients with gastrojejunostomies. Of these, 91% had Billroth II anastomoses and 9% had received Roux-en-Y reconstructions. We successfully reached the papilla of Vater with the endoscope in 92% of the patients with Billroth II gastrojejunostomies (54 of 59), but in only 33% of the patients with Roux-en-Y reconstructions (two of six). In 8% of the cases of Billroth II anastomosis, it was not possible to advance the endoscope into the duodenal stump, due to intestinal stenoses (5%) or excessive intestinal length (3%). Failure in case of regular Billroth II anatomy occurred only in patients who had not received Braun enteroenterostomies. Failure also occurred in 67% of the Roux-en-Y gastrojejunostomy cases due to excessive intestinal length. CONCLUSIONS: Most patients with Billroth II gastrojejunostomy (92% of those in the present study) and some patients with Roux-en-Y anastomosis (33% of those in the present study) can be investigated by ERCP and endoscopically treated in cases of pancreaticobiliary disorder. Braun enteroenterostomy has no negative impact on the endoscopic access to the papilla of Vater in patients with Billroth II gastrojejunostomy. Surgical reconstruction of the gastrointestinal tract to perform gastrojejunostomy should also take endoscopic requirements into account. In view of both the potential postoperative complications and endoscopic requirements, the jejunojejunostomy should be placed nearer to the gastrojejunostomy than 60 cm, and the afferent loop should be as short as possible.

Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy.

BACKGROUND AND STUDY AIMS: Some patients admitted for endoscopy present a gastrojejunostomy with a Billroth II anastomosis or Roux-en-Y reconstruction. The gastrointestinal reconstruction hampers endoscopic diagnosis and treatment of the biliary and pancreatic tract. The present paper describes a new procedure facilitating endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone gastrojejunostomy. PATIENTS AND METHODS: ERCP was attempted in 65 patients with gastrojejunostomy. A conventional side-viewing endoscope was advanced into the duodenal stump, and a modified catheter was pushed through the endoscope. The cutting wire of the modified catheter winds round the catheter at a pivotal point between the catheter's proximal and distal holes. This allows the catheter tip to be forced into an S-shape when the wire is pulled. Since the cutting wire can easily be adjusted to the papillary roof, safe and successful endoscopic sphincterotomy can be carried out. RESULTS: We were able to advance the conventional side-viewing endoscope into the duodenal stump in 92% of the patients (n = 59) with Billroth II gastrojejunostomies, and in 33% of the patients (n = 6) with Roux-en-Y anastomoses. Whenever it was possible to reach the duodenal stump, cannulation and sphincterotomy of the papilla of Vater was successful. Ninety-six percent of the patients who underwent sphincterotomy (n = 54) immediately benefited from biliary decompression. One major complication occurred, with a patient suffering a retroperitoneal perforation during endoscopic sphincterotomy; the patient later died, despite three subsequent surgical operations. CONCLUSIONS: In spite of previous gastrojejunostomy, most patients with Billroth II anastomoses (92%) and many patients with Roux-en-Y reconstructions (33%) can be treated endoscopically for biliary diseases. The use of a conventional side-viewing endoscope in conjunction with an S-shaped sphincterotome can be recommended. This allows safe and successful endoscopic treatment of all patients in whom endoscopic access to the papilla of Vater is possible.

Endoscopic management of biliary complications after orthotopic liver transplantation.

BACKGROUND/AIMS: Biliary complications after orthotopic liver transplantation are still a severe problem and often require a second surgical operation. MATERIAL AND METHODS: In our center we studied 500 patients after liver transplantation. RESULTS: In this patient population, we found 44 patients suffering from diseases of the bile duct system after liver transplantation. Biliary complications were caused by stenoses which were localized most often in the common bile duct of the recipient (65%) but also in the common bile duct of the donor liver (26%) as well as in the anastomosis of common bile duct (9%). In all cases ERC was able to identify location, entity and dimension of the biliary complication thus leading to therapeutic strategy. 66% (27 out of 41) of the patients with biliary complication could be cured definitely by endoscopic methods alone while 29% (12 out of 41) of these patients needed surgical operation and 5% (2 out of 41) received both, endoscopic and surgical therapy. Patients suffering from multiple complications could be cured partially by endoscopic methods improving patient condition for subsequent surgery. Ischemic type biliary lesions of the extrahepatic ducts (ITBL type I) as well as of the intrahepatic ducts (ITBL type II) could be successfully treated by endoscopy. Only rare cases of multiple lesions intra- and extrahepatically due to ITBL type III gave no chance to endoscopy and demanded directly surgical operation. CONCLUSIONS: Our results show that most of the biliary complications after liver transplantation can be resolved by endoscopic treatment.

Management of traction wire fracture complicating mechanical basket lithotripsy.

BACKGROUND AND STUDY AIMS: The application of basket catheters has become the main method of removing calculi from the biliary and pancreatic duct. However, larger or impacted stones have to be crushed and fragmented by mechanical lithotriptors before removal is possible. Sometimes, fracture of the traction wire occurs as a severe and fraught complication. We describe a precautionary measure which helps to manage this complication. PATIENTS AND METHODS: In a series of 569 consecutive patients suffering from bile or pancreatic duct stones we found 60 (10.5%) who required mechanical lithotripsy for oversized or impacted calculi. Mechanical lithotripsy was always performed initially with a long metal sheath (80 cm) in combination with a standard traction wire. If the traction wire fractured we replaced the long metal sheath stepwise by shorter ones (70cm, 60cm and 50 cm, respectively), allowing immediate continuation of the lithotriptic procedure using the same traction wire. RESULTS: During the lithotriptic procedure three of our patients (5%) were afflicted by traction wire fracture. Two patients could be relieved directly by changing the initial metal sheath to shorter ones. Because of the exceptional hardness of a pancreatic duct stone the third patient needed stone fragmentation by extracorporeal shock wave lithrotripsy (ESWL) before complete mechanical clearance of the duct could be accomplished. CONCLUSION: We advocate the initial use of a long metal sheath (80cm) to perform mechanical lithotripsy. In case of traction wire fracture the use of a shorter metal sheath allows immediate successful continuation of the procedure, thereby frequently avoiding procedures such as ESWL or surgery.

The wide-channel endoscope optimizes the success of emergency endoscopy.

INTRODUCTION: Success of emergency endoscopy in upper GI-hemorrhage for diagnostics and treatment is limited by masses of blood clots, food or both. Using standard endoscopes supported by adjuvant techniques bleeding source can be defined in 90 to 95%. These procedures are often time consuming. Only bleeding sources which are defined can be treated. This is difficult in cases of ongoing hemorrhage. Circulatory shock may occur as well as aspiration of gastric contents. For these reasons we developed the new wide-channel endoscope. METHODS: This endoscope (GIF-XT-30, Olympus, Tokyo) has two channels, one with a diameter of 6 mm and a jet channel with 1 mm. The outer diameter at the distal end is 13.7 mm. A three-way stopcock for suction and water input is connected to the 6 mm channel. RESULTS: We achieved complete evacuation of stomach contents in 122 of 123 patients (= 23% of all emergency patients in this series) with upper GI-bleeding, in whom complete gastric cleaning and identification of the bleeding source had proved impossible using standard endoscopes. Gastric emptying using the big channel endoscope was possible within 5 minutes in all successful cases. Optimal conditions for therapeutic procedures were therefore provided. CONCLUSIONS: The possibilities of this instrument enable a more aggressive technique of moving fixed coagula from ulcers to localize the vessel that is to be treated. Even in cases of provoked severe Forrest I A hemorrhage permanent visual control can be achieved. It is an indispensable tool for major endoscopic centers in emergency situations.

Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients.

BACKGROUND/AIMS: This paper evaluates the potential benefit of non mechanical bile duct stone lithotripsy techniques. The efficacy, limitations and risks of mechanical lithotripsy as first choice procedure were studied. MATERIAL AND METHODS: Endoscopic sphincterotomy was performed by Erlangen-type papillotomes, stone extraction by Olympus baskets and mechanical lithotripsy by the Wurbs-system. In an unselected series of 704 patients, everyone with common bile and hepatic duct stones (independent of size, number, location and stone consistency) was included in the study. RESULTS: Complete stone clearance by endoscopic sphincterotomy and basket extraction was possible in 87.6%. Additional mechanical lithotripsy led to a success rate of 98.4% and in combination with ESWL of 98.5%. In 11 patients without possibility of endoscopic stone removal (1.6%), 4 had no access transpapillary (B-II-situs or duodenal diverticulum), 5 anatomical problems (S-shaped common bile duct, intrahepatic stones or impacted stones in cystic duct orifice), and 2 refused further endoscopic interventions. Complication rate was 1.4% (thereof 1.1% successful treatment by endoscopic or surgical means), lethality rate 0.3%. CONCLUSIONS: A very high rate of stone clearance by standard endoscopic procedures is possible. In those patients where mechanical lithotripsy is not successful, other non-surgical lithotriptic procedures either cannot be applied because of anatomical reasons or if performed, the improvement in success rate is marginal.

Endoscopic resection of large colorectal adenomas: a combination of snare and laser ablation.

BACKGROUND AND STUDY AIMS: Endoscopic resection of large colorectal adenomas is still not a standard procedure, treatment with a high diathermic snare is considered as difficult and risky, and the main disadvantage of laser vaporization is the unavailability of histological evaluation. We studied a combined technique that enjoys the benefits of both techniques and avoids the disadvantages and risks of each. PATIENTS AND METHODS: In a prospective study, we combined the techniques of high-frequency snare resection as a preparatory method and Nd: YAG laser vaporisation as a second-stage treatment. In 72 patients, we resected 79 adenomas, most of them in the rectum (81.0%) and with a tubulovillous histology (69.6%), with a mean volume of 9.4 cm3 (1.5-29.0 cm3) and a base diameter ranging from 20 mm to 80 mm. RESULTS: After using the combined technique of preparatory mucosectomy as a first step and laser vaporization as the second step, follow-up evaluation was possible in 50 out of 72 patients (69.4%). Fourteen patients had a local relapse of adenoma (28.0%), with dysplasia histologically of the same grade or a lower one compared to the original grade, after a mean of 1.4 years. Since these local recurrences were diagnosed at a size of a few millimeters (less than 3 mm), a further session of laser treatment eliminated the material completely without complications. No colorectal carcinomas were observed. CONCLUSIONS: The high clinical long-term success of our combined electro-laser resection is not only a result of complete endoscopic adenoma resection, but also of a strong control regimen. This technique is applicable to the treatment of large colorectal adenomas with curative intent.

[Comparative imaging of HIV associated diseases of the hepatobiliary system in computerized tomography and cholangiography]. / Vergleichende Darstellung HIV-assoziierter Erkrankungen des hepatobiliären Systems in Computertomographie und Cholangiographie.

With the incidence of AIDS being on the rise, diagnostic work-up of hepatobiliary disease in these patients is of increasing interest. 57 x-ray cholangiograms and computed tomographic studies of 13 AIDS-patients with clinical signs of cholangitis were reviewed. Nine patients had abnormal cholangiographic findings. Computed tomography of 8 patients revealed hepatobiliary disease in six cases. Of three patients with cholangiograms reflecting bile duct dilatation of neoplastic aetiology, CT was required in two for definite diagnosis. Cholangiography is the method of choice for diagnosing AIDS-associated cholangitis, whereas computed tomography compares favourably in depicting neoplastic disease of the hepatobiliary system. Follow-up of AIDS-associated cholangitis usually delineates unchanged radiologic findings.

[Radioisomorphisms of sclerosing cholangitis]. / Radioisomorphismen sklerosierender Cholangitiden.

For differentiation of Primary Sclerosing Cholangitis (PSC) from AIDS-associated cholangitis (AAC), 95 CT or Cholangiography studies of 37 patients were reviewed and signs of biliary disease analysed. Only two each of PSC and AIDS-subjects were free from biliary lesions compatible with some kind of sclerosing cholangitis. Subgroup analysis revealed wide overlapping of morphological findings in PSC and AAC. We conclude that radioisomorphism of etiologically different forms of sclerosing cholangitis may indicate pathophysiologically similar courses.

[Digital image intensification radiography in endoscopic retrograde cholangiopancreatography]. / Digitale Bildverstärkerradiographie bei der endoskopischen retrograden Cholangio-Pankreatikographie.

The standard in ERCP is the use of the conventional radiography system. Digital radiography system are very seldom used in ERCP, and then mostly by digital luminescence radiography. In this study we report our experience with digital image amplification radiography (DIAR) in ERCP. We examined 53 patients of clinical routine aged from 21 to 90 years. During the ERCP we used the X-ray statues and the real-time exposures. At the end of an examination the image post-processing followed. Both conventional and digital image amplification radiography needed the same examination conditions. The special X-ray protection (special lead-shields) used at digital ERCP did not hinder the examination. The DIAR provided at least the same amount of information as conventional radiography. An advantage of DIAR is the possibility of image post-processing such as contrast change, zooming, etc., and the digital archiving and communication. The examination time was reduced by about 30% as compared conventional ERCP, resulting in a reduction of the X-ray exposure time for the patients. The disadvantages of DIAR can surely be compensated by a high ERCP-rate.

Improved endoscopic management of severe upper gastrointestinal hemorrhage using a new wide-channel endoscope.

Problems in emergency endoscopy for upper gastrointestinal bleeding may arise due to blood and food debris preventing proper endoscopic vision and orientation. We present here a new big channel endoscope with a 6 mm suction and drainage channel that achieved complete evacuation of stomach contents in 122 of 123 patients with upper gastrointestinal bleeding, in whom complete gastric cleaning and identification of the bleeding source had proved impossible using standard endoscopes. Gastric emptying using the big-channel endoscope was possible within five minutes in all successful cases. Optimal conditions for therapeutic procedures were therefore provided. The size of the instrumentation channel may open up new indications also for non-emergency endoscopic diagnosis and treatment.

[Delayed stenosis after endoscopic sphincterotomy (EST)?]. / Spätstenosierung nach endoskopischer Sphinkterotomie (EST)?

To answer the question of restenosis following endoscopic sphincterotomy (EST) different and sophisticated methods were performed. Using the Erlangen type papillotome we developed a practicable and standardised method for measurement of the size of the EST that is able to define a restenosis. Depending on the indication for EST we found different percentages of restenosis: common bile-duct stones 14%, papillary stenosis 23.1%, duodenal diverticula without bile duct stones as cholestatic entity 40%. On one hand reduction of EST size is not corresponding to clinical symptoms, on the other hand the symptoms of patients after EST with sufficient EST size have to explained in other ways such as gall bladder still existing. Due to these experiences in patients with symptoms following EST we propose a control ERC combined with mechanical measurement of the sphincterotomy size.