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Dong J, Feng Q, Teng G, Niu H, Bian D. Application of a New Hemostatic Clip to Prevent Delayed Bleeding After Endoscopic Sphincterotomy: A Propensity Score-matched Analysis. J Clin Gastroenterol 2024; 58:614-618. [PMID: 37646562 DOI: 10.1097/mcg.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND AIM Delayed bleeding after endoscopic sphincterotomy (ES) is a serious adverse event of endoscopic retrograde cholangiopancreatography. The aim of this study is to evaluate the effect of prevent delayed bleeding of hemostatic clip (Sureclip) after ES. METHODS Consecutive patients diagnosed with common bile duct stones with a high risk of delayed bleeding who received ES from January 1, 2013, to July 31, 2022, were analyzed retrospectively. A 1:1 propensity score-matching analysis and logistic regression analysis were used. The patients were allocated into the hemostatic clip and control groups. The rate of delayed bleeding, hyperamylasemia, pancreatitis, and hemostatic clip closing the bile duct or pancreatic duct by mistake were compared between the 2 groups. RESULTS Overall, 161 and 232 patients were allocated to the control and hemostatic clip groups, respectively, propensity score matching created 120 matched pairs. The rate of delayed bleeding was significantly lower in the hemostatic clip group than in the control group (1.67% vs. 7.5%, P =0.031). After adjusting for confounding factors, logistic regression showed hemostatic clip was associated with decreased odds of delayed bleeding (0.134, 95% CI: 0.025-0.719). No case of hemostatic clip closing the bile duct or pancreatic duct by mistake occurred in the hemostatic clip group. No significant differences were observed in postoperative hyperamylasemia and pancreatitis between the 2 groups. CONCLUSIONS This study indicated that the prophylactic application of a hemostatic clip is associated with a significantly reduced rate of delayed bleeding after ES in high-risk patients. This approach did not increase the risk of adverse event.
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Affiliation(s)
| | | | | | - Haixia Niu
- Endoscopy, Peking University First Hospital, Beijing, China
| | - Dapeng Bian
- Endoscopy, Peking University First Hospital, Beijing, China
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Chan H. Treatment for postendoscopic sphincterotomy bleeding with fully covered self‐expanding metal stent: A feasible and safe method. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hoi‐Hung Chan
- Division of Gastroenterology, Department of MedicineConde S. Januário Hospital Macau China
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Huang P, Tsai M, Chen T, Liu C, Tay Y. Management of postendoscopic sphincterotomy bleeding with fully covered self‐expanding metal stent. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Pi‐Teh Huang
- Division of Hepato‐Gastroenterology, Department of Internal MedicineTungs' Taichung Metro‐Harbor Hospital Taichung Taiwan
| | - Ming‐Hung Tsai
- Division of Hepato‐Gastroenterology, Department of Internal MedicineTungs' Taichung Metro‐Harbor Hospital Taichung Taiwan
| | - Tsung‐Ming Chen
- Division of Hepato‐Gastroenterology, Department of Internal MedicineTungs' Taichung Metro‐Harbor Hospital Taichung Taiwan
| | - Chung‐Cheng Liu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineTungs' Taichung Metro‐Harbor Hospital Taichung Taiwan
| | - Yeong‐Lin Tay
- Division of Hepato‐Gastroenterology, Department of Internal MedicineTungs' Taichung Metro‐Harbor Hospital Taichung Taiwan
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Bae SS, Lee DW, Han J, Kim HG. Risk factor of bleeding after endoscopic sphincterotomy in average risk patients. Surg Endosc 2019; 33:3334-3340. [PMID: 30604265 DOI: 10.1007/s00464-018-06623-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 12/04/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND For therapeutic endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (ES) is necessary but it can lead to complications such as bleeding. Thus, we investigated the risk factors of post-ES bleeding in average risk patients. METHODS We retrospectively reviewed the medical records of patients who had been treated for ERCP between April 2006 and March 2013. The length of the ES incision was defined as minimal (up to proximal hooding fold), medium (between minimal and full length), and full (up to superior margin of sphincter opening). Exclusion criteria were as follows: if performed precut sphincterotomy or balloon dilatation, patients having altered anatomy or anticoagulant medications. RESULTS A total of 3620 patients underwent ERCP and 1121 patients who underwent biliary ES were enrolled. Post-ES bleeding occurred in 108 of 1121 patients (9.6%) and mostly minor bleeding (94 patients, 87%). Length of ES was the only risk factor for post-ES bleeding in multivariate analysis. Complete hemostasis was achieved by endoscopic modalities and no serious complication developed after hemostasis. CONCLUSIONS In average risk patients, length of ES was independent risk factor for post-ES bleeding and endoscopic hemostasis was safe and effective.
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Affiliation(s)
- Sang Soo Bae
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 705-718, South Korea
| | - Dong Wook Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 705-718, South Korea.
| | - Jimin Han
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 705-718, South Korea
| | - Ho Gak Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 705-718, South Korea
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Köksal AŞ, Eminler AT, Parlak E. Biliary endoscopic sphincterotomy: Techniques and complications. World J Clin Cases 2018; 6:1073-1086. [PMID: 30613665 PMCID: PMC6306628 DOI: 10.12998/wjcc.v6.i16.1073] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/20/2018] [Accepted: 11/26/2018] [Indexed: 02/05/2023] Open
Abstract
Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.
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Affiliation(s)
- Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University, School of Medicine, Ankara 41000, Turkey
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Iwasaki E, Itoi T, Kanai T. Metal stent for refractory post-ES bleeding: Is this the ultimate treatment modality? Endosc Int Open 2016; 4:E1265-E1266. [PMID: 27995187 PMCID: PMC5161127 DOI: 10.1055/s-0042-117633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Eisuke Iwasaki
- Keio University School of Medicine - Internal
Medicine, Tokyo, Shinjukuku, Japan
| | - Takao Itoi
- Tokyo Medical University - Department of
Gastroenterology and Hepatology, Tokyo, Japan,Corresponding author Takao Itoi, MD,
PhD, FASGE, FACG Department of Gastroenterology and
HepatologyTokyo Medical
University6-7-1
NishishinjukuShinjuku-kuTokyo
160-0023Japan+81-(3)-3342-6111+81-(3)-5381-6654
| | - Takanori Kanai
- Keio University School of Medicine - Internal
Medicine, Tokyo, Shinjukuku, Japan
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Chon HK, Kim TH. Endoclip therapy of post-sphincterotomy bleeding using a transparent cap-fitted forward-viewing gastroscope. Surg Endosc 2016; 31:2783-2788. [DOI: 10.1007/s00464-016-5287-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/05/2016] [Indexed: 01/26/2023]
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Lee MH, Tsou YK, Lin CH, Lee CS, Liu NJ, Sung KF, Cheng HT. Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding. World J Gastroenterol 2016; 22:3196-3201. [PMID: 27003996 PMCID: PMC4789994 DOI: 10.3748/wjg.v22.i11.3196] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/30/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding. METHODS Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy. RESULTS A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding. CONCLUSION Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.
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Tonolini M, Pagani A, Bianco R. Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography. Insights Imaging 2015; 6:323-38. [PMID: 25716101 PMCID: PMC4444795 DOI: 10.1007/s13244-015-0393-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/19/2015] [Accepted: 01/30/2015] [Indexed: 02/07/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation. Teaching Points • Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders. • Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered. • Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections. • Diagnosis and management of complications rely on combined clinical, laboratory and imaging data. • Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy,
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography-related adverse events: general overview. Gastrointest Endosc Clin N Am 2015; 25:97-106. [PMID: 25442961 DOI: 10.1016/j.giec.2014.09.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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Parlak E, Dişibeyaz S, Köksal AŞ, Odemiş B, Saşmaz N, Şahin B. Factors affecting the success of endoscopic treatment of sphincterotomy bleeding. Clin Res Hepatol Gastroenterol 2013; 37:391-9. [PMID: 23164581 DOI: 10.1016/j.clinre.2012.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 09/24/2012] [Accepted: 10/02/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic methods are effective in the control of endoscopic sphincterotomy (ES) bleeding. Initial failure or recurrent bleeding may develop in some patients, which may require angiographic or surgical interventions. We aimed to determine the factors leading to failure of endoscopic treatment methods. METHODS Forty-six patients (1.37%) had endoscopic and/or clinically significant bleeding among a total of 3354 ESs (2998 primary, 356 re-ES) performed within 3 years. Forty-one patients (21 immediate, 20 late onset bleeding) underwent endoscopic treatment. Nineteen patients were treated initially by epinephrine injection and 22 with heat probe. The relation between demographic, laboratory parameters, presence of comorbidity, cholangitis, coagulopathy, and juxtapapillary diverticula, pre-cutting, type of ES, time and pattern of bleeding, treatment modality, the success and relapse of endoscopic treatment were evaluated. RESULTS The first method was successful in the treatment of bleeding in 18 patients with heat probe and epinephrine injection, each. Presence of cholangitis, coagulopathy and increased international normalized ratio (INR) levels were found to determine the success of first treatment method. Bleeding could be stopped in all of the patients either with initially preferred or combined methods. Five patients developed recurrent bleeding. Presence of cholangitis, coagulopathy, increased INR levels, low thrombocyte counts and performance of precutting were factors predicting recurrence. Both of the treatment methods were 100% effective in patients without coagulopathy and none of the patients developed recurrent bleeding. CONCLUSIONS Treatment of ES bleeding in patients with high risks such as coagulopathy require new effective methods. Patients with coagulopathy must be carefully followed for the development of recurrent bleeding.
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Affiliation(s)
- Erkan Parlak
- Türkiye Yüksek İhtisas Education and Training Hospital, Department of Gastroenterology, Ankara, Turkey.
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12
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Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterol Hepatol (N Y) 2013; 9:496-504. [PMID: 24719597 PMCID: PMC3980992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure used to treat problems associated with biliary and pancreatic diseases. The benefits of ERCP over surgical treatment are well documented; however, complications including infection, pancreatitis, hemorrhage, and perforation can occur even in expert hands. Several factors, such as patient selection, skill of the operator, and the complexity of the procedure, can add to the intrinsic risks of ERCP This review outlines the current knowledge regarding ERCP complications and solutions for improved outcomes.
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Affiliation(s)
- Nicholas M Szary
- Dr. Szary is an Advanced Endoscopy Fellow and Dr. Al-Kawas is a Professor of Medicine and Chief of Endoscopy in the Division of Gastroenterology at Georgetown University Hospital in Washington, DC
| | - Firas H Al-Kawas
- Dr. Szary is an Advanced Endoscopy Fellow and Dr. Al-Kawas is a Professor of Medicine and Chief of Endoscopy in the Division of Gastroenterology at Georgetown University Hospital in Washington, DC
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13
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Balmadrid B, Kozarek R. Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23:385-403. [PMID: 23540966 DOI: 10.1016/j.giec.2012.12.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure with the potential for a variety of adverse events, including acute pancreatitis, perforation, bleeding, and cardiopulmonary complications, which are well-established risk factors. It has become standard that patients undergoing ERCP are carefully selected based on appropriate indications. Once an ERCP is undertaken, preprocedure and intraprocedure risks should be assessed and appropriate risk-reducing modalities, such as prophylactic pancreatic stent placement and rectal indomethacin, should be used if patient or procedural factors suggest an increased risk of post-ERCP pancreatitis.
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Affiliation(s)
- Bryan Balmadrid
- Virginia Mason Medical Center Digestive Disease Institute, Seattle, WA 98101, USA
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Inatomi O, Bamba S, Shioya M, Mochizuki Y, Ban H, Tsujikawa T, Saito Y, Andoh A, Fujiyama Y. Threaded biliary inside stents are a safe and effective therapeutic option in cases of malignant hilar obstruction. BMC Gastroenterol 2013; 13:31. [PMID: 23410217 PMCID: PMC3598933 DOI: 10.1186/1471-230x-13-31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 02/12/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although endoscopic biliary stents have been accepted as part of palliative therapy for cases of malignant hilar obstruction, the optimal endoscopic management regime remains controversial. In this study, we evaluated the safety and efficacy of placing a threaded stent above the sphincter of Oddi (threaded inside plastic stents, threaded PS) and compared the results with those of other stent types. METHODS Patients with malignant hilar obstruction, including those requiring biliary drainage for stent occlusion, were selected. Patients received either one of the following endoscopic indwelling stents: threaded PS, conventional plastic stents (conventional PS), or metallic stents (MS). Duration of stent patency and the incident of complication were compared in these patients. RESULTS Forty-two patients underwent placement of endoscopic indwelling stents (threaded PS = 12, conventional PS = 17, MS = 13). The median duration of threaded PS patency was significantly longer than that of conventional PS patency (142 vs. 32 days; P = 0.04, logrank test). The median duration of threaded PS and MS patency was not significantly different (142 vs. 150 days, P = 0.83). Stent migration did not occur in any group. Among patients who underwent threaded PS placement as a salvage therapy after MS obstruction due to tumor ingrowth, the median duration of MS patency was significantly shorter than that of threaded PS patency (123 vs. 240 days). CONCLUSIONS Threaded PS are safe and effective in cases of malignant hilar obstruction; moreover, it is a suitable therapeutic option not only for initial drainage but also for salvage therapy.
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Affiliation(s)
- Osamu Inatomi
- Division of Gastroenterology, Shiga University of Medical Science, Seta-Tsukinowa cho, Otsu, Shiga, Japan.
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Samie AA, Theilmann L. Fully Covered Self-Expandable Metal Stents for Treatment of Post-Sphincterotomy Bleeding. Gastroenterology Res 2012; 5:167-170. [PMID: 27785199 PMCID: PMC5051086 DOI: 10.4021/gr435w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2012] [Indexed: 12/28/2022] Open
Abstract
Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP); however, serious complications are not uncommon. Post-sphincterotomy bleeding is one of the most frequent complications following ES and may occur in up to 10% of the patients. The spectrum of presentation may range from self-limited to severe live threatening hemorrhage. Different endoscopic treatment options are available. Angiographic embolisation and surgery are preserved for refractory cases not controlled by endoscopic means. Recently, completely covered self-expandable metal stents (CSEMS) have been applied to achieve hemostasis in severe post-sphincterotomy bleeding not controlled by other measures. We present our experience with this method to control delayed bleeding after ES in two patients requiring continuous therapeutic anticoagulation due to high cardiovascular embolic risk.
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Fully covered self-expandable metal stents for treatment of both benign and malignant biliary disorders. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2012; 2012:498617. [PMID: 22761543 PMCID: PMC3384904 DOI: 10.1155/2012/498617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 04/22/2012] [Accepted: 04/22/2012] [Indexed: 02/07/2023]
Abstract
Transpapillary stents are increasingly being used for biliary strictures, whether benign or malignant. However, there are different stent types and available data is controversial. Recently, completely covered self-expandable metal stents (CSEMSs) have been proposed as an alternative therapeutic option in different biliary indications, including strictures of the distal bile duct, anastomotic stenosis after orthotopic liver transplantation, bile duct leaks, periampullary perforation following endoscopic sphincterotomy (ES), and postsphincterotomy bleeding. Despite the higher costs of these devices, fully covered self-expanding metal stents seem to be a suitable therapeutic option to relief biliary obstruction due to bile duct stenosis, regardless of the underlying cause.
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Cheng CL, Tsou YK, Lin CH, Tang JH, Hung CF, Sung KF, Lee CS, Liu NJ. Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography. World J Gastroenterol 2012; 18:2396-2401. [PMID: 22654432 PMCID: PMC3353375 DOI: 10.3748/wjg.v18.i19.2396] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 03/02/2012] [Accepted: 03/20/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography. METHODS A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively. RESULTS A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC. CONCLUSION Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.
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Beyazit Y, Kekilli M, Haznedaroglu IC, Kayacetin E, Basaranoglu M. Ankaferd hemostat in the management of gastrointestinal hemorrhages. World J Gastroenterol 2011; 17:3962-70. [PMID: 22046083 PMCID: PMC3199553 DOI: 10.3748/wjg.v17.i35.3962] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/01/2011] [Accepted: 03/08/2011] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) bleeding refers to any hemorrhage ascribed to the pathologies of the gastrointestinal tract, extending from the mouth to the anal canal. Despite the recent improvements in the endoscopic, hemostatic and adjuvant pharmacologic techniques, the reported mortality is still around 5%-10% for peptic ulcer bleeding and about 15%-20% for variceal hemorrhages. Although endoscopic management reduces the rates of re-bleeding, surgery, and mortality in active bleeding; early recurrence ratios still occur in around 20% of the cases even with effective initial hemostatic measures. In this quest for an alternative pro-hemostatic agent for the management of GI bleedings, Ankaferd blood stopper (ABS) offers a successful candidate, specifically for “difficult-to-manage” situations as evidenced by data presented in several studies. ABS is a standardized mixture of the plants Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica. It is effective in both bleeding individuals with normal hemostatic parameters and in patients with deficient primary and/or secondary hemostasis. ABS also modulates the cellular apoptotic responses to hemorrhagic stress, as well as hemostatic hemodynamic activity. Through its effects on the endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics, and wound healing, ABS is now becoming an effective alternative hemostatic medicine for gastrointestinal bleedings that are resistant to conventional anti-hemorrhagic measurements. The aim of this review is to outline current literature experience suggesting the place of ABS in the management of GI bleeding, and potential future controlled trials in this complicated field.
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Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc 2010; 72:1274-8. [PMID: 20951987 DOI: 10.1016/j.gie.2010.08.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 08/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy (ES) is a basic technique for performing therapeutic interventions during ERCP. Bleeding after ES is a recognized complication and can be difficult to treat. OBJECTIVE To evaluate the role of temporary placement of fully covered self-expandable metal stents (SEMSs) for the treatment of difficult-to-control post-ES hemorrhage. DESIGN Retrospective case series. SETTING Interventional endoscopy unit at a tertiary care referral hospital. PATIENTS Five patients treated with temporary SEMSs for difficult-to-control post-ES hemorrhage. INTERVENTIONS ERCP with placement of fully covered, biliary SEMSs and subsequent stent removal within 8 weeks. MAIN OUTCOME MEASUREMENTS Technical success of SEMS placement, clinical success with hemostasis, complications related to SEMS placement and removal. RESULTS Five patients were treated with temporary fully covered SEMSs for post-ES hemorrhage over an 8-month period. Hemostasis was achieved in all patients. Within 8 weeks of the procedure, the SEMSs were easily removed in 3 patients; the SEMSs had spontaneously migrated without incident in the other 2. No other complications were seen. LIMITATIONS Retrospective series with a small number of patients. CONCLUSIONS Temporary placement of fully covered SEMSs across the biliary orifice seems to be an effective treatment for post-ES hemorrhage. However, stent migration is a concern and may limit this therapy in certain settings.
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Affiliation(s)
- Janak N Shah
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA
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