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Yin J, Wang D, He Y, Sha H, Zhang W, Huang W. The safety of not implementing endoscopic nasobiliary drainage after elective clearance of choledocholithiasis: a systematic review and meta-analysis. BMC Surg 2024; 24:239. [PMID: 39174997 PMCID: PMC11342491 DOI: 10.1186/s12893-024-02535-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis. METHODS Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures. RESULTS Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60). CONCLUSION It appears safe to no- ENBD after elective clearance of choledocholithiasis.
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Affiliation(s)
- Jie Yin
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Dongying Wang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yujing He
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hongcun Sha
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Wenhao Zhang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wei Huang
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China.
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Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122000. [PMID: 36556365 PMCID: PMC9781833 DOI: 10.3390/life12122000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Evidence supporting the feasibility of single-stage stone removal in patients with a moderate grade of acute cholangitis remains insufficient. The maximal size of a common bile-duct stone suitable for removal during a single-stage ERCP in a moderate grade of acute cholangitis is unknown. METHODS We prospectively enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis. For eligible patients, single-stage treatment involved stone removal at initial ERCP. RESULTS A total of 123 patients were included in the final analysis. The success rate of complete stone extraction was similar between patients with mild and moderate grades of acute cholangitis (89.2% vs. 95.9%; p = 0. 181). Complication rates were comparable between the two groups. In the moderate grade of the cholangitis group, among patients who underwent early single-stage ERCP, the length of hospitalization declined as short as the patients in the mild grade of cholangitis (10.6 ± 6.2 vs. 10.1 ± 5.1 days; p = 0.408). In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤10 days) (odds ratio (OR), 3.981; p = 0.001). A stone size less than 1.5 cm presented a high success rate (98.0%) for complete stone removal. CONCLUSIONS Single-stage retrograde endoscopic stone removal in mild and moderate grades of acute cholangitis may be safe and effective, which can obviate the requirement for a second session, thus reducing medical expenses. CLINICALTRIALS gov: NCT03754491.
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Ahmed W, Jeyaraj R, Reffitt D, Devlin J, Suddle A, Hunt J, Heneghan MA, Harrison P, Joshi D. Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease. Frontline Gastroenterol 2022; 13:416-422. [PMID: 36051950 PMCID: PMC9380771 DOI: 10.1136/flgastro-2021-102025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Nasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms. METHODS Consecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy. RESULTS Twenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2-67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1-45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases. CONCLUSION NBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.
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Affiliation(s)
- Wafaa Ahmed
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Rebecca Jeyaraj
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - David Reffitt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Devlin
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Hunt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Phillip Harrison
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
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Entezari P, Aguiar JA, Salem R, Riaz A. Role of Interventional Radiology in the Management of Acute Cholangitis. Semin Intervent Radiol 2021; 38:321-329. [PMID: 34393342 DOI: 10.1055/s-0041-1731370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.
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Affiliation(s)
- Pouya Entezari
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jonathan A Aguiar
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Riad Salem
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ahsun Riaz
- Division of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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Zhang X, Li G, Pan L, Chen Y, Shi R, Xu W, Zhou K, Cheng Y, Feng Y, Zhou A, Zhao K. The efficacy and safety of one-stage endoscopic treatment for ascending acute cholangitis caused by choledocholithiasis with severe comorbidities. Surg Endosc 2020; 34:3963-3970. [PMID: 31586253 DOI: 10.1007/s00464-019-07168-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/24/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emergency endoscopic retrograde cholangiopancreatography (ERCP) for ascending acute cholangitis in patients with severe comorbidities is challenging. Here, we evaluated the efficacy and safety of one-stage ERCP in such patients by performing a retrospective study. METHODS We included all patients with ascending acute cholangitis and undergoing ERCP between January 2017 and March 2019. In total, we recruited 212 patients: 74 and 138 with and without severe comorbidities, respectively. We collected and analyzed data related to basal characteristics, ERCP, and clinical outcomes. RESULTS Elderly age (76.20 ± 9.99 years vs. 66.52 ± 8.16 years, P = 0.000), higher levels of leukocyte count (15.86 ± 2.47 × 109/ml vs. 13.49 ± 1.65 × 109/ml, P = 0.000), and serum bilirubin (3.11 ± 1.29 mg/dl vs. 1.94 ± 0.90 mg/dl, P = 0.000) were present in patients with severe comorbidities. A significantly higher proportion of these patients were severe cases (32.4% vs. 6.5%, P = 0.000), American Society of Anesthesiologists (ASA) stage V status (37.8% vs. 10.1%, P = 0.000) and had undergone general anesthesia (56.8% vs. 18.8%, P = 0.000). Successful biliary cannulation and complete stone clearance in one session were achieved in 207 and 202 patients, respectively. Mean length of hospital stay was 8.02 ± 2.71 days. Forty-three patients required ICU stay with the mean length of 3.26 ± 3.51 days. In-hospital mortality occurred in seven patients; all these patients had severe comorbidities. ERCP details, including urgent and early ERCP, biliary cannulation, complete stone clearance in one session, stent insertion, and complications were not significantly different between the two groups. Patients with severe comorbidities had a longer in-hospital stay (9.39 ± 3.15 days vs. 7.29 ± 2.11 days, P = 0.000), a higher proportion of ICU admission (45.9% vs. 6.5%, P = 0.000), and a longer ICU stay length (4.88 ± 4.37 days vs. 1.44 ± 0.52 days, P = 0.000). Our data also revealed that early diagnosis is an important predictor associated with clinical outcomes. CONCLUSIONS One-stage ERCP is safe and effective for ascending acute cholangitis caused by choledocholithiasis. Early diagnosis is a significant predictor of clinical outcomes.
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Affiliation(s)
- Xiaoping Zhang
- Department of Gastroenterology, Jintan People Hospital Afflilated with Jiangsu University, 16 Nanmen Road, Jintan, 213200, China
| | - Guiqin Li
- Department of Gastroenterology, Lianshui People Hospital, 6 Hongri Road, Lianshui, 223400, China
| | - Liang Pan
- Department of Gastroenterology, Jintan People Hospital Afflilated with Jiangsu University, 16 Nanmen Road, Jintan, 213200, China
| | - Yue Chen
- Department of Gastroenterology, Lishui People Hospital, 86 Chongwen Road, Nanjing, 211200, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Wei Xu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Kun Zhou
- Department of Gastroenterology, Lianshui People Hospital, 6 Hongri Road, Lianshui, 223400, China
| | - Yajun Cheng
- Department of Gastroenterology, Lianshui People Hospital, 6 Hongri Road, Lianshui, 223400, China
| | - Yadong Feng
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China.
| | - Aijun Zhou
- Department of Gastroenterology, Lianshui People Hospital, 6 Hongri Road, Lianshui, 223400, China.
| | - Kai Zhao
- Department of Gastroenterology, Jintan People Hospital Afflilated with Jiangsu University, 16 Nanmen Road, Jintan, 213200, China.
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Hung K, Kuo C, Tsai C, Chiu Y, Lu L, Wu C, Sou F, Huang P, Tai W, Kuo C, Liang C, Chuah S. Single‐stage retrograde endoscopic common bile duct stone removal might be sufficient in moderate acute cholangitis with a stone size ≤12 mm: A retrospective cohort study with propensity score matching. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13173] [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: 12/07/2022]
Affiliation(s)
- Kuo‐Tung Hung
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chung‐Mou Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Cheng‐En Tsai
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Yi‐Chun Chiu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Lung‐Sheng Lu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Cheng‐Kun Wu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Fai‐Meng Sou
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Pao‐Yuan Huang
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Wei‐Chen Tai
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chung‐Huang Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chih‐Ming Liang
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
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Efficacy and Safety of Single-Session Endoscopic Stone Removal for Acute Cholangitis Associated with Choledocholithiasis. Can J Gastroenterol Hepatol 2018; 2018:3145107. [PMID: 30175087 PMCID: PMC6106953 DOI: 10.1155/2018/3145107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/20/2018] [Accepted: 08/02/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND/AIMS In early endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to choledocholithiasis, it is unclear that single-session stone removal can be safely performed. We examined the efficacy and safety of early single-session stone removal for mild-to-moderate acute cholangitis associated with choledocholithiasis. METHODS Among patients with mild-to-moderate acute cholangitis associated with choledocholithiasis who underwent early ERCP (n = 167), we retrospectively compared the removal group (patients who underwent single-session stone removal; n = 78) with the drainage group (patients who underwent biliary drainage alone; n = 89) and examined the effectiveness and safety of single-session stone removal by early ERCP. RESULTS The patients in the removal group had significantly fewer and smaller stones compared with those in the drainage group. The single-session complete stone removal rate was 85.9% in the removal group. The complication rate in early ERCP was 11.5% in the removal group and 10.1% in the drainage group, with no significant difference (P = 0.963). On comparing patients who underwent early endoscopic sphincterotomy (EST) with those who underwent elective EST after cholangitis had improved, the post-EST bleeding rates were 6.8% and 2.7%, respectively, with no significant difference (P = 0.600). The mean duration of hospitalization was 11.9 days for the removal group and 19.9 days for the drainage group, indicating a shorter stay for the removal group (P < 0.001). In multiple linear regression analysis, stone removal in early ERCP, number of stones, and C-reactive protein level were significant predictors of hospitalization period. CONCLUSIONS Single-session stone removal for mild-to-moderate acute cholangitis can be safely performed. It is useful from the perspective of shorter hospital stay.
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Mukai S, Itoi T, Baron TH, Takada T, Strasberg SM, Pitt HA, Ukai T, Shikata S, Teoh AYB, Kim MH, Kiriyama S, Mori Y, Miura F, Chen MF, Lau WY, Wada K, Supe AN, Giménez ME, Yoshida M, Mayumi T, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:537-549. [DOI: 10.1002/jhbp.496] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology; Tokyo Medical University Hospital; Tokyo Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology; Tokyo Medical University Hospital; Tokyo Japan
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology; University of North Carolina at Chapel Hill; NC USA
| | - Tadahiro Takada
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Steven M. Strasberg
- Section of HPB Surgery; Washington University in St. Louis; St. Louis MO USA
| | - Henry A. Pitt
- Lewis Katz School of Medicine at Temple University; Philadelphia PA USA
| | - Tomohiko Ukai
- Department of Family Medicine; Mie Prefectural Ichishi Hospital; Mie Japan
| | | | | | - Myung-Hwan Kim
- Department of Gastroenterology; University of Ulsan College of Medicine; Seoul Korea
| | - Seiki Kiriyama
- Department of Gastroenterology; Ogaki Municipal Hospital; Gifu Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Fumihiko Miura
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Miin-Fu Chen
- Division of General Surgery; Linkou Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - Wan Yee Lau
- Faculty of Medicine; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Keita Wada
- Department of Surgery; Teikyo University School of Medicine; Tokyo Japan
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology; Seth G S Medical College and K E M Hospital; Mumbai India
| | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery “Taquini”; University of Buenos Aires; Argentina DAICIM Foundation; Buenos Aires Argentina
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery; Chemotherapy Research Institute; International University of Health and Welfare; Chiba Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine; School of Medicine; University of Occupational and Environmental Health; Fukuoka Japan
| | - Koichi Hirata
- Department of Surgery; JR Sapporo Hospital; Hokkaido Japan
| | | | - Kazuo Inui
- Department of Gastroenterology; Second Teaching Hospital; Fujita Health University; Aichi Japan
| | - Masakazu Yamamoto
- Department of Surgery; Institute of Gastroenterology; Tokyo Women's Medical University; Tokyo Japan
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Abstract
OBJECTIVES Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis. METHODS Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death. RESULTS ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events. CONCLUSIONS ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.
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Ramchandani M, Pal P, Reddy DN. Endoscopic management of acute cholangitis as a result of common bile duct stones. Dig Endosc 2017; 29 Suppl 2:78-87. [PMID: 28425658 DOI: 10.1111/den.12848] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 02/08/2023]
Abstract
Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography (ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage (PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Partha Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Tsuchiya T, Sofuni A, Tsuji S, Mukai S, Matsunami Y, Nagakawa Y, Itoi T. Endoscopic management of acute cholangitis according to the TG13. Dig Endosc 2017; 29 Suppl 2:94-99. [PMID: 28425666 DOI: 10.1111/den.12799] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/28/2016] [Indexed: 02/08/2023]
Abstract
The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future.
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Affiliation(s)
- Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Isayama H, Yasuda I, Tan D. Current strategies for endoscopic management of acute cholangitis. Dig Endosc 2017; 29 Suppl 2:70-77. [PMID: 28425650 DOI: 10.1111/den.12805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 01/06/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIM At the pancreatobiliary session of Endoscopic Forum Japan (EFJ) 2016, current strategies for the endoscopic management of acute cholangitis were discussed. The topics consisted of two major parts, namely endoscopic management of acute cholangitis caused by common bile duct stones (CBDS) and biliary stent occlusion. METHODS Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. RESULTS Strategies for management of cholangitis due to CBDS were agreed upon, and the clinical guideline of acute cholangitis (Tokyo guidelines 2013) was accepted. The best timing for drainage in Grade 2 (moderate) cholangitis urgent or early (<24 h) was inconclusive, and more data is required on this issue. Another controversy was the feasibility of one step stone extraction in the patient with cholangitis vs stone removal after the cholangitis had resolved. There were various opinions with regards to the management of acute cholangitis due to stent occlusion, and the strategies differed according to the stricture location (distal or hilar) and stent type initially placed (Covered or uncovered metal stent). CONCLUSION Strategies for management of cholangitis caused by CBD stones are well established according to the TG13. More evidence is required before further recommendations can be made with regards to cholangitis due to stent occlusion. We aim to clarify this in the near future with questionnaires and consensus from experts.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Damien Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
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Sawas T, Arwani N, Al Halabi S, Vargo J. Sphincterotomy with endoscopic biliary drainage for severe acute cholangitis: a meta-analysis. Endosc Int Open 2017; 5:E103-E109. [PMID: 28229129 PMCID: PMC5314699 DOI: 10.1055/s-0042-120412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aims To investigate the role of endoscopic sphincterotomy (ES) with endoscopic biliary drainage (EBD) in acute severe obstructive cholangitis management by performing a meta-analysis of controlled trials. Method We searched PubMed and Embase for controlled studies that compared endoscopic drainage with ES versus Non-ES in acute obstructive cholangitis. Two reviewers selected the studies and extracted the data. Disagreement was addressed by a third reviewer. Heterogeneity of the studies was analyzed by Cochran's Q statistics. A Mantel-Haenszel risk ratio was calculated utilizing a random effects model. Results Four controlled studies met our inclusion criteria with 392 participants (201 ES, 191 Non-ES). The outcomes were drainage insertion success rate, drainage effectiveness, post drainage pancreatitis, bleeding, procedure duration, perforation, cholecystitis, and 30-day mortality. Drainage insertion success rate was identical in both groups (RR: 1.00, 95 %CI% 0.96 - 1.04). Effective drainage was not significantly different (RR: 1.11, 95 %CI 0.73 - 1.7). There was no significant difference in the incidence of pancreatitis post EBD between the ES and Non-ES groups at 3 % and 4 %, respectively (RR: 0.73, 95 %CI 0.24 - 2.27). However, there was a significant increase in post EBD bleeding with ES compared to Non-ES (RR: 8.58, 95 %CI 2.03 - 36.34). Thirty-day mortality was similar between ES and Non-ES groups at 0.7 % and 1 %, respectively (RR: 0.5, 95 %CI 0.05 - 5.28). Conclusion Our findings show that EBD without ES is an effective drainage technique and carries less risk for post procedure bleeding. Patients who are critically ill and have coagulopathy should be spared from undergoing ES in the acute phase.
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Affiliation(s)
- Tarek Sawas
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester,
Minnesota, USA,Corresponding author Tarek Sawas, MD Mayo Clinic216 2nd St SWRochesterMN 55902USA+1-507-255-7612
| | - Noura Arwani
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester,
Minnesota, USA
| | - Shadi Al Halabi
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio,
USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery
Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Balmadrid BL, Irani S. Approach to Acute Cholangitis. GI ENDOSCOPIC EMERGENCIES 2016:123-135. [DOI: 10.1007/978-1-4939-3085-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Eto K, Kawakami H, Haba S, Yamato H, Okuda T, Yane K, Hayashi T, Ehira N, Onodera M, Matsumoto R, Matsubara Y, Takagi T, Sakamoto N. Single-stage endoscopic treatment for mild to moderate acute cholangitis associated with choledocholithiasis: a multicenter, non-randomized, open-label and exploratory clinical trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:825-30. [PMID: 26510180 DOI: 10.1002/jhbp.296] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/20/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Two-stage treatment involving stone removal after drainage is recommended for mild to moderate acute cholangitis associated with choledocholithiasis. However, single-stage treatment has some advantages. We aimed to assess the efficacy and safety of single-stage endoscopic treatment for mild to moderate acute cholangitis associated with choledocholithiasis. METHODS A multicenter, non-randomized, open-label, exploratory clinical trial was performed in 12 institutions. A total of 50 patients with a naïve papilla and a body temperature ≥37 °C who were diagnosed with mild to moderate cholangitis associated with choledocholithiasis were enrolled between August 2012 and February 2014. RESULTS Of the 50 patients, 15 had mild cholangitis and 35 had moderate cholangitis. The median number of common bile duct stones was 2 (range, 1-8), and the median diameter of the common bile duct stones was 7.5 mm (range, 1-18). The cure rate of acute cholangitis within 4 days after single-stage treatment was 90% (45/50) based on a body temperature <37 °C for ≥24 h. The incidence of complications was 10% (5/50). CONCLUSION Single-stage endoscopic treatment may be effective and safe for mild to moderate acute cholangitis associated with choledocholithiasis (clinical trial registration number: UMIN000008494).
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Affiliation(s)
- Kazunori Eto
- Department of Gastroenterology, Tomakomai City Hospital, Tomakomai, Hokkaido, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Shin Haba
- Department of Gastroenterology, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Hiroaki Yamato
- Department of Gastroenterology, Municipal Hakodate Hospital, Hakodate, Hokkaido, Japan
| | - Toshinori Okuda
- Department of Gastroenterology, Oji General Hospital, Tomakomai, Hokkaido, Japan
| | - Kei Yane
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University Hospital, Sapporo, Hokkaido, Japan
| | - Nobuyuki Ehira
- Department of Gastroenterology, Japanese Red Cross Kitami Hospital, Kitami, Japan
| | - Manabu Onodera
- Department of Internal Medicine and Gastroenterology, Abashiri-Kosei General Hospital, Abashiri, Hokkaido, Japan
| | - Ryusuke Matsumoto
- Third Department of Internal Medicine, Obihiro Kosei General Hospital, Obihiro, Hokkaido, Japan
| | - Yu Matsubara
- Gastroenterology Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Tomofumi Takagi
- Department of Gastroenterology, Sapporo Hokushin Hospital, Sapporo, Hokkaido, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Xu XD, Dai JJ, Qian JQ, Wang WJ. Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis. World J Gastroenterol 2015; 21:2443-2449. [PMID: 25741153 PMCID: PMC4342922 DOI: 10.3748/wjg.v21.i8.2443] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/23/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the necessity of endoscopic nasobiliary drainage (ENBD) catheter placement after clearance of common bile duct (CBD) stones.
METHODS: Patients enrolled in this study were randomly divided into two groups, according to whether or not they received ENBD after the removal of CBD stones. Group 1 (ENBD group) was then subdivided into three groups: G1a patients received an endoscopic papillary balloon dilatation (EPBD), G1b patients received an endoscopic sphincterotomy (EST), and G1c patients received neither. Group 2 (non-ENBD group) patients were also subdivided into three groups (G2a, G2b, and G2c), similar to Group 1. The maximum CBD diameter, the time for C-reactive protein (CRP) to normalize, levels of serum amylase, total serum bilirubin (TB) and alanine aminotransferase (ALT), and postoperative hospitalization duration (PHD) were measured.
RESULTS: A total of 218 patients (139 males, 79 females), with an average age of 60.1 ± 10.8 years, were enrolled in this study. One hundred and thirteen patients who received ENBD were included in Group 1, and 105 patients who did not receive ENBD were included in Group 2. The baseline clinical characteristics were similar in both groups. There were no significant differences in post-endoscopic retrograde cholangiopancreatography (ERCP)-related complications when Groups 1 and 2 were compared. Seventy-seven patients underwent EPBD, and 41 received an ENBD tube (G1a) and 36 did not (G2a). Seventy-three patients underwent EST, and 34 patients received an ENBD tube (G1b) and 39 did not (G2b). The remaining 68 patients underwent neither EPBD nor EST; of these patients, 38 received an ENBD tube (G1c) and 30 did not (G2c). For each of the three pairs of subgroups (G1a vs G2a, G1b vs G2b, G1c vs G2c), there were no significant differences detected in the PHD or the time to normalization of CRP, TB and ALT. In the EPBD group, the incidence of post-ERCP pancreatitis, hyperamylasemia and overall patient complications was significantly higher for G2a (post-ERCP pancreatitis: 6/36 vs 0/41, P = 0.0217; hyperamylasemia: 11/36 vs 4/41, P = 0.0215; overall patient complications: 18/36 vs 7/41, P = 0.0029).
CONCLUSION: After successful CBD stone clearance, ENBD is only beneficial when an EPBD procedure has been performed.
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Ishigaki T, Sasaki T, Serikawa M, Minami T, Okazaki A, Yukutake M, Ishii Y, Kosaka K, Mouri T, Yoshimi S, Chayama K. Comparative study of 4 Fr versus 6 Fr nasobiliary drainage catheters: a randomized, controlled trial. J Gastroenterol Hepatol 2014; 29:653-9. [PMID: 24219852 DOI: 10.1111/jgh.12427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Despite the benefits of endoscopic nasobiliary drainage (NBD) in endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) and nose/throat discomfort can result. We aimed to determine whether the use of a smaller catheter alleviates these complications. METHOD A randomized, controlled trial at a tertiary care center compared 4 Fr and 6 Fr NBD catheters; 165 ERCP patients with naïve papillae were randomly assigned to a catheter-size group. RESULTS The prevalence of PEP was significantly lower in the 4 Fr group (3.7%; 3/82) than in the 6 Fr group (15.7%; 13/83; P = 0.019). No spontaneous catheter displacement occurred within 24 h. Discomfort visual analog scores were 2.6 and 4.3 in the 4 Fr and 6 Fr groups, respectively (P = 0.0048) on procedure day; on the following day, the scores were 2.3 and 3.6 (P = 0.028). Bile output was 16.3 mL/h and 21.4 mL/h in the 4 Fr and 6 Fr groups (P = 0.051). On obstructive jaundice subgroup analysis, bile drainage was 19.2 mL/h and 22.1 mL/h in the 4 Fr and 6 Fr groups (P = 0.40). The 4 Fr group required 5.6 days to reduce bilirubin levels versus 6.1 days in the 6 Fr group (P = 0.51). CONCLUSIONS In patients with naïve papillae, lower rates of PEP and less nose/throat discomfort are associated with the use of 4 Fr NBD catheters. In patients with obstructive jaundice, 4 Fr and 6 Fr catheters are comparable with regard to bile output and bilirubin level reduction.
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Affiliation(s)
- Takashi Ishigaki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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Zhang RL, Zhao H, Dai YM, Zhu F, Li L, Li BW, Luo SZ, Wan XJ. Endoscopic nasobiliary drainage with sphincterotomy in acute obstructive cholangitis: a prospective randomized controlled trial. J Dig Dis 2014; 15:78-84. [PMID: 24131862 DOI: 10.1111/1751-2980.12107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the efficacy and safety of endoscopic nasobiliary drainage (ENBD) with or without endoscopic sphincterotomy (EST) for temporary biliary decompression in patients with acute obstructive cholangitis. METHODS In total, 72 patients with acute obstructive cholangitis were prospectively randomized to undergo emergency ENBD with EST (EST group, n = 36) or without EST (non-EST group, n = 36). The clinical outcomes and complications between the two groups were compared. RESULTS Endoscopic nasobiliary decompression was successful in all 72 patients. Four patients underwent a second endoscopic retrograde cholangiopancreatography (ERCP) to replace the nasobiliary catheter due to blockage (one in the EST group and two in the non-EST group) or migration (one in the EST group). The mean serum γ-glutamyltransferase and total bilirubin levels after treatment were significantly higher in the non-EST group than in the EST group (P < 0.05). However, no significant differences were observed for other parameters evaluated. The total complication rate was similar between the two groups (EST 25.0% vs non-EST 19.4%). Although hemorrhage occurred more frequently in the EST group and acute pancreatitis in the non-EST group, these differences were not significant. CONCLUSIONS EST is helpful and safe for biliary drainage while ENBD without EST is the first choice for acute cholangitis. EST may increase the efficacy of ENBD in patients with papillary inflammatory stricture and thick bile.
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Affiliation(s)
- Ru Ling Zhang
- Department of Gastroenterology, Shanghai First People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Itoi T, Tsuyuguchi T, Takada T, Strasberg SM, Pitt HA, Kim MH, Belli G, Mayumi T, Yoshida M, Miura F, Büchler MW, Gouma DJ, Garden OJ, Jagannath P, Gomi H, Kimura Y, Higuchi R. TG13 indications and techniques for biliary drainage in acute cholangitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:71-80. [PMID: 23307008 DOI: 10.1007/s00534-012-0569-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Fu BQ, Xu YP, Tao LS, Yao J, Zhou CS. Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones. World J Gastroenterol 2013; 19:2425-2432. [PMID: 23613639 PMCID: PMC3631997 DOI: 10.3748/wjg.v19.i15.2425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 12/28/2012] [Accepted: 02/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones.
METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed.
RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P = 0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P = 0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P = 0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P = 0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P = 0.00).
CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.
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Abstract
Infection of the biliary tract, or cholangitis, is a potentially life-threatening condition. Bile duct stones are the most common cause of biliary obstruction predisposing to cholangitis. The key components in the pathogenesis of cholangitis are biliary obstruction and biliary infection. Several underlying mechanisms of bactibilia have been proposed. Characteristic clinical features of cholangitis include abdominal pain, fever, and jaundice. A combination of clinical features with laboratory tests and imaging studies are frequently used to diagnose cholangitis. Endoscopic retrograde cholangiopancreatography is the best diagnostic test. Less invasive imaging tests may be performed initially in clinically stable patients with uncertain diagnoses.
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Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
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Khashab MA, Tariq A, Tariq U, Kim K, Ponor L, Lennon AM, Canto MI, Gurakar A, Yu Q, Dunbar K, Hutfless S, Kalloo AN, Singh VK. Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clin Gastroenterol Hepatol 2012; 10:1157-61. [PMID: 22507875 DOI: 10.1016/j.cgh.2012.03.029] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 03/25/2012] [Accepted: 03/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute ascending cholangitis usually is treated with antibiotics, and biliary drainage is treated by endoscopic retrograde cholangiopancreatography (ERCP). We investigated the effects of the timing of ERCP on outcomes of patients with acute cholangitis factors that predict prolonged hospital stays, increased costs of hospitalization, and composite clinical outcomes (death, persistent organ failure, and admission to the intensive care unit). METHODS We performed a retrospective analysis of data from 90 patients (mean age, 60 y; 48% female) admitted to Johns Hopkins Hospital from January 1994 to June 2010 who were diagnosed with acute cholangitis and underwent ERCP. A delayed ERCP was defined as one performed more than 72 hours after admission. Electronic and paper medical records were reviewed, and relevant data were abstracted. RESULTS ERCP was performed successfully in 92% of the patients, at a mean time period of 38 hours after admission (14% of ERCPs were delayed). Factors that were associated independently with prolonged length of hospital stay (top 10%) included unsuccessful ERCP (odds ratio [OR], 52.5; P = .002) and delayed ERCP (OR, 19.8; P = .008). Factors associated with increased hospitalization cost (top 10%) included unsuccessful ERCP (OR, 33.8; P = .004) and delayed ERCP (OR, 11.3; P = .03). Factors associated with composite clinical outcome included age (OR, 1.1; P = .01), total level of bilirubin (OR, 1.36; P = .002), and delayed ERCP (OR, 7.8; P = .04). CONCLUSIONS Delayed and failed ERCP are associated with prolonged hospital stays and increased costs of hospitalization. Delayed ERCP is associated with composite clinical outcome (death, persistent organ failure, and/or intensive care unit stay). Older age and higher levels of bilirubin also are associated with patients' composite end point.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD 21205, USA.
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Abstract
OBJECTIVES The aim of this study was to determine trends in hospitalization rates and in-hospital mortality of cholangitis and also determine predictive factors of in-hospital mortality. METHODS The Nationwide Inpatient Sample database was utilized for inpatient data analysis from 1988 to 2006. Patients with primary cholangitis International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) discharge diagnosis were included. Age-adjusted procedure rates for endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement and sphincterotomy were also analyzed. Analysis of variance was used to evaluate trends, and linear Poisson multivariate regression model was used to control for variations in age, sex, time of diagnosis, and ethnicity. Logistic regression analysis was performed to determine predictive factors of in-hospital mortality. RESULTS The age-adjusted hospitalization rate of cholangitis decreased 24.8% from 2.34 per 100,000 in 1988 to 1.76 per 100,000 in 2006 (P < 0.01). The age-adjusted in-hospital mortality of cholangitis increased 9.2% from 165.0 to 181.6 per 100,000 from 1988 to 1998 (P < 0.01), and then declined 73% to 48.9 per 100,000 in 2006 (P < 0.01). The age-adjusted procedure rates for ERCP with biliary stenting increased from 0.55 to 15.23 per 100,000 from 1988 to 2006 (P < 0.01), as did the age-adjusted rates for ERCP with sphincterotomy from 1.06 to 35.64 per 100,000 (P < 0.01). CONCLUSIONS The hospitalization rate of cholangitis has been declining over the past 2 decades. The overall trend in mortality peaked in 1998 and has shown a subsequent decline that may in part be related to increased utilization of endoscopic biliary decompression.
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Abstract
Acute cholangitis is a potentially severe infection of the biliary tract, resulting from a biliary obstruction. The most frequent cause of cholangitis is common duct stones. Biliary tract obstruction and secondary bacterial colonization lead to infection. In most cases, the causative agents are intestinal microflora, mostly aerobic microorganisms (and, to a lesser extent, anaerobic bacteria). The Charcot triad constitutes the most frequent symptomatology. Diagnosis is confirmed by means of radiological techniques, such as ultrasonography, computed tomography scan, or magnetic resonance imaging of the liver, in which signs of obstruction of the biliary tract can be detected and its etiology can often be determined. In most patients the treatment of choice is early appropriate antimicrobial therapy and biliary drainage, generally using endoscopic techniques.
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Comparison between emergency and elective endoscopic sphincterotomy in patients with acute cholangitis due to choledocholithiasis: is emergency endoscopic sphincterotomy safe? J Gastroenterol 2009; 44:1080-8. [PMID: 19597758 DOI: 10.1007/s00535-009-0100-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 06/05/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE We retrospectively assessed post-EST complications and examined whether combination therapy comprising endoscopic biliary drainage (EBD) plus endoscopic sphincterotomy (EST) as the initial treatment is safe in patients with acute cholangitis due to choledocholithiasis. METHODS Among the 363 consecutive patients with acute cholangitis due to choledocholithiasis who were treated in our hospital between December 1992 and December 2006, the subjects comprised 127 patients with moderate acute cholangitis for whom EBD and EST were carried out. Factors influencing risk factors for post-EST pancreatitis, hemorrhage and hospitalization were determined by multivariate analysis. RESULTS Multivariate analysis revealed that only precut sphincterotomy (PST) was a significant risk factor for post-EST pancreatitis, and the incidence of pancreatitis in patients who underwent PST was significantly higher than that in those who did not (P = 0.041). Only age was a significant risk factor for post-EST hemorrhage, and younger patients were likely to experience hemorrhage after EST (P = 0.021). Total bilirubin and the timing of EST were significant factors associated with hospitalization. Hospitalization in patients who underwent EBD plus EST as the initial treatment (emergency EST) was significantly shorter than that in those who palliatively underwent EST after EBD (elective EST; 11.8 vs. 16.2 days, P = 0.001). CONCLUSIONS Combination therapy comprising EBD plus EST as the initial treatment for patients with moderate acute cholangitis due to choledocholithiasis was safe and did not prolong the period of hospitalization.
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Abstract
Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.
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Affiliation(s)
- John G Lee
- University of California Irvine Medical Center, 101 The City Drive, Building 53, Room 113, Orange, CA 92868, USA.
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Sharma BC, Agarwal N, Sharma P, Sarin SK. Endoscopic biliary drainage by 7 Fr or 10 Fr stent placement in patients with acute cholangitis. Dig Dis Sci 2009; 54:1355-9. [PMID: 18807184 DOI: 10.1007/s10620-008-0494-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 08/22/2008] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of 7 Fr and 10 Fr stent placement for biliary drainage in patients with acute cholangitis. PATIENTS AND METHODS We recruited 40 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7 Fr or a 10 Fr straight flap stent placement during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and clinical outcome. RESULTS Of 40 patients, 20 were randomized to the 7 Fr stent group and 20 to the 10 Fr stent group. All patients had biliary obstruction due to stones in the common bile duct. Indications for biliary drainage were: fever >100.4 degrees F (n = 27), hypotension (n = 6), peritonism (n = 10), impaired consciousness (n = 8), and failure to improve with conservative management (n = 13). Biliary drainage was achieved in all patients. Abdominal pain, fever, jaundice, hypotension, peritonism, and altered sensorium improved after a median period of 3 days in both groups. Leukocyte counts became normal after a median time of 4 days in the 7 Fr stent group and 6 days in the 10 Fr stent group. There were no ERCP-related complications. There were no instances of occlusion or migration of stent. The success rates of biliary drainage in cholangitis were not affected by the size of stent used. CONCLUSIONS Biliary drainage by 7 Fr stent or 10 Fr stent is equally safe and effective treatment for patients with severe cholangitis.
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Affiliation(s)
- B C Sharma
- Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
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Matsubayashi H, Fukutomi A, Kanemoto H, Maeda A, Matsunaga K, Uesaka K, Otake Y, Hasuike N, Yamaguchi Y, Ikehara H, Takizawa K, Yamazaki K, Ono H. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage. HPB (Oxford) 2009; 11:222-8. [PMID: 19590651 PMCID: PMC2697892 DOI: 10.1111/j.1477-2574.2008.00020.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 10/25/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD). METHODS A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively. RESULTS The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES. CONCLUSIONS Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.
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Affiliation(s)
| | - Akira Fukutomi
- Divisions of Gastrointestinal Oncology, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hideyuki Kanemoto
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Atsuyuki Maeda
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kazuya Matsunaga
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Yosuke Otake
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Noriaki Hasuike
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Yuichiro Yamaguchi
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hisatomo Ikehara
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kohei Takizawa
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kentaroh Yamazaki
- Divisions of Gastrointestinal Oncology, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hiroyuki Ono
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
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Dokas S, Kalampakas A, Delivorias P, Sion M, Tsitouridis I. Removal of a large stone growing around and encasing a plastic biliary stent: respect the ductal axis. Dig Liver Dis 2009; 41:319-21. [PMID: 18083076 DOI: 10.1016/j.dld.2007.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Revised: 10/21/2007] [Accepted: 10/25/2007] [Indexed: 12/11/2022]
Abstract
Plastic biliary stents are commonly used during Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The main indication for biliary stenting is benign or malignant obstruction. Plastic stents, among others, can be used as an escape route in patients with large common bile duct stones, or in cases of acute cholangitis with or without sphincterotomy to provide drainage until definitive treatment. Stent occlusion is the main disadvantage, limiting their patency to around 3 months, after which replacement is recommended. We present a case of a large, close to 2cm, stone developing around and encasing the proximal end of a plastic biliary stent. The stent/stone complex was successfully removed en bloc. The stent was placed in the common bile duct without sphincterotomy, and remained in situ for 2 years. The presented case highlights the importance of definitive treatment for common bile duct stones, the need to respect the ductal axis especially when dealing with large stones and the significance of biliary sphincterotomy during endoscopic interventions in the bile duct.
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Affiliation(s)
- S Dokas
- Department of Endoscopy, Papageorgiou Hospital, Thessaloniki, Greece.
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32
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Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am 2008; 92:925-60, x. [PMID: 18570948 DOI: 10.1016/j.mcna.2008.03.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.
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Affiliation(s)
- Siriboon Attasaranya
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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Maguchi H, Takahashi K, Katanuma A, Osanai M, Nakahara K, Matuzaki S, Urata T, Iwano H. Preoperative biliary drainage for hilar cholangiocarcinoma. ACTA ACUST UNITED AC 2007; 14:441-6. [PMID: 17909711 DOI: 10.1007/s00534-006-1192-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 10/16/2006] [Indexed: 12/28/2022]
Abstract
Hilar cholangiocarcinomas grow slowly, and metastases occur late in the natural history. Surgical cure and long-term survival have been demonstrated, when resection margins are clear. Preoperative biliary drainage has been proposed as a way to improve liver function before surgery, and to reduce post-surgical complications. Percutaneous transhepatic biliary drainage (PTBD) with multiple drains was previously the preferred method for the preoperative relief of obstructive jaundice. However, the introduction of percutaneous transhepatic portal vein embolization (PTPE) and wider resection has changed preoperative drainage strategies. Drainage is currently performed only for liver lobes that will remain after resection, and for areas of segmental cholangitis. Endoscopic biliary drainage (EBD) is less invasive than PTBD. Among EBD techniques, endoscopic nasobiliary drainage (ENBD) is preferable to endoscopic biliary stenting (EBS), because secondary cholangitis (due to the retrograde flow of duodenal fluid into the biliary tree) does not occur. ENBD needs to be converted to PTBD in patients with segmental cholangitis, those with a prolonged need for drainage, or when the extent of longitudinal tumor extension is not sufficiently well characterized.
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Affiliation(s)
- Hiroyuki Maguchi
- Center for Gastroenterology, Teine-Keijinkai Hospital, 1-jo 12-chome, Maeda, Sapporo, 006-8555, Japan
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34
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Abstract
Acute ascending cholangitis is a potential life-threatening emergency characterized by infection and obstruction of the biliary tree. This article reviews the pathogenesis and clinical approach to patients with ascending cholangitis and examines the literature on this topic.
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Affiliation(s)
- Timothy P Kinney
- Department of Medicine--Section of Gastroenterology--G5, University of Minnesota/Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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35
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Tsuyuguchi T, Takada T, Kawarada Y, Nimura Y, Wada K, Nagino M, Mayumi T, Yoshida M, Miura F, Tanaka A, Yamashita Y, Hirota M, Hirata K, Yasuda H, Kimura Y, Strasberg S, Pitt H, Büchler MW, Neuhaus H, Belghiti J, de Santibanes E, Fan ST, Liau KH, Sachakul V. Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. ACTA ACUST UNITED AC 2007; 14:35-45. [PMID: 17252295 PMCID: PMC2784512 DOI: 10.1007/s00534-006-1154-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 08/06/2006] [Indexed: 02/08/2023]
Abstract
Biliary decompression and drainage done in a timely manner is the cornerstone of acute cholangitis treatment. The mortality rate of acute cholangitis was extremely high when no interventional procedures, other than open drainage, were available. At present, endoscopic drainage is the procedure of first choice, in view of its safety and effectiveness. In patients with severe (grade III) disease, defined according to the severity assessment criteria in the Guidelines, biliary drainage should be done promptly with respiration management, while patients with moderate (grade II) disease also need to undergo drainage promptly with close monitoring of their responses to the primary care. For endoscopic drainage, endoscopic nasobiliary drainage (ENBD) or stent placement procedures are performed. Randomized controlled trials (RCTs) have reported no difference in the drainage effect of these two procedures, but case-series studies have indicated the frequent occurrence of hemorrhage associated with endoscopic sphincterotomy (EST), and complications such as pancreatitis. Although the usefulness of percutaneous transhepatic drainage is supported by the case-series studies, its lower success rate and higher complication rates makes it a second-option procedure.
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Affiliation(s)
- Toshio Tsuyuguchi
- Department of Medicine and Clinical Oncology, Graduate School of Medicine Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
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36
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Nagino M, Takada T, Kawarada Y, Nimura Y, Yamashita Y, Tsuyuguchi T, Wada K, Mayumi T, Yoshida M, Miura F, Strasberg SM, Pitt HA, Belghiti J, Fan ST, Liau KH, Belli G, Chen XP, Lai ECS, Philippi BP, Singh H, Supe A. Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. ACTA ACUST UNITED AC 2007; 14:68-77. [PMID: 17252299 PMCID: PMC2799047 DOI: 10.1007/s00534-006-1158-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 08/06/2006] [Indexed: 12/17/2022]
Abstract
Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment, and their condition has not improved. Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous transhepatic, and open methods. The clinical value of both endoscopic and percutaneous transhepatic drainage is well known. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization; therefore, this approach is advocated whenever it is applicable. In endoscopic drainage, either endoscopic nasobiliary drainage (ENBD) or tube stent placement can be used. There is no significant difference in the success rate, effectiveness, and morbidity between the two procedures. The decision to perform endoscopic sphincterotomy (EST) is made based on the patient's condition and the number and diameter of common bile duct stones. Open drainage, on the other hand, should be applied only in patients for whom endoscopic or percutaneous transhepatic drainage is contraindicated or has not been successfully performed. Cholecystectomy is recommended in patients with gallbladder stones, following the resolution of acute cholangitis with medical treatment, unless the patient has poor operative risk factors or declines surgery.
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Affiliation(s)
- Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Abstract
AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.
METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated.
RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupI, age < 60 years; group II, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in groupI. High fever (fever ≥ 38.0°C) was more common in groupI(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n = 34) and benign diseases in groupI(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0°C (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupIand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupI, 24 group II, stent: 64 groupI, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupI(2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupIcompared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4 ± 5.6, 7-30 d) than in groupIpatients (8.2 ± 2.4, 7-20 d).
CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.
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Affiliation(s)
- Naresh Agarwal
- Department of Gastroenterology, GB Pant Hospital, New-Delhi-110002, India
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Itoi T, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T. ROLE OF ENDOSCOPIC NASOBILIARY DRAINAGE INDICATION AND BASIC TECHNIQUE. Dig Endosc 2006. [DOI: 10.1111/j.1443-1661.2006.00636.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Abstract
Table 4 gives summary recommendations concerning the major decisions that are related to the diagnosis and management of suspected acute bacterial cholangitis. All of these decisions have to be made within the context of disease severity, degree of diagnostic uncertainty, and associated comorbidity. Although these recommendations are based on evidence, there are few randomized controlled trials. Antibiotics that cover gram negatives and anaerobes, along with fluid and electrolyte correction, frequently stabilize the patient. Imaging studies frequently confirm the diagnosis and identify the location and etiology of the obstruction. With or without a definitive diagnosis, ERCP or PTC can be done emergently to establish drainage to control sepsis. Although endoscopic and percutaneous drainage techniques have lower morbidity and mortality than does emergent surgical decompression, optimal management of this potentially life-threatening condition requires close cooperation between the gastroenterologist, radiologist, and surgeon.
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Affiliation(s)
- Waqar A Qureshi
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA..
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40
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Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin North Am 2003; 32:1145-68. [PMID: 14696301 DOI: 10.1016/s0889-8553(03)00090-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.
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Affiliation(s)
- Ian F Yusoff
- McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
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41
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Hui CK, Lai KC, Yuen MF, Ng M, Chan CK, Hu W, Wong WM, Lai CL, Wong BCY. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis? Gastrointest Endosc 2003; 58:500-4. [PMID: 14520280 DOI: 10.1067/s0016-5107(03)01871-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The treatment of patients with bile duct stones and acute suppurative cholangitis is emergent biliary decompression either by endoscopic sphincterotomy, nasobiliary drainage, or stent insertion. The aim of this retrospective study was to determine whether endoscopic sphincterotomy, in addition to an internal endoprosthesis, improves outcome for patients with acute suppurative cholangitis. METHODS A total of 74 patients with acute suppurative cholangitis and bile duct stones were included in the study; 37 had endoscopic sphincterotomy before insertion of plastic stent (Group 1), and 37 had a plastic stent inserted through an intact papilla (Group 2). RESULTS The success rates for stent insertion in Groups 1 and 2 were, respectively, 89.2% and 86.5% (p = 1.000). The complication rates in Group 1 and Group 2 were, respectively, 10.8% and 2.7% (p = 0.358). The median (interquartile range 25th-75th percentile) durations of hospital stay for patients in Group 1 and Group 2 were, respectively, 6.5 (4-11) days and 7 (5-12) days (p = 0.614). The median (interquartile range) lengths of time for resolution of jaundice in Group 1 and Group 2 were, respectively, 3 (2-6) days versus 4 (2-5) days (p = 0.981). CONCLUSIONS Endoscopic sphincterotomy, in addition to biliary stent insertion, is not required for successful biliary decompression in patients with severe acute cholangitis.
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Affiliation(s)
- Chee-Kin Hui
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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42
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Leung JW. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis? Gastrointest Endosc 2003; 58:570-2. [PMID: 14520292 DOI: 10.1067/s0016-5107(03)01881-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Koh JSB, Chow PKH, Chung AYF, Ooi LPJ, Wong WK, Fook-Chong S, Soo KC. Outcomes of emergency common bile duct exploration: impact of preoperative endoscopic decompression. ANZ J Surg 2003; 73:376-80. [PMID: 12801328 DOI: 10.1046/j.1445-2197.2003.t01-1-02651.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency common bile duct exploration (CBDE) is still required in patients acutely ill with complicated biliary tract stone disease when endoscopic decompression fails to reverse their condition. This study looks at the clinical profile of patients requiring emergency CBDE and examines the various factors influencing the postoperative outcome. METHODS Clinical records of patients with emergency CBDE in Singapore General Hospital from January 1991 to December 1998 were reviewed. Factors influencing postoperative outcomes, for example, pre-existing medical problems, hepatic parameters, the impact of endoscopic procedures (if any) and indications for surgery, were correlated with postoperative morbidity and 30-day mortality. RESULTS The records of 100 patients were available for review. Major indications for emergency CBDE were cholangitis (51%) and intraoperative findings of common bile duct obstruction during emergency laparotomy (23%). Six patients had emergency CBDE because of iatrogenic complication of attempted therapeutic endoscopic retrograde cholangiopancreaticography (ERCP) for biliary stones. Overall mortality was 14.0% and 8.0% had retained stones. Mortality was significantly influenced by age, prior biliary disease, preoperative endoscopic biliary decompression in acute cholangitis (33.3%vs 9.4%, P = 0.035) and endoscopic complications. CONCLUSIONS Among patients requiring emergency CBDE, uncomplicated preoperative endoscopic biliary decompression benefits patients with acute cholangitis.
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Affiliation(s)
- Joyce S B Koh
- Department of General Surgery, Singapore General Hospital, Singapore
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Skroubis G, Vagianos C, Polydorou A, Tzoracoleftherakis E, Androulakis J. Significance of bile leaks complicating conservative surgery for liver hydatidosis. World J Surg 2002; 26:704-8. [PMID: 12053223 DOI: 10.1007/s00268-002-6259-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatic hydatidosis presents a challenge in liver surgery, and there is still controversy regarding the appropriate surgical technique. A high incidence of postoperative bile leaks is reported as a significant disadvantage of conservative surgical procedures. The purpose of this study was to examine the incidence and clinical importance of bile leakage in patients being treated exclusively by a conservative surgical technique. From January 1985 to November 2000 a total of 187 patients were operated on at our department for hepatic hydatidosis. They were subjected to the standard conservative surgical technique (wide unroofing and cyst drainage). A total of 18 complications were related to bile leakage (10%), 3 of them bile abscesses (1 drained surgically and 2 percutaneously), 1 case of bile peritonitis due to an accessory bile duct in the gallbladder bed (treated surgically), and 14 fistulas (1 bronchobiliary and 13 biliocutaneous). Five of the fistulas, including the bronchobiliary one, were treated successfully by endoscopy; and the remaining nine healed after conservative treatment. Bile leakage, representing a significant complication following conservative operations for hepatic hydatidosis, can be effectively treated conservatively or endoscopically, not justifying more aggressive surgical approaches.
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Affiliation(s)
- George Skroubis
- Department of Surgery, University of Patras, Rion University Hospital, 26500 Patras, Greece
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45
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Lum DF, Leung JW. Bacterial Cholangitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:139-146. [PMID: 11469972 DOI: 10.1007/s11938-001-0026-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The treatment of acute bacterial cholangitis requires broad-spectrum antibiotics to cover against gram-negative aerobic enteric organisms (Escherichia coli, Klebsiella species, and Enterobacter species), gram-positive Enterococcus and anaerobic bacteria (Bacteroides fragilis and Clostridium perfringens). Approximately 20% of patients with acute cholangitis fail to respond to conservative treatment with antibiotic therapy and require urgent biliary decompression, which is the mainstay of therapy. This is best accomplished by endoscopic retrograde cholangiopancreatography (ERCP) and placement of a nasobiliary drainage tube or a large bore (10 F or larger) indwelling plastic stent. Alternative therapy includes percutaneous transhepatic biliary drainage or surgical biliary decompression, but these carry a significantly higher morbidity and mortality. Supportive care includes intravenous fluid hydration to prevent renal failure and close monitoring of vital signs for determination of potential septicemia.
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Affiliation(s)
- Donald F. Lum
- Division of Gastroenterology, University of California, Davis Health Care System, 4150 V Street, Suite 3500, Sacramento, CA 95817, USA.
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Abstract
Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.
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Affiliation(s)
- L H Hanau
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Sugiyama M, Atomi Y. Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older. Gastrointest Endosc 2000; 52:187-91. [PMID: 10922089 DOI: 10.1067/mge.2000.107285] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Little information is available on the outcomes of endoscopic sphincterotomy for choledocholithiasis in patients of advanced age (>/=90 years). METHODS Endoscopic sphincterotomy was performed for choledocholithiasis in 22 patients aged 90 years or more (group A) and 381 aged 70 to 89 years (group B). Clinical features and early outcomes of endoscopic sphincterotomy were compared between the two groups. In group A, long-term results for a mean follow-up period of 33 months were assessed. RESULTS Group A patients had a higher incidence of symptoms, acute cholangitis and concomitant diseases, as well as larger and more numerous gallstones than did group B patients. Endoscopic sphincterotomy was technically successful in 100% of group A patients and 98% of group B patients. The rate of early complications was low in both groups: 5% in group A and 7% in group B. No deaths related to endoscopic retrograde cholangiopancreatography occurred in group A patients. Complete stone clearance was achieved in 86% of group A patients and 95% of group B patients. Group A required an emergency procedure, general anesthesia, multiple sessions, mechanical lithotripsy, and permanent biliary stent placement more frequently than group B. Late complications occurred in 5% of group A patients. CONCLUSION Endoscopic sphincterotomy is safe and effective for the treatment of choledocholithiasis in patients 90 years of age or older. Biliary stent placement is a reasonable alternative treatment when stones prove to be difficult to extract.
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Affiliation(s)
- M Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, Shinkawa, Mitaka, Tokyo, Japan
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Affiliation(s)
- W R Brugge
- Gastrointestinal Unit, Massachusetts General Hospital, Boston 02114, USA.
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Pfau PR, Kochman ML. Endoscopic management of biliary tract disease. Curr Opin Gastroenterol 1999; 15:448-53. [PMID: 17023988 DOI: 10.1097/00001574-199909000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Endoscopic management of biliary tract disease continues to be influenced by new advances in technology and shaped by further examination of old controversies. This review covers and highlights recent world literature concerning biliary endoscopy and its effect on the management of biliary disorders. In particular, we examine the role and consequence of the endoscopic management of choledocholithiasis and the continuing controversy over endoscopic treatment of pancreatic disease. The increasing impact of endoscopic ultrasound in the biliary tree is explored, as well as the latest developments in biliary stent technology.
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Affiliation(s)
- P R Pfau
- Gastroenterology Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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