Endoscopic Retrograde Cholangiopancreatography

• Introduction
• Benign Biliary Disease
• Malignant Biliary Disease
• Tissue Sampling at ERCP
• Complications of ERCP
• Sphincter of Oddi Dysfunction (SOD)
• Chronic Pancreatitis
• Pancreatic Necrosis, Pseudocysts
• ERCP in Children
• References

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is still the subject of intensive clinical research. This year, new data were presented during the Digestive Disease Week (DDW) on biliary stenting, as well as ERCP-associated complications and methods of prevention. In addition, several abstracts discussed the use of combined ERCP and endoscopic ultrasonography (EUS) techniques for diagnostic and therapeutic management in biliary and pancreatic diseases. This review highlights the most relevant studies, which will be reported in detail. The remaining abstracts are cited as references, and in some cases summarized in the tables.

Benign Biliary Disease

Removal of common bile duct (CBD) stones can be achieved following either biliary sphincterotomy or endoscopic papillary balloon dilation (EPBD). A meta-analysis by Baron and Harewood summarized eight randomized controlled trials (including a total of 1106 patients), comparing the two techniques for CBD stone removal with regard to success rates and complication rates [1]. EPBD and biliary sphincterotomy resulted in similar outcomes with regard to overall successful stone removal (94.3 % vs. 96.5 %) and overall complications (10.5 % vs. 10.3 %). However, bleeding occurred less frequently with EPBD (0 % vs. 2 %; P = 0.001), whereas post-ERCP pancreatitis occurred more commonly in the EPBD group (7.4 % vs. 4.3 %; P = 0.05). Patients undergoing EPBD were also more likely to require mechanical lithotripsy for stone extraction (20.9 % vs. 14.8 %; P = 0.014). On the basis of these results, EPBD should be the strategy of choice over biliary sphincterotomy for endoscopic removal of CBD stones in patients with coagulopathy, although it cannot be routinely recommended. A second meta-analysis by Weinberg et al., summarizing 13 randomized controlled trials, confirmed these results [2]. Finally, a study compared EPBD vs. biliary sphincterotomy for CBD stones in liver cirrhosis patients with coagulopathy, showing a lower rate of bleeding and no significant difference with regard to post-ERCP pancreatitis [3].

An interesting retrospective study by Costamagna’s group assessed the role of extracorporeal shock-wave lithotripsy (ESWL) associated with ERCP in the endoscopic management of intrahepatic lithiasis in 129 patients [4]. Of 215 patients presenting with intrahepatic lithiasis, 76 underwent ERCP with stone extraction, and the remaining 129 had combined ERCP and ESWL. Combined therapy with ESWL appeared to be more successful for complete stone removal (53.9 % vs. 75.9 %; P < 0.05).

Endoscopic biliary stenting is the optimal nonsurgical therapy for biliary leaks resulting from trauma or occurring postoperatively. Escalante-Glorsky and colleagues investigated endoscopic therapy in extrahepatic (n = 206) and intrahepatic biliary leakage (n = 27) [5]. Treatment included biliary sphincterotomy and placement of a 7 - 10-Fr straight polyethylene stent to bypass the site of leakage, or within the leaking intrahepatic duct. Success rates relative to healing were 94 % for extrahepatic leakage and 85 % for intrahepatic biliary leakage, and there were no recurrences during a mean follow-up period of 23 months. While further prospective studies are warranted, endoscopic therapy can be regarded as the intervention of first choice in biliary leakage.

Surgical intervention for treatment of symptomatic gallbladder disease in patients with severe comorbidities is associated with high rates of morbidity and mortality. Conway and colleagues presented a retrospective series of 23 patients with end-stage liver disease who underwent endoscopic gallbladder stenting for biliary colic (74 %) or acute cholecystitis (26 %) [6]. Technical success was obtained in 20 patients. Only three patients developed recurrent symptoms after stent placement, and only one of these required surgery. This technique may be useful in highly selected patients with symptomatic gallbladder disease who are poor candidates for surgery.

Malignant Biliary Disease

Biliary stenting is the keystone of palliative therapy for malignant biliary obstruction. Self-expanding metallic stents (SEMS) may offer longer patency, with fewer short-term complications and repeat interventions, than plastic stents. A prospective, observational, multicenter cohort study by Perdue and the ERCOST study group compared outcomes between plastic stents and SEMS in hilar tumors [7]. In 62 patients, SEMS (n = 34) or plastic stents (n = 28) were placed in hilar tumors, depending on the endoscopist’s preference. Adverse outcomes (cholangitis or stent malfunction) during a follow-up period of 30 days occurred in 11.7 % of the SEMS patients versus 39.9 % of those with plastic stents (P = 0.017). Multivariate predictors of adverse outcomes were placement of a plastic stent, Bismuth IV tumors, and high bilirubin levels. An interesting point is that few of the patients had bilateral stenting (nine of 62), although drainage was assessed as complete in the majority of cases. SEMS thus appears to be superior to plastic stents relative to short-term adverse effects with hilar tumors; however, a randomized study, possibly with bilateral stenting, might be useful.

Two studies, a retrospective one in Japan [8] and a prospective one in France [9] reported the efficacy of covered SEMS in distal malignant biliary obstruction (Table [1]). A third randomized and prospective comparative study by Lee et al. showed that the patency duration was longer with covered SEMS in comparison with uncovered SEMS (216 days vs. 127 days; P < 0.05) [10]. In conclusion, covered SEMS appear to offer better palliation for distal malignant biliary obstruction, although there is a risk of cholecystitis and stent migration.

A new SEMS (Zilver; Wilson-Cook, Winston-Salem, North Carolina, USA), was evaluated for stenting in hilar [11] and distal [12]malignant biliary obstruction. These stents may have several design advantages, as they do not shorten after deployment [12], but prospective comparative studies with either plastic stents or other SEMS types are not yet available.

Tissue Sampling at ERCP

Tissue sampling for malignant biliary obstruction is enhanced by carrying out multiple types of biopsy and cytology during the same ERCP procedure. A prospective study by Lawrence and colleagues, including 40 consecutive patients [13], showed that by increasing the number of targeted biopsies to six, the sensitivity improves by 7.5 %, up to 55 %. Additional fine-needle aspiration (FNA) in the stricture further increases the sensitivity up to 72.5 %.

EUS-guided FNA has been found to be a superior method of tissue sampling in comparison with biliary stricture brushing in patients with biliary obstruction due to pancreatic cancer, and to a lesser degree in those with cholangiocarcinoma [14] [15] (Table [2]).

Complications of ERCP

Two meta-analyses were presented, evaluating the effect of somatostatin or octreotide [16] and corticosteroids [17] in post-ERCP prophylaxis (Table [3]). Globally, there was no significant difference in the incidence of acute pancreatitis for either agent. However, there does appear to be a protective benefit from the use of somatostatin in the subgroup of patients undergoing sphincterotomy.

Similarly, a large, double-blind, prospective, randomized, and controlled trial in Italy including 966 patients assessed the efficacy of somatostatin and gabexate in preventing post-ERCP complications [18]. After randomization, patients received an intravenous infusion of somatostatin, gabexate, or placebo, which was started 30 min before endoscopy and continued for 6 h afterward. No significant differences were observed in the occurrence of pancreatitis between the placebo (6.9 %), somatostatin (7.6 %), and gabexate (6.1 %) groups. However, no further details are given in the abstract concerning subgroup analyses.

Sphincter of Oddi Dysfunction (SOD)

Type II SOD is associated with recurrent pancreatitis, pancreatic or biliary-type pain, and with either a dilated duct or abnormal liver function tests. A retrospective study by Lawrence and colleagues questioned the role of manometry in this intermediate group [19]. A total of 262 patients with type II SOD underwent pancreatic and/or biliary sphincterotomy, without prior manometry. Overall, 59 % of the patients reported symptom improvement, and complications were observed in 4.3 %, which is similar to the general complication rate with therapeutic ERCPs.

Chronic Pancreatitis

An interesting study by Lee and colleagues evaluated endoscopic pancreatic duct balloon dilation (EPDBD) combined with pancreatic stenting in chronic pancreatitis patients with pancreatic duct strictures [20]. Sixty-two consecutive patients underwent additional EPDBD before pancreatic stenting, and were compared with a historical control group of 42 patients who received pancreatic stenting alone. The mean symptom-free period after stent removal was longer in the EPDBD group (21.8 months versus 16.7 months; P = 0.02), suggesting that additional balloon dilation is of value in chronic pancreatitis patients with pancreatic duct strictures.

ESWL plays a major role in the treatment of chronic pancreatitis. This is illustrated by a large multicenter study in Japan, including 555 chronic pancreatitis patients [21]. The complete stone clearance rate with ESWL alone or combined with ERCP was 72.6 %, and short-term symptom relief was observed in 91.1 % of the patients. During a follow-up period of 44.3 months (n = 504), 22 % of the patients had recurrent stones and only 4.1 % required surgery.

Another study emphasizing the role of endotherapy (ESWL and ERCP) in chronic pancreatitis patients is by Delhaye and colleagues [22]. It examines the short-term and long-term results of endotherapy for a group of 56 chronic pancreatitis patients during a long follow-up period of 14.4 years, as well as predictive factors for a successful outcome. Long-term clinical success was achieved in 66 % of the patients and 79 % of the patients avoided surgery. A good clinical outcome was associated with the cessation or absence of smoking.

Pancreatic Necrosis, Pseudocysts

A new endoscopic approach for treating infected liquefied necrosis in acute pancreatitis was presented by the Hamburg group. The method consists of (a) EUS-guided transmural and/or transpapillary drainage with stent and catheter insertion; (b) daily endoscopic necrosectomy with a Dormia basket and lavage by catheter irrigation; and, if necessary (c) sealing of a pancreatic duct fistula using cyanoacrylate [23]. Ten patients were treated, and the collections resolved. No serious complications were noted, and only two patients required further surgery.

The management of endoscopic pseudocysts is well known. Kahaleh and colleagues studied a group of 118 patients who underwent pseudocyst endoscopic drainage [24]. Resolution of the collections was noted in 86 % of the patients, and the only predictive factor associated with successful treatment was the administration of enteral feeding.

ERCP in Children

Published series concerning pediatric ERCP exist, but are still relatively small. In a case-control study, a group of 163 children (mean age 9.3 years) undergoing diagnostic or therapeutic ERCP for pancreaticobiliary problems were compared with a group of 116 adults, matched for all variables except age [25]. The procedural success rates were 97.5 % in the children and 98 % in the adults (not significant). The complication rate also did not differ significantly between the pediatric and adult populations.

References

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M. Arvanitakis, M. D.

Erasmus University Hospital

Route de Lennik 808 · 1070 Brussels · Belgium·

Fax: +32-2-5554697

Email: maarvani@ulb.ac.be

References

• 1 Baron T H, Harewood G C. Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a meta-analysis of randomized, controlled trials [abstract].  Gastrointest Endosc. 2004;  59 AB197
  PubMedSearch in Google Scholar
• 2 Weinberg B M, Shindy W, Lo S K. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones: a Cochrane collaboration meta-analysis [abstract].  Gastroenterology. 2004;  126 A171
  PubMedSearch in Google Scholar
• 3 Park D H, Kim M H, Lee S K. et al . Endoscopic sphincterotomy versus endoscopic papillary balloon dilatation for choledocholithiasis in liver cirrhosis with coagulopathy [abstract].  Gastrointest Endosc. 2004;  59 AB192
  PubMedSearch in Google Scholar
• 4 Spera G, Spada C, Mutignani M. et al . Extracorporeal shock wave lithotripsy (ESWL) and endoscopic management of intra-hepatic lithiasis [abstract].  Gastrointest Endosc. 2004;  59 AB196
  PubMedSearch in Google Scholar
• 5 Escalante-Glorsky S, Khandawalla H, Navarrete C. et al . Is there a different outcome between endoscopic treatment of intrahepatic (IHBL) versus extrahepatic biliary leak (EHBL)? [abstract].  Gastrointest Endosc. 2004;  59 AB181
  PubMedSearch in Google Scholar
• 6 Conway J D, Russo M W, Shrestha R. Endoscopic stenting of the gallbladder in patients with end stage liver disease and symptomatic gallbladder disease [abstract].  Gastrointest Endosc. 2004;  59 AB183
  PubMedSearch in Google Scholar
• 7 Perdue D G, Freeman M L, ERCOST S tudy . Self-expanding metallic stents (SEMS) versus plastic stents (PS) in hilar tumors: a prospective multicenter cohort study [abstract].  Gastrointest Endosc. 2004;  59 AB99
  PubMedSearch in Google Scholar
• 8 Isayama H, Nakai Y, Komatsu Y. et al . Covered metallic stents for the management of distal malignant biliary obstruction: risk factors for specific complications [abstract].  Gastrointest Endosc. 2004;  59 AB187
  PubMedSearch in Google Scholar
• 9 Coumaros D, Napoleon B, Balamane A. et al . Endoscopic drainage of malignant common bile duct (CBD) stenosis by a covered metal stent (CMS): results of a prospective study [abstract].  Gastrointest Endosc. 2004;  59 AB188
  PubMedSearch in Google Scholar
• 10 Lee S H, Cha S W, Cheon Y K. et al . A randomized controlled comparative study of covered versus uncovered self-expandable metal stent for malignant biliary obstruction [abstract].  Gastrointest Endosc. 2004;  59 AB188
  PubMedSearch in Google Scholar
• 11 Lawrence C, Desilets D J, Conklin D E. et al . Endoscopic 6 mm self-expanding metal stents (SEMS) for malignant obstruction of the bifurcation: a pilot study [abstract].  Gastrointest Endosc. 2004;  59 AB188
  PubMedSearch in Google Scholar
• 12 Mein S M, Cruz E, Bagatelos K C. et al . Comparison of the Zilver stent to three other self-expanding metal stents (SEMS) in the endoscopic palliation of malignant biliary obstruction [abstract].  Gastrointest Endosc. 2004;  59 AB191
  PubMedSearch in Google Scholar
• 13 Lawrence C, Howell D A, Lukens F J. et al . ERCP tissue sampling to maximize yield: randomized study of two forceps types during triple sampling [abstract].  Gastrointest Endosc. 2004;  59 AB98
  PubMedSearch in Google Scholar
• 14 Bernandino K, Gordon S R, Robertson D J. Diagnostic yield of standard brush cytology (BC) versus EUS-FNA for pancreatic cancer with associated malignant biliary stricture: is it time to bury the standard biliary brush [abstract]?.  Gastrointest Endosc. 2004;  59 AB232
  PubMedSearch in Google Scholar
• 15 Wasan S M, Kaw M. A comparison of sampling techniques of suspected malignant biliary strictures [abstract].  Gastrointest Endosc. 2004;  59 AB230
  PubMedSearch in Google Scholar
• 16 Lung E. The use of somatostatin or octreotide to prevent post-ERCP pancreatitis: a meta-analysis of randomized, controlled trials [abstract].  Gastrointest Endosc. 2004;  59 AB107
  PubMedSearch in Google Scholar
• 17 Sison C M, Jamias J D, Daez L O. The use of corticosteroids in the prevention of ERCP-induced pancreatitis: a meta-analysis [abstract].  Gastrointest Endosc. 2004;  59 AB208
  PubMedSearch in Google Scholar
• 18 Andriulli A, Solmi L, Loperfido S. et al . Somatostatin (SS) and gabexate (GM) are ineffective in preventing post-ERCP complications [abstract].  Gastrointest Endosc. 2004;  59 AB106
  PubMedSearch in Google Scholar
• 19 Lawrence C, Howell D A, Conklin D E. et al . ERCP sphincterotomy without initial manometry for type II sphincter of Oddi dysfunction patients: a safe and effective strategy [abstract].  Gastrointest Endosc. 2004;  59 AB99
  PubMedSearch in Google Scholar
• 20 Lee S S, Kim M H, Lee S K. et al . Does the addition of balloon dilatation to stent insertion decrease recurrence of pancreatic duct stricture in patients with chronic pancreatitis [abstract]?.  Gastrointest Endosc. 2004;  59 AB205
  PubMedSearch in Google Scholar
• 21 Inui K, Tazuma S, Yamaguchi T. et al . Treatment of pancreatic stones with extracorporeal shock wave lithotripsy: results of a multicenter study [abstract].  Gastroenterology. 2004;  126 A230
  PubMedSearch in Google Scholar
• 22 Delhaye M, Arvanitakis M, Verset G. et al . Long-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis [abstract].  Gastroenterology. 2004;  126 A232
  PubMedSearch in Google Scholar
• 23 Seewald S, Groth S, Brand B. et al . Novel endoscopic ”triple“ approach for treatment of postnecrotizing pancreatic abscesses [abstract].  Gastrointest Endosc. 2004;  59 AB106
  PubMedSearch in Google Scholar
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M. Arvanitakis, M. D.

Erasmus University Hospital

Route de Lennik 808 · 1070 Brussels · Belgium·

Fax: +32-2-5554697

Email: maarvani@ulb.ac.be