Outcome of Obstructive Jaundice Patients after Endoscopic Retrograde Cholangiopancreatography

Introduction: Obstructive jaundice is frequently encountered worldwide including Bangladesh. Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) is one of the procedures to manage obstructive jaundice. Objectives: To ascertain the outcome of obstructive jaundice patients who underwent ERCP. Materials and Methods: It was a hospital based cross sectional observational study, carried out in Gastroenterology Department of Combined Military Hospital (CMH) Dhaka from May 2017 to May 2019. Total 200 patients were included in the study. Verbal consents were taken from patients. Data were collected with a checklist and analyzed by using SPSS 20. Results: Total 200 patients’ mean age±SD was 56.5±14.5 years with range 21 to 92 years and majority were 41 to 60 years 80(40%) followed by 61 to 80 years 78(39%). Etiology of obstructive jaundice were, benign 137(68.5%) and malignant 63(31.5%). Among the benign: 69(34.5%) were choledocholithiasis, 45(22.5%) biliary stricture, 20(10.0%) papillary stenosis and 3(1.5%) biliary warms. Among the malignant: 24(12.0%) were distal cholangiocarcinoma, 21(10.5%) periampullary tumors, 10(5.0%) Klatskin tumor, 4(2.0%) carcinoma head of pancreas, and 4(2.0%) other malignancy. Mean serum bilirubin level 17.6 mg/dl with minimum 0.6mg/dl, maximum 41.3mg/dl; mean alkaline phosphatase (ALP) level 351.4U/L with minimum 111U/L and maximum 1262U/L; mean alanine aminotransferase (ALT) level 118.8 U/L with minimum 28 U/L, maximum 521 U/L; ERCP were successfully done in 188(94.0%) patients with single attempt 171 (85.5%), repeated sessions 17(8.5%) and 12(6.0%) patients unsuccessful ERCP; complications occurred in 17(8.5%)patients, of whom post-ERCP pancreatitis 9(4.5%) and post procedure cholangitis 4(2.0%)patients. Conclusion: Benign etiologies of obstructive jaundice were more common than malignant one. Both benign and malignant etiology of obstructive jaundice can be successfully managed with ERCP with few complications. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 27-30

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.

A Rare Case of Eosinophilic Gastroenteritis and Ampullitis Leading to Benign Papillary Stenosis

Eosinophilic gastroenteritis is characterized by eosinophilic infiltration of the gastrointestinal wall. There have been limited studies of eosinophilic infiltration involving the ampulla. We present a 70-year-old woman with a history of asthma, eosinophilic esophagitis, and eosinophilic sinusitis, who underwent work up for postprandial abdominal pain and abnormal liver function tests. The patient had various imaging studies done, including computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP). Dilated extrahepatic bile duct with distal tapering towards the ampulla was noted on MRCP and afterwards on endoscopic ultrasound (EUS). Endoscopic retrograde cholangiopancreatography (ERCP) revealed an inflamed major ampulla with benign papillary stenosis. The patient was treated with sphincterotomy, sphincteroplasty/dilation of distal common bile duct, and placement of an 11.5 Fr × 7 cm plastic stent into the bile duct. Additionally, she was started on prednisone, which was gradually tapered down. The patient demonstrated significant improvement with systemic steroid therapy. Liver function tests (LFTs) completely normalized after ERCP. Ampullitis leading to papillary stenosis secondary to eosinophilic infiltration of the major papilla is a rare manifestation of eosinophilic gastrointestinal disorders (EGIDs). Early diagnosis would lead to appropriate medical and endoscopic management.

A Comparison of Clinical Outcomes between Endoscopic Resection and Surgical Resection in Ampullary Tumors

Background and objectives: This study aimed to elucidate the clinical outcomes of endoscopic resection (ER) through comparison with surgical resection (SR) through a meta-analysis. Materials and Methods: This meta-analysis was performed using 32 studies. The complete resection and recurrence rates of treatment for ampullary tumors were investigated and compared between ER and SR. In addition, complications, including pancreatitis, cholangitis, cholecystitis, perforation, and papillary stenosis, and mortality of ER and SR, respectively, were estimated. Results: The rates of complete resection were 0.812 (95% confidence interval, CI, 0.758–0.856) and 0.929 (95% CI 0.739–0.984) in ER and SR, respectively. Recurrence rates were 0.145 (95% CI 0.107–0.193) and 0.126 (95% CI 0.057–0.257) in ER and SR, respectively. There were no significant differences in complete resection and recurrence rates between ER and SR in the meta-regression tests (p = 0.164 and p = 0.844, respectively). The estimated rates of pancreatitis, cholangitis/cholecystitis, perforation, and papillary stenosis were 12.8%, 4.4%, 5.2%, and 4.3% in ER and 9.9%, 5.6%, 2.3%, and 5.6% in SR, respectively. There was no significant difference in complications between ER and SR. The mortality rate of SR was slightly higher than that of ER (0.041, 95% CI 0.015–0.107 vs. 0.031, 95% CI 0.005–0.162). Our results show that ER had no significant differences in terms of complete resection and recurrence rates compared to SR, regardless of tumor behaviors. Conclusions: By comparing the complication and mortality rates between ER and SR, the safety of ER was proven.

The efficacy of prophylactic pancreatic stents against complications of post-endoscopic papillectomy or endoscopic ampullectomy: a systematic review and meta-analysis

Background: Endoscopic resection has been increasingly adopted for neoplasms in the major duodenal papilla. Previous studies have reached varying conclusions on whether prophylactic pancreatic stent (PS) placement is an effective measure against post-procedure complications. We aimed to investigate whether PS could reduce the incidence of post-procedure complications. Methods: The PubMed, Cochrane Library, and EMBASE databases were systematically searched from the inception dates to 25 December 2018 to identify all randomized controlled trials (RCTs) and retrospective cohort studies (RCSs) comparing prophylactic PS and no PS against post-procedure complications. The main outcomes measurements were post-procedure pancreatitis, bleeding, perforation and late papillary stenosis. Results: 23 RCSs (1001 subjects) and 2 RCTs met the inclusion criteria. Meta-analysis of the RCSs showed that prophylactic PS decreased the odds of post-procedure pancreatitis (OR, 0.71; 95% CI, 0.36–1.40; p = 0.325) as well as late papillary stenosis (OR, 0.35; 95% CI, 0.07–1.75; p = 0.200; I2 =0%) and increased the odds of bleeding (OR, 1.32; 95% CI, 0.50–3.46; p = 0.572; I2 = 0%) and perforation (OR, 2.25; 95% CI, 0.33–15.50; p = 0.412; I2 = 0%) but not significantly. Sensitivity analysis illustrated prophylactic PS significantly decreased the risk of post-procedure pancreatitis (OR, 0.44; 95% CI, 0.24–0.80; p = 0.007). Conclusions: PS placement was prophylactic against post-procedure complications although not significantly. Sensitivity analysis suggests the significant effect of prophylactic PS against post-procedure pancreatitis. More RCTs are required to validate the statistical significance of our results and potentially relevant characteristics improving the prophylactic efficacy of stents.