Biliary ERCP

Although therapeutic biliary endoscopic retrograde cholangiopancreatography (ERCP) was introduced over 30 years ago, its application has continued to evolve. From a technologic standpoint, not only has video endoscopy supplanted its fiberoptic predecessor, but accessories have been expanded, are now primarily disposable, and can be utilized using either a long-wire or short-wire technique. Plastic prostheses, vulnerable to occlusion by biofilm, have been supplanted by self-expandable metal stents (SEMS) in many patients with unresectable malignant biliary strictures, and uncovered SEMS have variably been replaced with covered stents because of tumor ingrowth or elicitation of granulation tissue. From a technical standpoint, we have learned to change our practice patterns in response to results in previously published clinical series or controlled trials. Many of us now place small diameter pancreatic prostheses in patients at high risk of procedural pancreatitis. We recognize that multiple large diameter prostheses are more likely to result in long-term resolution of benign biliary strictures than placement of a single stent. And we know that both endoscopic sphincterotomy and stenting are effective treatments for most patients with a cystic duct leak following cholecystectomy.

There are still numerous debates that orbit the endoscopic component of our practice. Should we routinely remove the gallbladder in patients with an intact gallbladder who have their bile duct stones treated endoscopically? Has anything improved tissue yield in the delineation of benign from malignant biliary strictures? Are covered Wallstents really better than uncovered ones in malignant disease, and do the former have a role to play in benign disorders? Are there additional endotherapies that hold promise in pancreaticobiliary malignancies? Finally, we recognize that ERCP entails risk to the patient, but does it also entail risk to the endoscopist? The present review summarizes pertinent individual or paired papers published in the past year that address these issues.

References

• 1 Drake B B, Arguedas M R, Kilgore M L. et al . Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: wait and see or surgery?.  Am J Gastroenterol. 2006;  101 746-752
• 2 Lau J Y, Leow C K, Fung T M. et al . Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.  Gastroenterology. 2006;  130 96-103
• 3 Boerma D, Rauws E A, Keulemans Y C. et al . Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial.  Lancet. 2002;  360 761-765
• 4 Dumonceau J M. ERCP and biliary topics.  Endoscopy. 2006;  38 11-15
• 5 Fogel E L, deBellis M, McHenry L. et al . Effectiveness of a new long cytology brush in the evaluation of malignant biliary obstruction: a prospective study.  Gastrointest Endosc. 2006;  63 71-77
• 6 Lee J G. Brush cytology and the diagnosis of pancreaticobiliary malignancy during ERCP.  Gastrointest Endosc. 2006;  63 78-80
• 7 Shah R J, Langer D A, Antillon M R, Chen Y K. Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology.  Clin Gastroenterol Hepatol. 2006;  4 219-225
• 8 Tsuyuguchi T, Fukuda Y, Saisho H. Peroral cholangioscopy for the diagnosis and treatment of biliary diseases.  J Hepatobiliary Pancreat Surg. 2006;  13 94-99
• 9 Tischendorf J J, Kruger M, Trautwein C. et al . Cholangioscopic characterization of dominant bile duct stenoses in patients with primary sclerosing cholangitis.  Endoscopy. 2006;  38 665-669
• 10 Nakai Y, Isayama H, Komatsu Y. et al . Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction.  Gastrointest Endosc. 2005;  62 742-748
• 11 Isayama H, Komatsu Y, Tsujino T. et al . A prospective randomised study of “covered” versus “uncovered” diamond stents for the management of distal malignant biliary obstruction.  Gut. 2004;  53 729-734
• 12 Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial.  Gastrointest Endosc. 2006;  63 986-995
• 13 Yoon W J, Lee J K, Lee K H. et al . A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction.  Gastrointest Endosc. 2006;  63 996-1000
• 14 Raju G S, Sud R, Elfert A A. et al . Biliary drainage by using stents without a central lumen: a pilot study.  Gastrointest Endosc. 2006;  63 317-320
• 15 Kuzela L, Oltman M, Sutka J. et al . Prospective follow-up of patients with bile duct strictures secondary to laparoscopic cholecystectomy, treated endoscopically with multiple stents.  Hepatogastroenterology. 2005;  52 1357-1361
• 16 Kassab C, Prat F, Liguory C. et al . Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study.  Gastroenterol Clin Biol. 2006;  30 124-129
• 17 Adler D G, Baron T H, Davila R E. et al . Standards of Practice Committee of American Society for Gastrointestinal Endoscopy. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.  Gastrointest Endosc. 2005;  62 1-8
• 18 Familiari P, Bulajic M, Mutignani M. et al . Endoscopic removal of malfunctioning biliary self-expandable metallic stents.  Gastrointest Endosc. 2005;  62 903-910
• 19 Corvera C U, Blumgart L H, Darvishian F. et al . Clinical and pathologic features of proximal biliary strictures masquerading as hilar cholangiocarcinoma.  J Am Coll Surg. 2005;  201 862-869
• 20 Kamisawa T, Egawa N, Nakajima H. et al . Gastrointestinal findings in patients with autoimmune pancreatitis.  Endoscopy. 2005;  37 1127-1130
• 21 Zoepf T, Jakobs R, Arnold J C. et al . Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy.  Am J Gastroenterol. 2005;  100 2426-2430
• 22 Ortner M E, Caca K, Berr F. et al . Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study.  Gastroenterology. 2003;  125 1355-1363
• 23 Shim C S, Cheon Y K, Cha S W. et al . Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment.  Endoscopy. 2005;  37 425-433
• 24 Cotton P B. Analysis of 59 ERCP lawsuits; mainly about indications.  Gastrointest Endosc. 2006;  63 378-382
• 25 Trap R, Adamsen S, Hart-Hansen O, Henriksen M. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.  Endoscopy. 1999;  31 125-130
• 26 Petrini Jr J L. Fools rush in ….  Gastrointest Endosc. 2006;  63 383-384
• 27 Frakes J T. The ERCP-related lawsuit: “Best avoid it!”.  Gastrointest Endosc. 2006;  63 385-388