ANNUAL REVIEWS Annu. Rev. Med. 1990. 41:211-22 Copyright © 1990 by Annual Reviews Inc. All rights reserved
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CRITICAL APPRAISAL OF THERAPEUTIC ENDOSCOPY IN Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY TRACT DISEASES Peter B. Cotton, M.D., F.R.C.P.
Dukc University Medical Center, Department of Medicine, Durham, North Carolina 27710 KEY WORDS:
choledochoscopy, gallstones, bile duct stones, biliary strictures, sclerosing cholangitis, papillary stenosis, malignant jaundice, biliary leaks.
ABSTRACT
�
Endoscopic treatment (by sphincterotomy) is now the preferred method for patients with retained or recurrent bile duct stones after surgery. It is also applicable to many acutely ill or high-risk patients who have not undergone cholecystectomy. Endoscopic stenting is preferable to the percutaneous transhepatic method for palliation of malignant biliary obstruction in patients unfit or unsuitable for surgery. Balloon dilatation and stenting can be used for management of postoperative bile duct trauma and biliary fistulae, and in patients with dominant strictures in sclerosing cholangitis. Papillary sten osis and sphincter of Oddi dysfunction can be treated by sphincterotomy after careful patient selection. Endoscopy is a new and simpler form of surgery. A team approach including endoscopists, surgeons, and radiologists is essential for appro priate patient care and for objective evaluation of new methods. INTRODUCTION
Cannulation of the papilla of Vater by duodenoscopy (endoscopic retro grade cholangiopancreatography, ERCP) was first described more than 211 0066-4219/90/0401-0211$02.00
212
COTTON
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
20 years ago. The introduction of duodenoscopic sphincterotomy for duct stones (in 1974) opened a new era in biliary therapy (1). Endoscopic methods have now superseded orthodox surgical intervention in many patients with biliary obstruction, whether caused by stones, benign stric tures, or malignancy. It is worth emphasizing that optimal results are obtained only by skilled endoscopists working with assistants well trained in these procedures, in collaboration with specialist surgeons and radiologists. Teamwork and attention to detail are essential. Poorly trained endoscopists working in isolation are less effective and more dangerous. BILE DUCT STONES
Therapeutic ERCP is performed in a standard x-ray suite, under sedation, with antibiotic prophylaxis. Coagulation parameters are checked. When retrograde cholangiography confirms a stone, the diagnostic catheter is replaced by a sphincterotome. Diathermy current is applied to unroof the papilla and ablate the biliary sphincters. Stones are extracted with balloon catheters or baskets (2). Sphincterotomy should be achieved in more than 95% of attempts, and the ducts cleared of stones in a similar proportion. Success rates depend upon the expertise of the endoscopist and on patient selection. Some papillae are more difficult to access, e.g. within a diverticulum or after diversionary surgery such as Billroth II partial gastrectomy. Difficulties in deep bile duct cannulation have led some to use and recommend the technique of "preeutting" using a needle knife. This tech nique is more dangerous than standard sphincterotomy and should be used only by experts when there is a strong indication. Stones less than 1 em in diameter are usually easy to extract. Larger stones may require adjunctive techniques including crushing baskets, intraduct lithotripsy with either lasers (Figure 1) or e1eetrohydraulic shockwaves (provided under direct vision with "mother and baby" choledochoscope systems), or external shockwave lithotripsy (3). Endoscopically placed nasobiliary drains (Figure 2) provide a route for infusion of chemical solvents, but the effects have been disappointing with large stones, which tend not to have a high cholesterol content. Complications
Sphincterotomy and stone extraction carry an approximately 10% inci dence of complications (including pancreatitis, sepsis, bleeding, and retro peritoneal perforation). Most complications are managed conservatively,
213
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
Figure 1
Laser lithotripsy. A sleeve containing a laser fiber
the stone, and fragmentation has begun.
(arrow) has been passed up to
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
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COTTON
Figut'e 2
Nasobiliary drain inserted at endoscopy in a patient with stones impacted in a
cystic duct stump.
but surgical intervention may be necessary. The procedure-related mor tality is 0.5-1 %; the thirty-day mortality depends upon the type of patients being treated (4). Indications
There are three main clinical factors influencing the use of endoscopic treatment (apart from the availability of appropriate experts) (4). These are the age and general health of the patient, the acuteness of the biliary
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
215
illness, and the status of the gallbladder (prior cholecystectomy or not). Patients discovered to have retained stones on a postoperative T-tube cholangiogram are usually best managed by radiologists, who can extract stones through the T-tube tract after it has matured (4-5 weeks). This percutaneous extraction method is preferred to sphincterotomy because it is safer, but endoscopic treatment is appropriate (a) if the percutaneous method is not applicable (T-tube too small or poorly placed, or stone too big) or if it fails, or (b) when the necessary delay is clinically unacceptable. Patients who retain stones after cholecystectomy (without T tubes) should all be considered initially for endoscopic management. This is undoubtedly safer than surgery in elderly and high-risk patients. While it cannot claim to be safer in young and fit patients, it is substantially quicker and simpler (4). At least 80% of patients are able to leave the hospital on the day after sphincterotomy. The main concern about using sphincter otomy in younger patients is the potential long-term complication of sphincter ablation. Long-term results of surgical sphincteroplasty appear
to have been satisfactory, and data accumulating from endoscopic follow up series are somewhat reassuring (4). Endoscopic management for duct stones in the presence of a gallbladder is more controversial, but it has been shown to be beneficial in two inter linking contexts (4). The most dramatic are patients with acute suppurative cholangitis or with acute gallstone pancreatitis. Emergency endoscopic decompression (by sphincterotomy with or without nasobiliary drainage) relieves the acute problem and cholecystectomy is usually performed once the patient is stable. This approach is widely accepted in cholangitis (5), but it is more controversial in pancreatitis since in most patients the crisis subsides spontaneously; ERCP is advised if the patient is in a high-risk group, and certainly if he or she is not improving within 48 hours (6). Endoscopic treatment is also valid in some high-risk patients with gallbladders in whom the symptoms from the duct stones are less dramatic, e.g. those suffering recurrent attacks of biliary colic. Chronic disability such as a cardiorespiratory disease may substantially increase the risk of surgical intervention. Many studies have now shown that thc gallbladder can be left in place (after endoscopic clearance of the duct) with reasonable safety. Fewer than 20% of patients appear to require cholecystectomy in follow-up periods of five to ten years (4). This approach-primary endoscopic management of duct stones and "wait and see" chole cystectomy-is justified in patients at the highest risk, but is more con troversial in those lower down on the risk spectrum. Some experts sug gested that all patients with duct and gallbladder stones should undergo endoscopic sphincterotomy and then a cholecystectomy-rather than
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COTTON
doing the whole job surgically-since the combined complication rates should be less. A randomized study gave no support for this approach (7). Discussion of the management of patients with bile duct and gallbladder stones is increasingly complicated by the proliferation of alternative treat ments for gallbladder stones, including shockwave lithotripsy and chemical dissolution. Even an endoscopic approach to the gallbladder is not impos sible; catheters can be placed into the gallbladder via the cystic duct at ERCP for later infusion of solvents.
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
MALIGNANT BILIARY OBSTRUCTION
Duodenoscopy and ERCP, together with high-quality imaging techniques (ultrasound, computed tomography, and endoscopic ultrasound), can now provide excellent documentation of the anatomical problem in patients with malignant obstruction to the bile duct. A tissue diagnosis can be obtained in many patients by endoscopic brushing cytology or forceps biopsy within the duct systems; in other cases, percutaneous fine needle aspiration cytology or "Tru-cut" biopsy is more successful (8). In patients who are poor surgical candidates, biliary obstruction can usually be relieved by nonoperative techniques. Sphincterotomy and snare/ laser ablation can be used for obstructing tumors of the papilla, and strictures higher up the bile duct are managed by placement of stents. Endoscopic Biliary Stenting
ERCP is performed in the standard way, with a large-channel duodeno scope. Once the biliary stricture has been identified radiologically, a guide wire is passed through it, and a stent (of at least 10 French gauge) is pushed into place (Figures 3A, 3B) (9). Tumors of the bifurcation can usually be managed by a single stent into one liver lobe. However, there is a risk of sepsis developing in the undrained lobe; if it does, a second stent must be placed, either by endoscopy or percutaneously (or by a combined percutaneous-endoscopic procedure). The success rate for endoscopic stent placement exceeds 90%, and the immediate complications are trivial. Most series indicate that jaundice is relieved in 80-90% of patients (10). The only significant problem is the tendency for the stents to occlude with time-the median time for stents of 10 French guage is about 6 months. For most patients with advanced disease this is sufficient, but about 30% live long enough to require stent exchange. The stent should be replaced promptly at the first sign of recur rent jaundice in order to prevent cholangitis and sepsis. Alternatively, the stent can be changed as a planned procedure at about four months if the patient's condition is stable. Attempts to prolong stent life by using differ-
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
Figure 3A
ERCP showing a malignant mid bile duct stricture
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Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
218 COTTON
Figure 3B
Stent in correct position, in the bile duct.
BILIARY ENDOSCOPY
219
ent materials and coatings have not yet proved successful. Experimental expandable stents are being evaluated.
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
Surgical Bypass, Percutaneous or Endoscopic Palliation?
Biliary stenting can be performed by interventional radiologists using a percutaneous transhepatic approach (10). The endoscopic approach is preferred where technically possible since it eliminates the risks involved in puncturing the liver. Endoscopic stenting proved to be more effective and safer than percutaneous stenting in one randomized controlled trial (11). The clinical issue usually devolves into a choice between endoscopic stenting or surgical intervention (10). We have to consider a spectrum of patients, ranging from the young and fit with a small tumor load to the elderly debilitated and complicated patients with large tumors and metastatic disease. There are a few terminal patients in whom any inter vention would be meddlesome. Surgery is indicated when there is any real hope of resection and in the presence of duodenal obstruction. However, endoscopic stenting is effective and preferred in elderly high-risk patients with a large tumor load (but without duodenal obstruction), since surgery in this group carries significant morbidity and mortality. The most difficult decisions occur in the middle of this spectrum, and it is within this context of patients (probably not resectable, reasonably fit for surgery) that a randomized study has produced predictable results (12). Endoscopic man agement is safer and cheaper in the short term, but more patients need to return to hospital for further management in the subsequent months (for stent occlusion, duodenal obstruction) (Table 1). The relative roles of surgery and endoscopic intervention are also determined by the expertise available.
Table 1
Preliminary results of a randomized study (12) comparing surgical
bypass with endoscopic stenting in patients with low bile duct obstruction judged not suitable for resection Surgical bypass
Endoscopic stenting
Total number of patients
67
67
Relief of jaundice
91
94
36
\0
(%) Major complications (%) 30-day mortality (%) Late recurrent jaundice (%) Duodenal bypass (%)
19
7
3
22
1
6
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COTTON
Preoperative Drainage?
Endoscopic biliary stenting has been used in some patients prior to attempted resection, in an effort to reduce the operative risk. The vogue for preoperative drainage by percutaneous means passed when it became evident that the risks outweigh any advantages-but endoscopic internal drainage remains attractive. Randomized studies are under way but are unlikely to show major benefit since the operative mortality in selected cases and centers is already very low.
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
Endoscopic Treatment of Tumors
The endoscopic approach can be used for direct treatment of biliary tumors. Iridium wires have been placed via temporary nasobiliary drains, or inside "hot stents." Attempts are being made to ablate biliary tumors by lasers, applied either through specially designed balloons or under direct vision with choledochoscopes passed up and down the bile duct. BENIGN BILIARY STRICTURES AND LEAKS
Endoscopists are often called upon to investigate patients with symptoms or signs of obstruction following biliary surgery. Those with recurrent stones are simply managed. Unfortunately, some patients have strictures resulting from operative trauma. Unless the duct has been completely disrupted, it is usually possible to pass a guidewire and catheter through the stricture and dilate it with a balloon up to 6 or 8 mm. The effects of balloon dilatation are usually short lived, and the stricture is normally splinted endoscopically with a stent for three months to one year (9). The long-term results of endoscopic management are not yet available; it is by no means clear that endoscopic therapy is preferable to (expert) surgical intervention. Extrahepatic strictures in patients with primary sclerosing cholangitis can be managed by similar balloon and stent techniques (13). Initial results appear good, but the long-term effects on disease progress are difficult to assess. It appears likely that stasis due to major extrahepatic strictures (and intermittent temporary obstruction by small bile pigment stones) can aggravate the primary condition. The role of endoscopic management is currently being evaluated alongside other new medical treatments for sclerosing cholangitis. Endoscopic intervention does not compromise sub sequent transplantation. Endoscopy is effective in the management of patients with biliary leaks from the anastomosis after liver transplantation, and in those with fistulae after other forms of bilill:ry surgery. The leaking cystic duct stump after
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
221
cholecystectomy, or an intrahepatic duct after liver resection, can be man aged simply by lowering the pressure distally, using standard sphincter otomy with or without temporary stenting. Papillary stenosis is perhaps the most controversial subject in this field (14). Many patients with impressive "postcholecystectomy pain" are found at ERCP to have no evidence of stone or bile duct stricture. Sphincter dysfunction or stenosis can be diagnosed if there are objective findings such as abnormal liver function test in association with attacks of pain, a bile duct that is getting larger since cholecystectomy, and definite delayed drainage after cholangiography. Patients exhibiting such symptoms prob ably have fibrosis within the sphincter zone, resulting from prior stones or surgical bouginage. Other patients are assumcd to have dysfunction (spasm) of the sphincter, a condition more difficult to document. Various provocation tests have been proposed, and endoscopic biliary manometry is used by some as a "gold standard" (15). Manometry is difficult to perform and interpret, but attempts must be made to document the situ
ation precisely before recommending sphincterotomy, not least because the risks are greater than in patients with stones. Patients with suspected "papillary stenosis or spasm" are best managed in specialist centers. ENDOSCOPIC APPROACHES NOT INVOLVING ERCP
Endoscopes can be inserted into the biliary tree by other routes for diag nostic and therapeutic purposes. Choledochoscopes (passed at open oper ation, via a percutaneous T-tube tract, or through a specially constructed transhepatic fistula) can be used for electrohydraulic or laser lithotripsy or for tumor ablation. Endoscopes are even being used after percutaneous cholecystostomy to fragment gallbladder stones as an adjunct to external lithotripsy and dissolution techniques. CONCLUSION
Most patients with biliary obstruction can now be managed by expert endoscopic techniques. Which patients should be managed with endos copy, as opposed to surgical (or radiological) approaches? This is a ques tion that can only be answered by careful prospective and objective evalu ation pursued by clinical scientists. The issue should not be seen as a competition between surgery and endoscopy, since endoscopic treatment is simply a new type of surgery. Greater integration of medical and surgical gastroenterology will be necessary to achieve the teamwork required for ensuring that patients obtain optimal advice and treatment.
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COTTON
Literature Cited
I. Cotton, P. B. 1977. Progress report ERCP. GU/18: 316-41 2. Cotton, P. B., Williams, C. B. 1982.
3.
4.
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
5.
6.
7.
8.
Practical Gastrointestinal Endoscopy, Boston: Blackwell Scientific. 2nd ed. Classen, M., Hagenmuller, F., Knyrim, K., Frinberger, E. 1988. Giant bile duct stones-nonsurgical treatment. Endos copy 20: 21-2 Cotton, P. B. 1984. Endoscopic man agement of bile duct stones (apples and oranges). Gut 25: 587-97 Leese, T., Neoptolemos, J. P., Baker, A. R., Carr-Locke, D. L. 1986. Man agement of acute cholangitis and the impact of endoscopic sphincterotomy. ' Br. J. Surg. 73: 988-92 Neoptolemos, J. P., London, N. J., James, D., Carr-Locke, D. L., Bailey, 1. A., Fossard, D. P. 1988. Controlled trial of urgent endoscopic retrograde chol angiopancreatography and endoscopic sphicterotomy versus conservative treat ment for acute pancreatitis due to gall stones. Lancet 2: 979-83 Neoptolemos, J. P., Carr-Locke, D. L., Fossard, D. P. 1987. Prospective ran domized study of preoperative endo scopic sphincterotomy versus surgery alone for commom bile duct stones. Br. J. Surg. 294: 470--74 Jennings, P. E., Coral, A., Donald, J. J.,
9.
10
11.
12.
13.
14. 15.
Rode, J., Lees, W. R. 1989. Ultrasound guided core biopsy. Lancel I: 1369-71 Huibregtse, K. 1988. Endoscopic biliary and pancreatic drainage. Stuttgart/New York: Georg Thieme Verlag Cotton, P. B. 1989. Nonsurgical pal liation of jaundice in pancreatic cancer. In The Surgical Clinics ofNorth America, ed. H. A. Reber, Philadelphia: Saunders 69: 613-28 Speer, A. G., Cotton, P. B., Russell, R. C. G., et al. 1987. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaun dice. Lancet 2: 57-fJ2 Dowsett, J. F., Russell, R. C. G., Hatfield, A. R. W., et al. 1988. Malig nant obstructive jaundice: What is the best management? A prospective ran domized trial of surgery versus endo scopic stenting. Gut 29: AI493 (Abstr.) Johnson, G. K., Geener, J. E., Venu, R. P., Hogan, W. J. 1987. Endoscopic treatment of biliary duct strictures in sclerosing cholangitis: follow-up assess ment of a new therapeutic approach. Gas/roinlest. Endosc. 33: 9-12 Guelrud, M. 1988. Papillary stenosis. Endoscopy 20(1): 193-202 Hogan, W. J., Geenen, J. E. 1988. Biliary dyskinesia. Endoscopy 20(1): 179-83
Further
Quick links to online content
CRITICAL APPRAISAL OF THERAPEUTIC ENDOSCOPY IN Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY TRACT DISEASES Peter B. Cotton, M.D., F.R.C.P.
Dukc University Medical Center, Department of Medicine, Durham, North Carolina 27710 KEY WORDS:
choledochoscopy, gallstones, bile duct stones, biliary strictures, sclerosing cholangitis, papillary stenosis, malignant jaundice, biliary leaks.
ABSTRACT
�
Endoscopic treatment (by sphincterotomy) is now the preferred method for patients with retained or recurrent bile duct stones after surgery. It is also applicable to many acutely ill or high-risk patients who have not undergone cholecystectomy. Endoscopic stenting is preferable to the percutaneous transhepatic method for palliation of malignant biliary obstruction in patients unfit or unsuitable for surgery. Balloon dilatation and stenting can be used for management of postoperative bile duct trauma and biliary fistulae, and in patients with dominant strictures in sclerosing cholangitis. Papillary sten osis and sphincter of Oddi dysfunction can be treated by sphincterotomy after careful patient selection. Endoscopy is a new and simpler form of surgery. A team approach including endoscopists, surgeons, and radiologists is essential for appro priate patient care and for objective evaluation of new methods. INTRODUCTION
Cannulation of the papilla of Vater by duodenoscopy (endoscopic retro grade cholangiopancreatography, ERCP) was first described more than 211 0066-4219/90/0401-0211$02.00
212
COTTON
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
20 years ago. The introduction of duodenoscopic sphincterotomy for duct stones (in 1974) opened a new era in biliary therapy (1). Endoscopic methods have now superseded orthodox surgical intervention in many patients with biliary obstruction, whether caused by stones, benign stric tures, or malignancy. It is worth emphasizing that optimal results are obtained only by skilled endoscopists working with assistants well trained in these procedures, in collaboration with specialist surgeons and radiologists. Teamwork and attention to detail are essential. Poorly trained endoscopists working in isolation are less effective and more dangerous. BILE DUCT STONES
Therapeutic ERCP is performed in a standard x-ray suite, under sedation, with antibiotic prophylaxis. Coagulation parameters are checked. When retrograde cholangiography confirms a stone, the diagnostic catheter is replaced by a sphincterotome. Diathermy current is applied to unroof the papilla and ablate the biliary sphincters. Stones are extracted with balloon catheters or baskets (2). Sphincterotomy should be achieved in more than 95% of attempts, and the ducts cleared of stones in a similar proportion. Success rates depend upon the expertise of the endoscopist and on patient selection. Some papillae are more difficult to access, e.g. within a diverticulum or after diversionary surgery such as Billroth II partial gastrectomy. Difficulties in deep bile duct cannulation have led some to use and recommend the technique of "preeutting" using a needle knife. This tech nique is more dangerous than standard sphincterotomy and should be used only by experts when there is a strong indication. Stones less than 1 em in diameter are usually easy to extract. Larger stones may require adjunctive techniques including crushing baskets, intraduct lithotripsy with either lasers (Figure 1) or e1eetrohydraulic shockwaves (provided under direct vision with "mother and baby" choledochoscope systems), or external shockwave lithotripsy (3). Endoscopically placed nasobiliary drains (Figure 2) provide a route for infusion of chemical solvents, but the effects have been disappointing with large stones, which tend not to have a high cholesterol content. Complications
Sphincterotomy and stone extraction carry an approximately 10% inci dence of complications (including pancreatitis, sepsis, bleeding, and retro peritoneal perforation). Most complications are managed conservatively,
213
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
Figure 1
Laser lithotripsy. A sleeve containing a laser fiber
the stone, and fragmentation has begun.
(arrow) has been passed up to
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
214
COTTON
Figut'e 2
Nasobiliary drain inserted at endoscopy in a patient with stones impacted in a
cystic duct stump.
but surgical intervention may be necessary. The procedure-related mor tality is 0.5-1 %; the thirty-day mortality depends upon the type of patients being treated (4). Indications
There are three main clinical factors influencing the use of endoscopic treatment (apart from the availability of appropriate experts) (4). These are the age and general health of the patient, the acuteness of the biliary
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
215
illness, and the status of the gallbladder (prior cholecystectomy or not). Patients discovered to have retained stones on a postoperative T-tube cholangiogram are usually best managed by radiologists, who can extract stones through the T-tube tract after it has matured (4-5 weeks). This percutaneous extraction method is preferred to sphincterotomy because it is safer, but endoscopic treatment is appropriate (a) if the percutaneous method is not applicable (T-tube too small or poorly placed, or stone too big) or if it fails, or (b) when the necessary delay is clinically unacceptable. Patients who retain stones after cholecystectomy (without T tubes) should all be considered initially for endoscopic management. This is undoubtedly safer than surgery in elderly and high-risk patients. While it cannot claim to be safer in young and fit patients, it is substantially quicker and simpler (4). At least 80% of patients are able to leave the hospital on the day after sphincterotomy. The main concern about using sphincter otomy in younger patients is the potential long-term complication of sphincter ablation. Long-term results of surgical sphincteroplasty appear
to have been satisfactory, and data accumulating from endoscopic follow up series are somewhat reassuring (4). Endoscopic management for duct stones in the presence of a gallbladder is more controversial, but it has been shown to be beneficial in two inter linking contexts (4). The most dramatic are patients with acute suppurative cholangitis or with acute gallstone pancreatitis. Emergency endoscopic decompression (by sphincterotomy with or without nasobiliary drainage) relieves the acute problem and cholecystectomy is usually performed once the patient is stable. This approach is widely accepted in cholangitis (5), but it is more controversial in pancreatitis since in most patients the crisis subsides spontaneously; ERCP is advised if the patient is in a high-risk group, and certainly if he or she is not improving within 48 hours (6). Endoscopic treatment is also valid in some high-risk patients with gallbladders in whom the symptoms from the duct stones are less dramatic, e.g. those suffering recurrent attacks of biliary colic. Chronic disability such as a cardiorespiratory disease may substantially increase the risk of surgical intervention. Many studies have now shown that thc gallbladder can be left in place (after endoscopic clearance of the duct) with reasonable safety. Fewer than 20% of patients appear to require cholecystectomy in follow-up periods of five to ten years (4). This approach-primary endoscopic management of duct stones and "wait and see" chole cystectomy-is justified in patients at the highest risk, but is more con troversial in those lower down on the risk spectrum. Some experts sug gested that all patients with duct and gallbladder stones should undergo endoscopic sphincterotomy and then a cholecystectomy-rather than
216
COTTON
doing the whole job surgically-since the combined complication rates should be less. A randomized study gave no support for this approach (7). Discussion of the management of patients with bile duct and gallbladder stones is increasingly complicated by the proliferation of alternative treat ments for gallbladder stones, including shockwave lithotripsy and chemical dissolution. Even an endoscopic approach to the gallbladder is not impos sible; catheters can be placed into the gallbladder via the cystic duct at ERCP for later infusion of solvents.
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
MALIGNANT BILIARY OBSTRUCTION
Duodenoscopy and ERCP, together with high-quality imaging techniques (ultrasound, computed tomography, and endoscopic ultrasound), can now provide excellent documentation of the anatomical problem in patients with malignant obstruction to the bile duct. A tissue diagnosis can be obtained in many patients by endoscopic brushing cytology or forceps biopsy within the duct systems; in other cases, percutaneous fine needle aspiration cytology or "Tru-cut" biopsy is more successful (8). In patients who are poor surgical candidates, biliary obstruction can usually be relieved by nonoperative techniques. Sphincterotomy and snare/ laser ablation can be used for obstructing tumors of the papilla, and strictures higher up the bile duct are managed by placement of stents. Endoscopic Biliary Stenting
ERCP is performed in the standard way, with a large-channel duodeno scope. Once the biliary stricture has been identified radiologically, a guide wire is passed through it, and a stent (of at least 10 French gauge) is pushed into place (Figures 3A, 3B) (9). Tumors of the bifurcation can usually be managed by a single stent into one liver lobe. However, there is a risk of sepsis developing in the undrained lobe; if it does, a second stent must be placed, either by endoscopy or percutaneously (or by a combined percutaneous-endoscopic procedure). The success rate for endoscopic stent placement exceeds 90%, and the immediate complications are trivial. Most series indicate that jaundice is relieved in 80-90% of patients (10). The only significant problem is the tendency for the stents to occlude with time-the median time for stents of 10 French guage is about 6 months. For most patients with advanced disease this is sufficient, but about 30% live long enough to require stent exchange. The stent should be replaced promptly at the first sign of recur rent jaundice in order to prevent cholangitis and sepsis. Alternatively, the stent can be changed as a planned procedure at about four months if the patient's condition is stable. Attempts to prolong stent life by using differ-
Annu. Rev. Med. 1990.41:211-222. Downloaded from www.annualreviews.org Access provided by Mahidol University on 01/23/15. For personal use only.
BILIARY ENDOSCOPY
Figure 3A
ERCP showing a malignant mid bile duct stricture
217
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218 COTTON
Figure 3B
Stent in correct position, in the bile duct.
BILIARY ENDOSCOPY
219
ent materials and coatings have not yet proved successful. Experimental expandable stents are being evaluated.
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Surgical Bypass, Percutaneous or Endoscopic Palliation?
Biliary stenting can be performed by interventional radiologists using a percutaneous transhepatic approach (10). The endoscopic approach is preferred where technically possible since it eliminates the risks involved in puncturing the liver. Endoscopic stenting proved to be more effective and safer than percutaneous stenting in one randomized controlled trial (11). The clinical issue usually devolves into a choice between endoscopic stenting or surgical intervention (10). We have to consider a spectrum of patients, ranging from the young and fit with a small tumor load to the elderly debilitated and complicated patients with large tumors and metastatic disease. There are a few terminal patients in whom any inter vention would be meddlesome. Surgery is indicated when there is any real hope of resection and in the presence of duodenal obstruction. However, endoscopic stenting is effective and preferred in elderly high-risk patients with a large tumor load (but without duodenal obstruction), since surgery in this group carries significant morbidity and mortality. The most difficult decisions occur in the middle of this spectrum, and it is within this context of patients (probably not resectable, reasonably fit for surgery) that a randomized study has produced predictable results (12). Endoscopic man agement is safer and cheaper in the short term, but more patients need to return to hospital for further management in the subsequent months (for stent occlusion, duodenal obstruction) (Table 1). The relative roles of surgery and endoscopic intervention are also determined by the expertise available.
Table 1
Preliminary results of a randomized study (12) comparing surgical
bypass with endoscopic stenting in patients with low bile duct obstruction judged not suitable for resection Surgical bypass
Endoscopic stenting
Total number of patients
67
67
Relief of jaundice
91
94
36
\0
(%) Major complications (%) 30-day mortality (%) Late recurrent jaundice (%) Duodenal bypass (%)
19
7
3
22
1
6
220
COTTON
Preoperative Drainage?
Endoscopic biliary stenting has been used in some patients prior to attempted resection, in an effort to reduce the operative risk. The vogue for preoperative drainage by percutaneous means passed when it became evident that the risks outweigh any advantages-but endoscopic internal drainage remains attractive. Randomized studies are under way but are unlikely to show major benefit since the operative mortality in selected cases and centers is already very low.
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Endoscopic Treatment of Tumors
The endoscopic approach can be used for direct treatment of biliary tumors. Iridium wires have been placed via temporary nasobiliary drains, or inside "hot stents." Attempts are being made to ablate biliary tumors by lasers, applied either through specially designed balloons or under direct vision with choledochoscopes passed up and down the bile duct. BENIGN BILIARY STRICTURES AND LEAKS
Endoscopists are often called upon to investigate patients with symptoms or signs of obstruction following biliary surgery. Those with recurrent stones are simply managed. Unfortunately, some patients have strictures resulting from operative trauma. Unless the duct has been completely disrupted, it is usually possible to pass a guidewire and catheter through the stricture and dilate it with a balloon up to 6 or 8 mm. The effects of balloon dilatation are usually short lived, and the stricture is normally splinted endoscopically with a stent for three months to one year (9). The long-term results of endoscopic management are not yet available; it is by no means clear that endoscopic therapy is preferable to (expert) surgical intervention. Extrahepatic strictures in patients with primary sclerosing cholangitis can be managed by similar balloon and stent techniques (13). Initial results appear good, but the long-term effects on disease progress are difficult to assess. It appears likely that stasis due to major extrahepatic strictures (and intermittent temporary obstruction by small bile pigment stones) can aggravate the primary condition. The role of endoscopic management is currently being evaluated alongside other new medical treatments for sclerosing cholangitis. Endoscopic intervention does not compromise sub sequent transplantation. Endoscopy is effective in the management of patients with biliary leaks from the anastomosis after liver transplantation, and in those with fistulae after other forms of bilill:ry surgery. The leaking cystic duct stump after
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BILIARY ENDOSCOPY
221
cholecystectomy, or an intrahepatic duct after liver resection, can be man aged simply by lowering the pressure distally, using standard sphincter otomy with or without temporary stenting. Papillary stenosis is perhaps the most controversial subject in this field (14). Many patients with impressive "postcholecystectomy pain" are found at ERCP to have no evidence of stone or bile duct stricture. Sphincter dysfunction or stenosis can be diagnosed if there are objective findings such as abnormal liver function test in association with attacks of pain, a bile duct that is getting larger since cholecystectomy, and definite delayed drainage after cholangiography. Patients exhibiting such symptoms prob ably have fibrosis within the sphincter zone, resulting from prior stones or surgical bouginage. Other patients are assumcd to have dysfunction (spasm) of the sphincter, a condition more difficult to document. Various provocation tests have been proposed, and endoscopic biliary manometry is used by some as a "gold standard" (15). Manometry is difficult to perform and interpret, but attempts must be made to document the situ
ation precisely before recommending sphincterotomy, not least because the risks are greater than in patients with stones. Patients with suspected "papillary stenosis or spasm" are best managed in specialist centers. ENDOSCOPIC APPROACHES NOT INVOLVING ERCP
Endoscopes can be inserted into the biliary tree by other routes for diag nostic and therapeutic purposes. Choledochoscopes (passed at open oper ation, via a percutaneous T-tube tract, or through a specially constructed transhepatic fistula) can be used for electrohydraulic or laser lithotripsy or for tumor ablation. Endoscopes are even being used after percutaneous cholecystostomy to fragment gallbladder stones as an adjunct to external lithotripsy and dissolution techniques. CONCLUSION
Most patients with biliary obstruction can now be managed by expert endoscopic techniques. Which patients should be managed with endos copy, as opposed to surgical (or radiological) approaches? This is a ques tion that can only be answered by careful prospective and objective evalu ation pursued by clinical scientists. The issue should not be seen as a competition between surgery and endoscopy, since endoscopic treatment is simply a new type of surgery. Greater integration of medical and surgical gastroenterology will be necessary to achieve the teamwork required for ensuring that patients obtain optimal advice and treatment.
222
COTTON
Literature Cited
I. Cotton, P. B. 1977. Progress report ERCP. GU/18: 316-41 2. Cotton, P. B., Williams, C. B. 1982.
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Practical Gastrointestinal Endoscopy, Boston: Blackwell Scientific. 2nd ed. Classen, M., Hagenmuller, F., Knyrim, K., Frinberger, E. 1988. Giant bile duct stones-nonsurgical treatment. Endos copy 20: 21-2 Cotton, P. B. 1984. Endoscopic man agement of bile duct stones (apples and oranges). Gut 25: 587-97 Leese, T., Neoptolemos, J. P., Baker, A. R., Carr-Locke, D. L. 1986. Man agement of acute cholangitis and the impact of endoscopic sphincterotomy. ' Br. J. Surg. 73: 988-92 Neoptolemos, J. P., London, N. J., James, D., Carr-Locke, D. L., Bailey, 1. A., Fossard, D. P. 1988. Controlled trial of urgent endoscopic retrograde chol angiopancreatography and endoscopic sphicterotomy versus conservative treat ment for acute pancreatitis due to gall stones. Lancet 2: 979-83 Neoptolemos, J. P., Carr-Locke, D. L., Fossard, D. P. 1987. Prospective ran domized study of preoperative endo scopic sphincterotomy versus surgery alone for commom bile duct stones. Br. J. Surg. 294: 470--74 Jennings, P. E., Coral, A., Donald, J. J.,
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Rode, J., Lees, W. R. 1989. Ultrasound guided core biopsy. Lancel I: 1369-71 Huibregtse, K. 1988. Endoscopic biliary and pancreatic drainage. Stuttgart/New York: Georg Thieme Verlag Cotton, P. B. 1989. Nonsurgical pal liation of jaundice in pancreatic cancer. In The Surgical Clinics ofNorth America, ed. H. A. Reber, Philadelphia: Saunders 69: 613-28 Speer, A. G., Cotton, P. B., Russell, R. C. G., et al. 1987. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaun dice. Lancet 2: 57-fJ2 Dowsett, J. F., Russell, R. C. G., Hatfield, A. R. W., et al. 1988. Malig nant obstructive jaundice: What is the best management? A prospective ran domized trial of surgery versus endo scopic stenting. Gut 29: AI493 (Abstr.) Johnson, G. K., Geener, J. E., Venu, R. P., Hogan, W. J. 1987. Endoscopic treatment of biliary duct strictures in sclerosing cholangitis: follow-up assess ment of a new therapeutic approach. Gas/roinlest. Endosc. 33: 9-12 Guelrud, M. 1988. Papillary stenosis. Endoscopy 20(1): 193-202 Hogan, W. J., Geenen, J. E. 1988. Biliary dyskinesia. Endoscopy 20(1): 179-83
