Digestive Endoscopy 2014; 26 (Suppl. 2): 144–146
doi: 10.1111/den.12249
How to perform balloon assisted enteroscopic ERCP? – Current status and tips for procedures
Post-endoscopic retrograde cholangiopancreatography pancreatitis caused by papillary large-balloon dilation of incidental intrapapillary fistula in Roux-en-Y patients: Lesson from a case Kentaro Ishii, Takao Itoi, Fumihide Itokawa, Takayoshi Tsuchiya and Atsushi Sofuni Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
Endoscopic papillary large-balloon dilation (EPLBD) has been popular worldwide for difficult stones. At the primary stage, EPLBD is done immediately after endoscopic sphincterotomy (ES) or after previous ES. Recently, several endoscopists have reported the feasibility and safety of EPLBD without ES and postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) as adverse events. Herein, we encountered a case of PEP in which EPLBD was carried out through a spontaneous fistula in the
Key words: endoscopic papillary large-balloon dilation, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, single-balloon enteroscopy
INTRODUCTION
CASE REPORT
INCE ERSOZ AND his colleagues1 described the first report on endoscopic papillary large-balloon dilation (EPLBD) for difficult stones (e.g. large stones and built-up stones), numerous papers on EPLBD have been published.2–9 Furthermore, the technique has been applied to patients with surgical altered anatomy (e.g. Billroth II gastrectomy, gastrectomy plus Roux-en-Y reconstruction [R-Y]).10,11 The terminology of EPLBD includes large balloon dilation following endoscopic sphincterotomy (ES), which is standard procedure, large balloon dilation alone without ES and large balloon dilation alone in cases of prior ES being carried out. To date, the necessity for ES before papillary dilation using a large dilating balloon is controversial regardless of altered anatomy.12–15 Herein, we describe a case in which severe post-ERCP pancreatitis (PEP) occurred after large-balloon dilation of incidental intrapapillary fistula.
A
S
Corresponding: Takao Itoi, Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected] Received 8 December 2013; accepted 6 January 2014.
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papillary roof, although there was no manipulation of the pancreatic duct. We learned a lesson from the present case in which possible PEP might occur during the procedure of EPLBD without ES.
52-YEAR-OLD MAN WHO had undergone subtotal gastrectomy plus R-Y was transferred to our hospital from another hospital with obstructive jaundice and cholangitis as a result of common bile duct stones. Singleballoon enteroscopy-assisted ERCP was conducted for the treatment of bile duct stones. After reaching the end of the blind loop, we found a flow of pus from the fistula (Fig. 1a) just above the papillary orifice (Fig. 1b). We guessed that the fistula was created by spontaneous passage of stone. Subsequently, we carried out large-balloon dilation of the fistula using a 12–15-mm dilating balloon (CRE; Boston Scientific Japan, Tokyo, Japan) without any contact of the papillary orifice (Fig. 2). Finally, all residual stones and debris were extracted. The patient had severe abdominal pain 6 h after the procedure. Laboratory data showed elevated leukocytes (14 × 109/L) and hyperamylasemia (2580 mg/dL). Computed tomography (CT) scan showed acute pancreatitis with edematous parenchyma of the pancreas and peripancreatic fluid collection (Fig. 3). Antibiotics and maximum protein degeneration enzyme inhibitors were given for post-ERCP pancreatitis. His condition gradually improved but it took 14 days after EPLBD until recovery of his condition.
Digestive Endoscopy 2014; 26 (Suppl. 2): 144–146
a
Post-ERCP pancreatitis after EPLBD 145
b
Figure 1 Endoscopic imaging around the major papilla. (a) Endoscopic finding of fistula just above the true papillary orifice. (b) Endoscopic finding of major papilla (catheter was inserted through the fistula).
a
b
Figure 2 Single-balloon enteroscopyassisted endoscopic retrograde cholangiopancreatography. (a) Cholangiogram by balloon catheter. (b) Papillary balloon dilation using large dilating balloon.
a
b
Figure 3 Abdominal computed tomography. (a) Edematous parenchyma of pancreas and peripancreatic fluid collection suggesting pancreatitis. (b) Peripancreatic fluid distributed to anterior pararenal space.
DISCUSSION
M
EINE AND BARON et al. summarize 1292 cases of EPLBD with ES.16 In their study, they revealed that the initial and final technical success rates of the procedure were 91% and 98%, respectively. In contrast, the adverse event rate was 5%, including 2.8% PEP (36/1292), 1.2% bleeding, 0.2% perforation, and 0.4% cholangitis.16 These data seem similar to previous data of ES for the treatment of bile duct stones.17 In the present case, the mechanism of pathogenesis of pancreatitis is debatable because the catheter did not contact the pancreatic duct orifice. Furthermore, the balloon in the balloon-overtube did
not compress the papilla. Thus, in the present case, we guess one possibility for PEP was the large dilating balloon in the fistula compressing the papillary orifice and, as a result of this obstacle, pancreatic juice flow might occur. Park et al. described the outcome of EPLBD through a fistulotomy tract created intentionally and this procedure may be a feasible and safe alternative method for the removal of bile duct stones in patients in whom cannulation is difficult, even though they carried out six cases only.18 However, there is a discrepancy in the risk of PEP between intentional fistulotomy and spontaneous fistula formation as in the present study, because intentional fistulotomy is created by electrical cautery precut after failed selective biliary
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canuulation which traumatizes the pancreatic duct orifice. Nevertheless, PEP occurred in the present case with spontaneous fistula. Thus, when the papillary large-balloon dilation technique is used, we should keep the possibility of PEP in mind even if we do not touch the pancreatic duct. There are several limitations in the present case. This was only one case in which we encountered PEP as a result of large balloon dilation of an incidental fistula. However, all the mechanisms of PEP have not yet been clarified. For example, Kim and Kim reported that the PEP rate of EPLBD without ES was higher than that of EPLBD with ES (14.7% vs 3.4%, P = 0.095) although there was no statistical significance.19 Thus, in the near future, large and prospective trials are warranted to clarify which patients and which procedures cause PEP. In conclusion, we encountered PEP following papillary large balloon dilation of an incidental fistula just above the papillary orifice. Although further studies are mandatory, our case may suggest some lessons in the causes of PEP as a result of EPLBD without ES.
CONFLICT OF INTERESTS
A
UTHORS DECLARE NO conflict of interests for this article.
REFERENCES 1 Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest. Endosc. 2003; 57: 156–9. 2 Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy 2007; 39: 958–61. 3 Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J. Gastroenterol. 2007; 13: 2179–82. 4 Attasaranya S, Cheon YK, Vittal H et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: A multi- center series. Gastrointest. Endosc. 2008; 67: 1046–52. 5 Misra SP, Dwivedi M. Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones. Endoscopy 2008; 40: 209–13. 6 Heo JH, Kang DH, Jung HJ et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointest. Endosc. 2007; 66: 720–6.
Digestive Endoscopy 2014; 26 (Suppl. 2): 144–146
7 Itoi T, Itokawa F, Sofuni A et al. Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones. Am. J. Gastroenterol. 2009; 104: 560–5. 8 Itoi T, Sofuni A, Itokawa F et al. New large-diameter balloonequipped sphincterotome for removal of large bile duct stones (with videos). Gastrointest. Endosc. 2010; 72: 825–30. 9 Itoi T, Ishii K, Itokawa F, Kurihara T, Sofuni A. Large balloon papillary dilation for removal of bile duct stones in patients who have undergone a Billroth II gastrectomy. Dig. Endosc. 2010; 22 (Suppl 1): S98–S102. 10 Teoh AY, Cheung FK, Hu B et al. Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones. Gastroenterology 2013; 144: 341–5. 11 Itoi T, Ishii K, Sofuni A et al. Large balloon dilatation following endoscopic sphincterotomy using a balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis. Dig. Liver Dis. 2011; 43: 237–41. 12 Jeong S, Ki SH, Lee DH et al. Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: A preliminary study. Gastrointest. Endosc. 2009; 70: 915–22. 13 Chan HH, Lai KH, Lin CK et al. Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones. BMC Gastroenterol. 2011; 11: 69. 14 Jang HW, Lee KJ, Jung MJ et al. Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: A single center experience. Dig. Dis. Sci. 2013; 58: 1737– 43. 15 Kogure H, Tsujino T, Isayama H et al. Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones. Scand. J. Gastroenterol. 2014; 49: 121–8. 16 Meine GC, Baron TH. Endoscopic papillary large-balloon dilation combined with endoscopic biliary sphincterotomy for the removal of bile duct stones (with video). Gastrointest. Endosc. 2011; 74: 1119–26. 17 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: An attempt at consensus. Gastrointest. Endosc. 1991; 37: 383–93. 18 Park SY, Park CH, Yoon KW et al. Endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in a difficult cannulation. Gastrointest. Endosc. 2009; 69: 955–9. 19 Kim KH, Kim TN. Endoscopic papillary large balloon dilation in patients with periampullary diverticula. World J. Gastroenterol. 2013; 19: 7168–76.
doi: 10.1111/den.12249
How to perform balloon assisted enteroscopic ERCP? – Current status and tips for procedures
Post-endoscopic retrograde cholangiopancreatography pancreatitis caused by papillary large-balloon dilation of incidental intrapapillary fistula in Roux-en-Y patients: Lesson from a case Kentaro Ishii, Takao Itoi, Fumihide Itokawa, Takayoshi Tsuchiya and Atsushi Sofuni Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
Endoscopic papillary large-balloon dilation (EPLBD) has been popular worldwide for difficult stones. At the primary stage, EPLBD is done immediately after endoscopic sphincterotomy (ES) or after previous ES. Recently, several endoscopists have reported the feasibility and safety of EPLBD without ES and postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) as adverse events. Herein, we encountered a case of PEP in which EPLBD was carried out through a spontaneous fistula in the
Key words: endoscopic papillary large-balloon dilation, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, single-balloon enteroscopy
INTRODUCTION
CASE REPORT
INCE ERSOZ AND his colleagues1 described the first report on endoscopic papillary large-balloon dilation (EPLBD) for difficult stones (e.g. large stones and built-up stones), numerous papers on EPLBD have been published.2–9 Furthermore, the technique has been applied to patients with surgical altered anatomy (e.g. Billroth II gastrectomy, gastrectomy plus Roux-en-Y reconstruction [R-Y]).10,11 The terminology of EPLBD includes large balloon dilation following endoscopic sphincterotomy (ES), which is standard procedure, large balloon dilation alone without ES and large balloon dilation alone in cases of prior ES being carried out. To date, the necessity for ES before papillary dilation using a large dilating balloon is controversial regardless of altered anatomy.12–15 Herein, we describe a case in which severe post-ERCP pancreatitis (PEP) occurred after large-balloon dilation of incidental intrapapillary fistula.
A
S
Corresponding: Takao Itoi, Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected] Received 8 December 2013; accepted 6 January 2014.
bs_bs_banner
144
papillary roof, although there was no manipulation of the pancreatic duct. We learned a lesson from the present case in which possible PEP might occur during the procedure of EPLBD without ES.
52-YEAR-OLD MAN WHO had undergone subtotal gastrectomy plus R-Y was transferred to our hospital from another hospital with obstructive jaundice and cholangitis as a result of common bile duct stones. Singleballoon enteroscopy-assisted ERCP was conducted for the treatment of bile duct stones. After reaching the end of the blind loop, we found a flow of pus from the fistula (Fig. 1a) just above the papillary orifice (Fig. 1b). We guessed that the fistula was created by spontaneous passage of stone. Subsequently, we carried out large-balloon dilation of the fistula using a 12–15-mm dilating balloon (CRE; Boston Scientific Japan, Tokyo, Japan) without any contact of the papillary orifice (Fig. 2). Finally, all residual stones and debris were extracted. The patient had severe abdominal pain 6 h after the procedure. Laboratory data showed elevated leukocytes (14 × 109/L) and hyperamylasemia (2580 mg/dL). Computed tomography (CT) scan showed acute pancreatitis with edematous parenchyma of the pancreas and peripancreatic fluid collection (Fig. 3). Antibiotics and maximum protein degeneration enzyme inhibitors were given for post-ERCP pancreatitis. His condition gradually improved but it took 14 days after EPLBD until recovery of his condition.
Digestive Endoscopy 2014; 26 (Suppl. 2): 144–146
a
Post-ERCP pancreatitis after EPLBD 145
b
Figure 1 Endoscopic imaging around the major papilla. (a) Endoscopic finding of fistula just above the true papillary orifice. (b) Endoscopic finding of major papilla (catheter was inserted through the fistula).
a
b
Figure 2 Single-balloon enteroscopyassisted endoscopic retrograde cholangiopancreatography. (a) Cholangiogram by balloon catheter. (b) Papillary balloon dilation using large dilating balloon.
a
b
Figure 3 Abdominal computed tomography. (a) Edematous parenchyma of pancreas and peripancreatic fluid collection suggesting pancreatitis. (b) Peripancreatic fluid distributed to anterior pararenal space.
DISCUSSION
M
EINE AND BARON et al. summarize 1292 cases of EPLBD with ES.16 In their study, they revealed that the initial and final technical success rates of the procedure were 91% and 98%, respectively. In contrast, the adverse event rate was 5%, including 2.8% PEP (36/1292), 1.2% bleeding, 0.2% perforation, and 0.4% cholangitis.16 These data seem similar to previous data of ES for the treatment of bile duct stones.17 In the present case, the mechanism of pathogenesis of pancreatitis is debatable because the catheter did not contact the pancreatic duct orifice. Furthermore, the balloon in the balloon-overtube did
not compress the papilla. Thus, in the present case, we guess one possibility for PEP was the large dilating balloon in the fistula compressing the papillary orifice and, as a result of this obstacle, pancreatic juice flow might occur. Park et al. described the outcome of EPLBD through a fistulotomy tract created intentionally and this procedure may be a feasible and safe alternative method for the removal of bile duct stones in patients in whom cannulation is difficult, even though they carried out six cases only.18 However, there is a discrepancy in the risk of PEP between intentional fistulotomy and spontaneous fistula formation as in the present study, because intentional fistulotomy is created by electrical cautery precut after failed selective biliary
146
K. Ishii et al.
canuulation which traumatizes the pancreatic duct orifice. Nevertheless, PEP occurred in the present case with spontaneous fistula. Thus, when the papillary large-balloon dilation technique is used, we should keep the possibility of PEP in mind even if we do not touch the pancreatic duct. There are several limitations in the present case. This was only one case in which we encountered PEP as a result of large balloon dilation of an incidental fistula. However, all the mechanisms of PEP have not yet been clarified. For example, Kim and Kim reported that the PEP rate of EPLBD without ES was higher than that of EPLBD with ES (14.7% vs 3.4%, P = 0.095) although there was no statistical significance.19 Thus, in the near future, large and prospective trials are warranted to clarify which patients and which procedures cause PEP. In conclusion, we encountered PEP following papillary large balloon dilation of an incidental fistula just above the papillary orifice. Although further studies are mandatory, our case may suggest some lessons in the causes of PEP as a result of EPLBD without ES.
CONFLICT OF INTERESTS
A
UTHORS DECLARE NO conflict of interests for this article.
REFERENCES 1 Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest. Endosc. 2003; 57: 156–9. 2 Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy 2007; 39: 958–61. 3 Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J. Gastroenterol. 2007; 13: 2179–82. 4 Attasaranya S, Cheon YK, Vittal H et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: A multi- center series. Gastrointest. Endosc. 2008; 67: 1046–52. 5 Misra SP, Dwivedi M. Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones. Endoscopy 2008; 40: 209–13. 6 Heo JH, Kang DH, Jung HJ et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointest. Endosc. 2007; 66: 720–6.
Digestive Endoscopy 2014; 26 (Suppl. 2): 144–146
7 Itoi T, Itokawa F, Sofuni A et al. Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones. Am. J. Gastroenterol. 2009; 104: 560–5. 8 Itoi T, Sofuni A, Itokawa F et al. New large-diameter balloonequipped sphincterotome for removal of large bile duct stones (with videos). Gastrointest. Endosc. 2010; 72: 825–30. 9 Itoi T, Ishii K, Itokawa F, Kurihara T, Sofuni A. Large balloon papillary dilation for removal of bile duct stones in patients who have undergone a Billroth II gastrectomy. Dig. Endosc. 2010; 22 (Suppl 1): S98–S102. 10 Teoh AY, Cheung FK, Hu B et al. Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones. Gastroenterology 2013; 144: 341–5. 11 Itoi T, Ishii K, Sofuni A et al. Large balloon dilatation following endoscopic sphincterotomy using a balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis. Dig. Liver Dis. 2011; 43: 237–41. 12 Jeong S, Ki SH, Lee DH et al. Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: A preliminary study. Gastrointest. Endosc. 2009; 70: 915–22. 13 Chan HH, Lai KH, Lin CK et al. Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones. BMC Gastroenterol. 2011; 11: 69. 14 Jang HW, Lee KJ, Jung MJ et al. Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: A single center experience. Dig. Dis. Sci. 2013; 58: 1737– 43. 15 Kogure H, Tsujino T, Isayama H et al. Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones. Scand. J. Gastroenterol. 2014; 49: 121–8. 16 Meine GC, Baron TH. Endoscopic papillary large-balloon dilation combined with endoscopic biliary sphincterotomy for the removal of bile duct stones (with video). Gastrointest. Endosc. 2011; 74: 1119–26. 17 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: An attempt at consensus. Gastrointest. Endosc. 1991; 37: 383–93. 18 Park SY, Park CH, Yoon KW et al. Endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in a difficult cannulation. Gastrointest. Endosc. 2009; 69: 955–9. 19 Kim KH, Kim TN. Endoscopic papillary large balloon dilation in patients with periampullary diverticula. World J. Gastroenterol. 2013; 19: 7168–76.
