Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

Abstract

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP.

Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features.

Results Technical success was achieved in all cases (100 %).

Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months.

12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation.

Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

• References

• 1 Williams EJ, Green J, Beckingham I. et al. British Society of Gastroenterology Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57: 1004-1021
• 2 Christensen M, Matzen P, Schulze S. et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721-731
• 3 Sherman S, Ruffolo TA, Hawkes RH. et al. Complications of endoscopic sphincterotomy: a prospective series with emphasis on increased risk associated with sphincter of Oddi dysfunction and non-dilated bile ducts. Gastroenterology 1991; 101: 1068-1075
• 4 Costamagna G, Tringali A, Shah SK. et al. Long-Term Follow-Up of Patients After Endoscopic Sphincterotomy for Choledocholithiasis and Risk Factors for Recurrence. Endoscopy 2002; 34: 273-279
• 5 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 6 Stapfer M, Selby RR, Stain SC. et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000; 232: 191-198
• 7 Testoni PA. Repeat Sphincterotomy: Does its safety depend on the interval from the initial procedure?. Am J Gastroenterol 2003; 98: 1
• 8 Seifert E. Long-term follow up after endoscopic sphincterotomy (EST). Endoscopy 1988; 20: 232-235
• 9 Ikeda S, Tanaka M, Matsumoto S. et al. Endoscopic sphincterotomy : long term results in 480 patients with complete follow up. Endoscopy 1988; 20: 13-17
• 10 Bourke MJ, Elfant AB, Scheider D. et al. Sphincterotomy-associated biliary strictures: features and endoscopic management. Gastroint Endosc 2000; 52: 494-499
• 11 Cui PJ, Yao J, Zhao YJ. et al. Biliary stenting with or without sphincterotomy for malignant biliary obstruction: a meta-analysis. World J Gastroenterol 2014; 20: 14033-14039
• 12 Geenen JE, Toouli J, Hogan WJ. et al. Endoscopic sphincterotomy: follow up evaluation of effects on the sphincter of Oddi. Gastroenterology 1984; 87: 754-758
• 13 Veldkamp MC, Rauws EA, Dijkgraaf MG. et al. Iatrogenic ampullary stenosis: history, endoscopic management, and outcome in a series of 49 patients. Gastrointest Endosc 2007; 66: 708-716
• 14 Costamagna G, Tringali A, Mutignani M. et al. Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc 2010; 72: 551-557
• 15 Dumonceau JM, Tringali A, Blero D. et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012; 44: 277-298
• 16 Fiocca F, Salvatori FM, Fanelli F. et al. Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous. Gastrointest Endosc 2011; 74: 1393-1398
• 17 Maltz GS, Geenen JE. Is there an increased risk of complications from repeat endoscopic sphincterotomy?. Am J Gastroenterol 1990; 85: 1253
• 18 Mavrogiannis C, Liatsos C, Papanikolaou IS. et al. Safety of extension of a previous endoscopic sphincterotomy: a prospective study. Am J Gastroenterol 2003; 1: 72-76
• 19 Sugiyama M, Suzuki Y, Abe N. et al. Endoscopic treatment of recurrent choledocholithiasis after sphincterotomy. Gut 2004; 53: 1856-1859
• 20 Andriulli A, Loperfido S, Napolitano G. et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102: 1781-1788
• 21 Leung JWC, Chan FKL, Sung JJY. et al. Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastroint Endosc 1995; 42: 550-554
• 22 Stolte M, Wiessner V, Schaffner O. et al. Vaskularization der papilla Vateri und blutungsgefahr bei der papillotomie. Leber Magen Darm 1980; 10: 293-301
• 23 Donatelli G, Cereatti F, Dumont JL. et al. Post-biliary sphincterotomy bleeding despite covered metallic stent deployment. SAGE Open Medical Case Reports 2016; 4: 1-3
• 24 Canena J, Liberato M, Horta D. et al. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, post-sphincterotomy bleeding, and perforations. Surg Endosc 2013; 27: 313-324