The Study Of Single-Operator Wire-Guided Cannulation Technique And Early Diagnosis Of Surgical Biliary Obstruction

Objective:With the emerging of MRCP for diagnosing of hepatobiliary pancreatic disorders, ERCP has been diverted mainly to a minimally invasive surgical technique for treatment. Accordingly, the original cannulation technique (probing with a catheter and contrast injection) changed to a wire-guided cannulation (probing with a guidewire). Wire-guided cannulation technique requires one well-trained assistant to manipulate the wire. Excellent communication and precise coordination between the endoscopist and assistant are required, especially for difficult cannulation. The cannulation time and success rate greatly depend on the experience of a well-trained assistant. The single-operator wire-guided cannulation technique become possible until the emergence of rapid exchange system (short guide-wire system). The main objective of this study was to determine the efficiency of single-operator wire-guided cannulation in terms of the number of attempts at cannulation, cannulation time, success rate, and complications. The second objective of this study was to evaluate the role of assistant in this new technique.Methods:From October2007to November2008and from December2009to December2010, hospitalized patients with pancreas and biliary diseases referred to the authors for ERCP were recruited into this study. The exclusion criteria were previous endoscopic sphincterotomy, surgically altered anatomy (e.g. Billroth II gastrectomy) or diagnostic duodenoscopy. A total of465consecutive patients were recruited in this prospective study and randomly divided into two groups. A new single-operator wire-guided cannulation technique performed by the same experienced endoscopist, with experienced assistants (Group A) and inexperienced ones (Group B). The number of attempts at cannulation, cannulation time, success rate, and procedure-related complications were recorded.ResultsSuccessful cannulation was achieved in460out of the465patients (98.92%). The incidences of post-ERCP pancreatitis, bleeding, infection, and perforation were5.16%,0.64%,1.08%, and0%, respectively. There were no severe complications or death. The cannulation time, number of attempts at cannulation and complications were not significantly different between the two groups (all P>0.05). ConclusionsThe single-operator wire-guided cannulation technique doesn’t require an experienced assistant and precise coordination between the assistant and endoscopist. It was a safe, efficient and feasible technique. Part Ⅱ The value of intrahepatic biliary dilation on the diagnosis and treatment of anastomotic stricture with ERCP after orthotopic liver transplantationObjective:Anastomotic stricture is the most common biliary complication after liver transplantation and the main cause of obstructive jaundice. Differentiating surgical jaundice from non-surgical one is of vital important after liver transplantation. Intrahepatic biliary dilation is a key point for the diagnosis of surgical biliary obstruction. However, intrahepatic biliary dilation is usually ignored after liver transplantation. It has been reported that biliary injury and liver fibrosis can lead to decreasing of biliary compliance after liver transplantation, making intrahepatic bile duct difficult to dilate when obstruction occuring. Therefore, intrahepatic bilary dilation is considered less valuable for the judgement of biliary complication after liver transplantation. As an important rule to judge surgical biliary obstruction, will intrahepatic biliary dilation lost its diagnosis value in anastomotic stricture after liver transplantation? In this study, we aimed to assess the diagnostic value of intrahepatic biliary dilation in anastomotic stricture after liver transplantation.Methods:A total of28jaundice patients were diagnosed as post-transplant anastomotic stricture in the first affiliated hospital, Zhejiang University, school of medicine from May2004to June2010. Twenty-eight patients who underwent sucessful endoscopic retrograde cholangiopancreatography treatments for post-transplant anastomotic stricture were classified into two groups:anastomotic stricture with intrahepatic biliary dilation (Group A, n=22) and anastomotic stricture without intrahepatic biliary dilation (Group B, n=6). The diagnosis of anastomotic stricture was made by elevation of total bilirubin and MRCP. All patients were treated successfully by balloon dilation, nasobiliary drainage, or stent placement. The clinical outcomes of the two groups were evaluated.Results:The median time intervals from liver transplantation to the occurrence of anastomotic stricture were38d and434d for Group A and Group B, respectively. The median total bilirubin significantly decreased from142umol/L to49umol/L (P<0.05) two weeks after ERCP treatment in Group A. Fourteen patients (63.6%) was cured and the other8were effective in Group A. But total bilirubin was not improved after the ERCP treatment in Group B (P>0.05).Conclusions:Intrahepatic biliary dilation is a key point to differentiate surgical or nonsurgical jaundice. Therapeutic ERCP is not effective in anastomotic stricture without intrahepatic biliary dilation after liver transplantation. Part III Early Diagnosis of Surgical Biliary ObstructionObjective:Jaundice is yellowish pigmentation of the skin, the sclerae and other mucous membranes due to hyperbilirubinemia caused by abnormal bilirubin metabolism and excretion. Surgical obstructive jaundice is caused by biliary obstruction, including calculus, tumor, scar, inflammation or parasite, which needs operation or invasive intervention. Early detection of obstructive jaundice could help diagnosis and treatment of hepatobiliary and pancreatic disorders; however, currently it remains a difficult clinical problem.MethodsThis study reviewed commonly used laboratory tests (alkaline phosphatase and γ-glutamyl transpeptidase) and imaging techniques (percutaneous transhepatic cholangiography, endoscopic retrograde cholangiography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography) for diagnosis of biliary obstruction. We focused on the role of bile duct dilation found by imaging study in diagnosis of biliary obstruction, and further analyzed the manifestation of bile duct dilation under obstruction in varied anatomical location, urgency and severity.ResultsBy non-invasive MRCP findings, we defined the dilation of intrahepatic bile duct into three categories:dilation (clearly viewed tertiary bile duct branch, diameter>=2mm), suspicious dilation (clearly viewed tertiary bile duct branch, diameter<2mm) and normal size (no visualization of tertiary bile duct branch). Our finding suggested that intrahepatic bile duct dilation detected by MRCP is important evidence supporting the diagnosis of biliary obstruction. In contrast to extrahepatic bile duct dilation that could be influenced by confounding factors, intrahepatic bile duct dilation has showed its diagnostic specificity. Moreover, it is an earlier sign than liver biochemical abnormality for bile duct obstruction, especially for chronic incomplete bile duct obstruction. Combined with other laboratory tests, image finding of intrahepatic bile duct obstruction could potentially contribute to early diagnosis of postoperative anastomosis stricture of biliary reconstruction, differentiating obstructive and non-obstructive jaundice, and detecting early biliary tumor.ConclusionsIn conclusion, our study suggested that detecting intrahepatic bile duct dilation combined with liver function tests is an important strategy in early identification of biliary obstruction, and it would help the diagnosis and treatment of obstructive hepatobiliary and pancreatic disease.