Endoscopic management of obstructive jaundice


  ENDOSCOPIC MANAGEMENT OF
  OBSTRUCTIVE JAUNDICE

   Dr.Anil Haripriya


...
that incises the papilla and sphincter muscles surrounding the distal
common bile duct by electrodiathermy using a papillo...
catheter is employed through the endoscope to extract the CBD stones. The
technical success of performing ES approaches 85...
dissolution can be attempted via the naso‑biliary tube or the patient is
taken for laparotomy.
B.      LATE COMPLICATIONS
...
morbidity and mortality are less than those following transabdominal
  surgery. The procedure can be repeated if stenosis ...
With the development of ultra‑slim (23mm) cholangioscopes which can be
passed over a guide wire through the channel of a c...
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Endoscopic Management Of Obstructive Jaundice

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Endoscopic Management Of Obstructive Jaundice

  1. 1. Endoscopic management of obstructive jaundice ENDOSCOPIC MANAGEMENT OF OBSTRUCTIVE JAUNDICE Dr.Anil Haripriya INTRODUCTION The treatment of all patients with obstructive jaundice remained a domain of surgeons until the early 1970's so much so that it had been designated as "surgical jaundice". The cause of jaundice remained obscure till these patients were operated, as the pre-operative work up of these patients did not provide an accurate diagnosis. Moreover, patients not fit for surgery were left to conservative management despite the fact that there may have been an obstruction to the bile duct. The pancreatic and biliary trees were considered unapproachable without surgery and per-operative cholangiogram with its limitations used to be the only method to delineate the pancreas. ERCP (Endoscopic Retrograde Pancreatico Cholangiography) has not only made tremendous advancement in the diagnosis of patients with obstructive jaundice but also to carry out various therapeutic procedures to relieve the obstruction in the biliary system without surgical laparotomy. DIAGNOSTIC ENDOSCOPY The technique of ERCP was first introduced in 1970. It allows access to the second part of duodenum, papilla of vater, bile duct and pancreatic duct. It is a sophisticated technique that can be mastered by the trained endoscopist. It is performed to define biliary obstruction and its nature i.e. stone or stricture ‑ the two most common causes of obstructive jaundice. The selective cannulation of the pancreatic biliary ductal system can be done in 95% cases by an expert endoscopist trained in the technique to perform an ERCP. The cannulation of the papilla requires the use of a special side viewing duodenoscope and a Teflon 5F diameter cannula. ERCP can be performed as an outpatient procedure provided the patient's general condition is fit. Once the ampulla is cannulated the contrast material is injected under fluoroscopy and serial radiographs are taken as the dye fills the pancreatic biliary ductal system. ERCP is far superior to ultrasound and C.T. scan for detection of stone or stricture in the bile duct. Papillotome cutting the sphincter ENDOSCOPIC SPHINCTEROTOMY Endoscopic sphincterotomy (ES) has become the corner stone in the management of obstructive biliary tract disease. It was first introduced in Japan and Germany in 1977. It Is an endoscopic therapeutic modality
  2. 2. that incises the papilla and sphincter muscles surrounding the distal common bile duct by electrodiathermy using a papillotome which Is used to make a 0.5 to 1.5 cm incision. The sphincterotomes consist of a long Teflon catheter and a cautery wire. The wire traverses the entire Teflon tube and is exposed for a variable length of 2 to 3 cm near the tip of sphincterotome. By applying traction on the proximal end of the wire, the distal end of the catheter bends to assume a semilunar shape. When current is applied, incision of the tissue in contact with wire takes place. INDICATIONS (a) Retained common bile duct stone following cholecystectomy with or without T‑tube. (b) Stone with gall bladder In situ in high surgical risk patients (c) Acute suppurative cholangitis with CBD stone (d) Gall stone pancreatitis (e) Placement of nasobiliary catheter, biliary stents, dilatation of biliary strictures and chemical dissolution of stones etc. Stone extraction by dormia basket after sphincterotomy CONTRAINDICATIONS (a) Significant coagulation defect (b) Long stricture of distal common bile duct ES FOR RETAINED CBD STONES Despite intra-operative cholangiogaphy common bile duct stones are overlooked in 1-14% of cases. More than 50% of these cases develop complications so the removal is usually indicated. The surgical re‑exploration of bile duct carries a higher morbidity and mortality than that associated with endoscopic sphincterotomy. ES WITH GALL BLADDER IN SITU Wider application of endoscopic sphincterotomy has led to an increasing proportion of patients with an intact gall bladder being treated for bile duct stones. ES alone, for C8D stones in the elderly or other poor surgical risk patients who have an intact gall bladder, is well accepted though a similar management for younger, fit patients with symptomatic stone is controversial. However, ES as a planned precholecystectomy procedure is currently being evaluated. ES IN SEVERE ACUTE CHOLANGITIS WITH CBD STONE Emergency ES offers a safer method of biliary decompression (mortality rate 4.7%) than emergency surgery (mortality 21.4%) in those patients with cholangitis not responding to initial conservative measures. SUCCESS RATE OF ES IN DELIVERING THE CBD STONE With an adequate sphincterotomy most stones less than I cm pass spontaneously. In about 25% cases a dormia (wire) basket or balloon
  3. 3. catheter is employed through the endoscope to extract the CBD stones. The technical success of performing ES approaches 85‑90% and stone extraction is achieved in 80-90%. The main reasons for failure are a large CBD stone (>2cm), intrahepatic stones and a relatively small distal common bile duct. ENDOSCOPIC MANAGEMENT LARGE CBD STONE Mechanical Lithotripsy : Large stones (> 2 cm) that cannot be removed, can be pushed by mechanical lithotripsy (special wire basket) passed through the endoscope. After crushing the CBD stone mechanically the stone fragments are removed subsequently or pass spontaneously. Electrohydraulic Lithotripsy : The basic principle is similar to that of Extracorporeal Shock Wave Lithotripsy. A modified electrohydraulic lithotripter probe has been designed which can be inserted into the CBD through the endoscope. The lithotripter is placed in close proximity to the stone and the shock waves generated break the stone. Chemical Dissolution : The insertion of nasobiliary catheter through the endoscope into the CBD, prevents stone impaction and enables subsequent chemical dissolution by using various soIvents like, Monooctanoin, 1 % EDT, methyl Terbutyl ether, etc. COMPLICATIONS OF ES A. ACUTE COMPLICATIONS i. Heamorrhage: Usually ES is not association with much bleeding; however, in about 2‑3% severe bleeding can occur. Urgent surgery may be required to control the bleeding if coagulation current application is not successful in controlling the bleeding. ii. Perforation : The patient experiences sudden abdominal pain and extravasation of the contrast is seen on the television screen. Since the perforation is retroperitioneal the abdominal signs may not be very striking. Treatment is conservative and most patients recover with parenteral antibiotics and nasogastric suction. iii. Cholangitis : There is no evidence that prophylactic antibiotics prevent this complication although some workers recommend this step. It infection occurs, the best treatment is a combination of ampicillin, gentamicin and metronidazole, which achieve effective concentrations in bile. iv. Pancreatitis :The incidence of clinical pancreatitis ranges from 1.5 to 5.50A, although hyper amylasaemia invariably occurs. v. Impaction of calculus and dormia basket This occurs when the stone size is larger than the length of the sphincterotomy. The stone cannot be dislodged from the basket and both get stuck in the CBD. The best approach is to cut the basket wire below the handle and to withdraw the endoscope and reintroduce it to enlarge the sphincterotomy. If this is not possible, a nasobiliary tube is introduced and the patient is returned to the ward with the basket in situ. Frequently the basket and the stone pass out spontaneously after the oedema subsides. Failing this stone
  4. 4. dissolution can be attempted via the naso‑biliary tube or the patient is taken for laparotomy. B. LATE COMPLICATIONS These complications occur in about 1-10% patients but are generally mild and of not much importance. These are: i) Stenosis of the sphincterotomy ii) Cholangitis and cholecystitis iii) New stone formation PRE AND POST PROCEDURE MEASURES 1) The routine use of pre and postoperative antibiotics in patients with obstruction to the pancreatico‑billary system remains controversial. The usual drugs are broad spectrum antibiotics like ampicillin or aminoglycosides (gentamicin). 2) After the procedure the patient is kept fasting for 2 hours. The vital signs are constantly checked and the patient is examined for signs of free perforation. If everything is normal, the patient is allowed liquid feeds followed by solids. 3) The patients are encouraged to' pass stools in a pan for the next 48 hours and to look for gallstones, If stones are definetely identified, this may obviate the need for a repeat ERCP. CAUSES OF FAILURE In about 5-10% cases ES is unsuccessful even in the most experienced hands. The various causes of failure are: I) Operator's inexperience ii) Anatomical abnormalities iii) Large stone size IV) Development of immediate complications necessitating the abandoning of the procedure. NASOBILIARY CATHETER DRAINAGE Temporary or short term biliary decompression can be accomplished by placing a Nasobiliary Catheter (NBC) above common bile duct stones or strictures. It functions like a T-tube. NBC Is a long polyethylene tube, one end of which is placed inside the biliary tree through an endoscope while the other end exits through the nostril and connects to a bile drainage bag. INDICATIONS FOR NASOBILIARY CATHETER DECOMPRESSION a. Ascending cholangitis secondary to impaction of stone. b. Ascending cholangitis with CBD stone and coagulopathy. c. Pre-operative biliary decompression to decrease severe jaundice due to extrahepatic biliary obstruction. d. Biliary perfusion with stone dissolution agents. e. Intraluminal irradiation therapy in selected cases of malignant stricture. ENDOSCOPIC BILIARY STRICTURE DILATATION Endoscopic dilatation of bile duct stenosis is technically feasible, though often difficult. It may even provide long term relief. The
  5. 5. morbidity and mortality are less than those following transabdominal surgery. The procedure can be repeated if stenosis recurs. After a diagnostic ERCP, a small sphincterotomy is performed to facilitate the manipulation through the ampulla. Atraumatic slip guide wire is passed through the endoscope and manipulated through the stricture under fluoroscopic control. Over this guide wire is passed a tapered dilating catheter and removed after initial dilatation leaving the guide wire in place. Then a polyethylene balloon catheter is advanced over the guide wire and into the stricture. The balloon is distended under pressure to break the fibrous tissue and dilate the stricture. Once the stricture is adequately dilated, a large caliber stent is endoscopically inserted over the guide wire and placed across the stricture. The stent generally needs to be replaced periodically (6 months to 1 year). It is removed only after the stricture remains adequately dilated. The early results are promising and it will be interesting to see the long term follow up results. ENDOSCOPIC THERAPY OF BILIARY OBSTRUCTION DUE TO MALIGNANCY The approach to bile duct obstruction due to malignant obstruction is determined by the site of obstruction and the clinical manifestation. Fig: Endoscopic dilatation of biliary stricture Obstruction of distal bile duct : Carcinoma of the pancreas and periampullary carcinoma are the most important causes of malignant distal biliary obstruction. Surgical resection is not possible in majority of the patients. Endoscopic stent placement is an important option for selected patients. The technique of stent placement is similar to that described for benign stricture. Seriously ill patients should be managed with endoscopic sphincterotomy and placement of stents if feasible. Obstruction,of fhe middle extrahepatic bile duct : Carcinoma of gall bladder and cholangiocarcinorna cause obstruction of the middle extrahepatic bile duct. The management is as in distal obstruction. Obstruction of the left and l or right hepatic duct : For mechanical reasons, malignant stenosis of the proximal bile ducts present difficult technical problems for endoscopic management because the endoscopist has relatively less mechanical control in maneovering guide wire and stents through the stenosis. When both the left and right hepatic ducts are involved, endoscopic decompression of both sides can be a formidable problem. INTRALUMINAL IRRADIATION Currently another method of palliation of bile duct malignancies by endoscopic placement or iridium wire into the malignant biliary stricture is being evaluated. MINISCOPES
  6. 6. With the development of ultra‑slim (23mm) cholangioscopes which can be passed over a guide wire through the channel of a conventional duodenoscope, a direct cholangiopancreaticoscopy is possible. This could be used to fragment impacted or large CBD stone under direct vision using a dye laser. This may also help in placement of guide wires through difficult biliary strictures.

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