Chapters Transcript Video DoIM Educational Conference: Overview of the interventional management of cholangitis My name is I'm one of the interventional gastroenterologists at Roswell Park. I have uh no personal um or financial relationships with any commercial interests pertaining to this activity. Here are our learning objectives. Today, we will talk about the characteristics of er C P. We will identify possible management for Chong and we will review the indications and contraindications to performing er C P are outlined for today. Um Again, we will review er C P and details of indications tools and complications. We will review alternative which is percutaneous transat billary drainage and we will review the updated literature and discuss current management guidelines. This is the um paper that we will be focusing on at the end of our talk. This is, this was published in 2021 this is the A S G E or the American Society of G I Endoscopy Guidelines on the management of chole. And their purpose was to answer three main questions. The first question was in patients with chole is endoscopic or percutaneous drainage. The fevered method of biliary decompression and does it vary by severity? Number two in patients with chole init does early er C P performed at less than 48 hours after admission, improved clinical outcome related to patients undergoing er C P at greater than 48 hours. And number three in patients with chole, what is the role of endoscopic therapy including sphincterotomy, lithotripsy and stone clearance combined with decompression just to stop alone versus decompression alone. Um during the initial er C P and this table shows us the indications, most common indications for er C P. We can do ampulla for ampulla polyps. There are biliary indications including most commonly collis or stones in the common Bial duct treatment of bio leaks, biliary structures with whether they are malignant in the setting of pancreatic cancer, cholangiocarcinoma or apiary adenocarcinoma or benign such as in P S D posttransplant structures or in chronic pancreatitis. We can also use er C P for treatment of sphincter of O D dysfunction and pancreatic hei including recur acute pancreatitis, chronic pancreatitis, pancreatic duct leak or again, sphincter of O D dysfunction. And this is basically um an overview of the er C P. When we are doing an er C P. We are using a side viewing scope or do anoscope. In this, on the side of the scope, we have an A nozzle, a camera, a light and an elevator um which helps us pass instruments and lift them up to achieve what we need to do for the procedure. The scope is passed into the mouth through the esophagus into the stomach and into the second portion of the duodenum where we reach the Aula and start doing what we need to do in their toolbox. We have a variety of tools that we can use to accomplish the therapeutic indications. The first step we're going to talk about are balloons. We have retrieval balloons that can be helpful to remove stones and sludge and hidrotic balloons that can be used to dilate structures. And these, this is a little um schematic of the different types of balloons. On the left hand side, we have our extraction balloons that come in a variety of sizes that can be passed over the wire into the duct to remove stones. And on the right hand side, we have our hydrostatic balloons that can be used to dilate either trans papillary to make the orifice bigger or into the duct. If there is a structure, we will watch two videos looking at the um extraction balloons as well as the dilating balloon. This is the first video um that will demonstrate how we pass the balloon over the wire into the duct and remove stones. Every er C P starts the same with the cannulation where the wire is advanced into the Bial dut. A sphincterotomy is then performed to open the orifice of the bio dut. Once that is done, the tomb is removed over the wire and the balloon will be advanced over that same wire. Here comes the balloon, it is advanced above the stone under fluoroscopic guidance. The balloon is expanded and slowly removed to allow that stone to pass through the opening of the Aula. The balloon is deflated and again passed into the duct above the next stone that has to be removed, reinflated this time to a bigger size because it's a bigger stone and that helps you remove the stone. The next month, video is a little bit of a clinical scenario. And in this, they use a dilating balloon because they can't perform a sphincterotomy to alleviate an obstruction. Do we have to play the whole thing or can you add this now in? Because I don't have to talk about this. The next tool we have in our basket are wire baskets. Sometimes the uh balloon extraction or balloon dilation is not enough to remove a big stone. The wire baskets help us grasp the stones and if they're very large, helps us crush a stone, this is what they look like. And again, the principals are saying they are advanced over the wire into the duct under fluoroscopic guidance, can grasp a stone and remove it and we'll watch a video that demonstrates that again. Every er C P starts the same with the cannulation in the bile duct. Then a sphincterotomy this victor to is removed. And this time the retrieval basket is passed over the wire and into the bio dut, the basket is opened and manipulated around the stone close and if it's a small stone, you can just remove the stone. If it's a larger stone like this one, it's grass in the basket but will not come out of the o or so. This time, we can crush it that helps break the stone up into pieces and you can extract the fragments of the stone out. Now, sometimes, um, obstruction or chole itis can be due to um strictures or tumors into the biliary tree. Stents can help uh ameliorate those obstructions. We have a variety of stents available. Um We have plastic stents and a variety of metal stents. We have uncovered metal which are permanent stents and these cannot be removed. We have fully covered metal stents and partially covered metal stents. On the right hand shows you a of a variety of strictures and tumors that can happen and stents that we can place so we can place unilateral metal stents, unilateral plastic stents or bilateral metal and plastic stents. And this video will demonstrate a stent deployment. The stent is loaded on an introducer, the producer and the stent are advanced over the wire through the narrowed portion of the bio dut. This is also done under fluoroscopic guidance. The introducer and the wire are removed and the stent stays in place. And lastly, we can um biopsy when we are um trying to determine what the ideology of a stricture or stenosis is to do that. We have forceps as well as brush cytology. This is a variety of types of brush brushes that we can advance into the bio duck to take our sample. Next we'll watch a video that demonstrates that. So the brush is advanced into the bile duct over a catheter. The brush has radio pick markers that allows us to see on fluoroscopic guidance that it is in fact, brushing the area of stenosis and withdrawn back and forth to take the sample. And next we come to direct endoscopic visualization of the duct. This is known as KIOS copy and essentially it is a mini scope that is attached to the larger scope that allows us to um go into the bio dut itself. Look at the duct do variety of therapeutic interventions like biopsies or lithotripsy to break up larger stones. We'll watch a video of a patient with a stricture um who is getting a chaos copy with biopsies. A 65 year old woman presented with jaundice and severe coagulopathy with an I N R of 2.5 due to calaio sepsis. Er C P shows spontaneous emptying of large amounts of white puss through the paella. This is enforced by suction after cannulation of the common bile duct fluoroscopy shows a singular one centimeter stone in the middle portion of the duct. Because of the coagulopathy, we decided to avoid pappy loamy but rather perform dilation of the papilla to minimize the risk of procedure related bleeding. A dilation catheter was introduced over a guide wire. The balloon has a one centimeter width and four centimeter length to avoid perforation of the duct. The maximum width of the balloon should not exceed the width of the bile duct at fluoroscopy. This is a crucial point to the procedure. The middle portion of the balloon should be positioned right at the center of the pa pillar to minimize the chances of dislocating the balloon proximately or distally during inflation. Fluoroscopic control shows the indentation that is caused by the paella. The balloon is kept inflated for 20 seconds during dilation. It is important to provide adequate analgesia and sedation for the patient. As dilation of the paella might be painful after dilation. The balloon is deflated and removed. There is no significant bleeding and dilation offers a comfortable to the billy tract. In the next step. A balloon catheter is introduced and inflated above the stone. Some suction and a straighter patient position help to dislocate the stone to the distal portion of the bile duct. From here, the stone is easily removed by pulling the halfway blocked balloon catheter through the bile duct. The biliary tract is decompressed and the stone is extracted. Subsequent fluoroscopic control shows complete extraction of the stone. The patient recovered quickly thereafter and was discharged three days later. Now, those are some of the things that we can do while we do, er C P. But they come with risks. Complications can be up to 6.8% in during an er C P. The most common one is post er C P pancreatitis and this occurs at up to 3.5%. Bleeding is the next most common and it occurs at a rate of about 1.3%. Although the incidence of severe hemorrhage is less than one in 1000 infections occur at less than 1%. A duodenal or biliary per perforation can occur at 10.1% to 0.6%. And other risks include cardiovascular anesthesia, related the mortality rate associated with er C P is about 0.3%. I'm gonna focus a little bit on post T R C P pancreatitis as that is the most common complication that can occur. The risk factors associated with post C R C P. Pancreatitis. We break them up into definitive and likely risks. The definitive risks for pancreatitis include increased cannulation attempts, pancreatic guide wire passage more than once into the pancreatic duct injection of contrast into the pancreatic duct. A history of previous pancreatitis, suspected sphincter of O D dysfunction and female gender likely risks include failure to remove bile duct stones completely. An endoscopic papyri balloon dilation or performance of a pancreatic sphincterotomy. There are some things that we can do to decrease the incidence and risk of post T R C P. Pancreatitis. Procedural factors include placement of A P D stent if the wire is introduced to the pancreatic duct or using guide wire guided cannulation to decrease the risk of trauma and ende to the papilla, anti-inflammatory agents including rectal Endomycin can be used. And that is considered the most reliable and beneficial agent for prevention of pancreatitis as well as aggressive hydration, which is the principal evidence based treatment of acute pancreatitis related to any cause. Now, if we can't perform A, er C P, we will call our interventional radiology colleagues for a percutaneous transat biliary drainage. And what that is is an image guided procedure under fluoroscopy or combined ultrasound and fluoroscopic guidance for placement of a tube into the undrained segment of the Bial dut. Local anesthesia can be used. However, in some cases, conscious sedation or general anesthesia is required and it plays an important role for management and biliary pathology that is not amenable to endoscopic intervention. The indications are similar to er C P. Benign biliary causes can be secondary to chronic pancreatitis, biliary stones or uh liver transplantation. And then the malignant biliary obstructions can be related to gallbladder, cancer, per apiary cancer, cio carcinoma, pancreatic cancer or metastatic disease. The contraindications include absolute contra indications such as an unreal bleeding disease or relative contra indications including an I N R greater than 1.5 platelet count less than 5 50,000 aides or multiple hepatic cysts. Complications include minor complications such as pain or per catheter leak or majors such as chole biliary peritus hemorrhage or pancreatitis. So, now that we have laid the foundation of the procedure, the tools and the alternatives. We will go back to talk about the A S G E guidelines on the Manager Minute of Chole. So this was a Standards of Practice Committee that was published in May 19th of 2021. And again, their goal was to answer three main questions, the modality of drainage, whether endoscopic or percutaneous, the timing of intervention, whether performed within 48 hours of admission or greater than 48 hours. And then the extent of initial intervention, should it be comprehensive therapy or just decompression? The outcomes that they looked at were mor mortality, successful decompression, length of stay and adverse events. So their first question was asking er C P versus percutaneous optic biliary drainage as the favored method of biliary decompression, they looked at six comparative observational trials that included 745 patients with Chong managed by er C P. 10 of those previously underwent a failed percutaneous drain placement. 244 patients underwent a percutaneous drain placement and 12 of those had prior unsuccessful er C P. The outcomes that they saw was that although no different 30 day mortality was higher in patients with percutaneous strain placement. Drainage success was higher in patients undergoing er C P. The adverse events were lower in patients undergoing er C P and the length of stay was lower in patients going undergoing er C P. So the panel consensus for that clinical question was that they favored er C P given its reduced length of stay, less of adverse events. And based on patient values, the caveats to this were patients with surgically altered an anatomy who could not undergo er C P. And there is a subset of clinically ill patients who are not ideal candidates for er C P and then a percutaneous strain may be the acceptable treatment option. The second clinical question was timing of intervention. Does it matter if the procedure is formed within 48 hours or greater than 48 hours? And the outcomes here were inpatient mortality, 30 day mortality, persistent organ failure and length of hospitalization. They looked at nine observational studies. They were two prospective seven retrospective and they had a total patient count of 7534. What they noted was that inpatient mortality was lower in patients undergoing early er C P. 30 day mortality was lower in patients undergoing early er C P. Although not significant, the organ failure was lower in patients undergoing early er C P and length of stay was shortened by about 5.6 days in patients undergoing early er C P. The panel consensus here was they recommend performance of an er C P within 48 hours of admission. The desirable effects of er C P less than 48 hours include lower inpatient mortality, lower 30 day readmission and a shorter length of stay. And then lastly, they looked at whether there is a difference between combined endoscopic therapy using the modalities that we talked about earlier or just endoscopic decompression by placement of a stent and their outcomes here were effective decompression, adverse events, length of hospitalization and need for reintervention. They looked at nine studies, one was a randomized control trial and eight of them were retrospective observational studies. They had a total of 903 patients. 418 underwent decompression alone and 485 underwent decompression with other forms of therapy. What they noted was that the drainage success was higher in just endoscopic decompression, although not significant adverse events were higher in patients undergoing combined endoscopic therapy, bleeding was higher in patients undergoing combined endoscopic therapy and pancreatitis was about the same. The length of stay was lower in patients undergoing combined endoscopic therapy. Their conclusion was that they favored combined endoscopic therapy except if the patients are hemodynamically unstable coagulopathic or on antithrombotic agents and who would need to have anti coagulation resumed immediately after sphincterotomy is performed and this is a summary of their recommendations. They state for patients with chole, we suggest er C P over a percutaneous transat biliary drainage. For patients with chole, we suggest the performance of er C P within 48 hours of admission. And for patients with collegis, we suggest biliary drainage should be combined with other maneuvers such as sphincterotomy and stone removal versus a stent alone. The conclusion at the end of the paper was that controlled studies are still needed to define the outcomes of specific endoscopic therapies for COIT, especially in the setting of common bile duct stones, the adverse events and cost of initial procedure as well as subsequent treatment need to be accounted for when making these decisions and then to optimally guide clinical management, additional studies should report and stratify outcomes by disease severity and rigor rigorously address new endoscopic therapies and technologies and colonitis. Created by
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