The Effectiveness of Endoscopic Retrograde Cholangio- pancreatography in the Management of Patients with Jaundice at Cipto Mangunkusumo Hospital, Jakarta
Arman A. Abdullah
1, Murdani Abdullah
2, Ahmad Fauzi
2, Ari F. Syam
2, Marcellus Simadibrata
2, Dadang Makmun
21 Department of Radiology, Faculty of Medicine University of Indonesia - Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia. Correspondence mail: [email protected].
2 Department of Internal Medicine, Faculty of Medicine University of Indonesia - Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71 Jakarta Pusat 10430, Indonesia
ABSTRAK
Tujuan: untuk mengevaluasi manfaat endoscopic retrograde cholangiopancreatography (ERCP) dalam penanganan pasien yang memiliki gambaran klinis ikterus. Metode: sebuah studi deskriptif retrospektif dilakukan dengan menganalisa 129 prosedur ERCP yang dilaksanakan untuk 122 pasien di Rumah Sakit Umum Pusat Cipto Mangunkusumo dari Januari 2008 hingga Desember 2010. Tujuh orang pasien menjalani prosedur ERCP kedua. Keluhan utama adalah gambaran ikterus pada kulit pasien. ERCP dilaksanakan sesuai indikasi, dengan catatan lengkap mengenai distribusi penyakit yang diderita, hasil dari prosedur serta komplikasi yang terjadi.
Hasil: subjek pada studi ini terdiri dari 63 pria (52%) dan 59 wanita (48%). Tujuh pasien menjalani ERCP dua kali. Data menunjukkan bahwa 68 prosedur (pada 63 pasien) diindikasikan oleh batu empedu, 53 prosedur (pada 52 pasien) diindikasikan oleh tumor atau massa, dan 8 prosedur (pada 7 pasien) dengan indikasi infeksi. Sepuluh dari 129 prosedur (8%) menunjukkan hasil normal, 96 prosedur (74%) menunjukkan hasil yang abnormal. Pada 23 kasus (18%), kanulasi yang sulit terjadi selama ERCP dan akses ke duktus koledokus (common bile duct) tidak tercapai. Dari 53 pasien dengan temuan batu positif, ektraksi berhasil dilakukan pada 43 pasien (81%); termasuk 12 pasien dengan ERCP sulit yang masih menyisakan fragmen-fragmen batu (23%).
Ekstraksi tidak berhasil dilakukan pada 10 pasien (19%). Dari 53 pasien, 51 (96%) diantaranya memiliki batu radiolusen dan 2 pasien (4%) memiliki batu radioopak. Stent terpasang pada duktus koledokus (30 kasus, 83%), duktus pankreas (4 kasus, 11%), dan diluar duktus koledokus (2 kasus, 5%). Komplikasi terjadi pada 3 kasus (2%), termasuk migrasi stent keluar dari duktus koledokus (2 kasus) dan satu kasus dengan basket yang pecah.
Kesimpulan: prosedur ERCP sangat berguna membantu klinisi dalam diagnosa dan tindakan terapi kelainan- kelainan pankreatobilier yang membutuhkan ektstraksi batu empedu dan pemasangan stent.
Kata kunci: ERCP, ikterus, koledokolithiasis, tumor pankreatobilier.
ABSTRACT
Aim:.to evaluate endoscopic retrograde cholangiopancreatography (ERCP) benefits in treating patients with clinical appearance of yellowish discoloration. Methods: a descriptive retrospective cross-sectional study was performed on 122 patients at Cipto Mangunkusumo Hospital from January 2008 to December 2010. The main complained was yellowish discoloration of the skin. ERCPs were performed as appropriate, and then the distribution of disease entity, results of procedure and complications were noted. Results: subjects of this study consist of 63 males (52%) and 59 females (48%), 7 patients have undergone ERCP 2 times. Data showed 63 cases (51%) were indicated by stone and 52 cases (43%) by tumor/mass and 7 cases by infection (6%).
Ten out of 122 cases (7%) showed normal results. Difficult canulation was encountered in 23 cases (18%) as access to the CBD could not be obtained. From 53 cases with stone, the extraction was successful in 43 (81%)
including while 12 procedures with high grade of difficult ERCP left stone remnants (23%), and the remaining 10 procedures entailed stones retention (19%). Radioopaque stones found in 2 cases (4%) and radioluscent in51 cases (96%). Stent placement was done in CBD (30 cases, 83%), pancreatic duct (4 cases, 11%), and extraneous CBD (2 cases, 5%). Complications found 3 cases (2%) migration stent outside CBD in 2 cases, 1 case with crand radioluscentin 51 acked basket. Conclusion: ERCP procedure is really helpful in assisting clinicians to diagnose and manage therapeutic measures, especially in pancreaticobilliar tract disorder, while performing stone extraction and stent placement.
Key words: ERCP, icterus, choledocholithiasis, pancreaticobiliary tumor.
INTRODUCTION
Since its discovery 30 years ago,the use of endoscopic retrograde cholangiopancreatography (ERCP) has developed rapidly, not only as a diagnostic tool but also for therapeutic uses especially in patients with pancreaticobiliary diseases. Other diagnostic modalities of these diseases still could not replace ERCP main role, this superiority a malgamated by peripherals development of ERCP such as sphincterectomy device, stent replacement apparatus, and stone extraction instruments.
The most frequent abnormality encountered in pancreaticobiliary tract is obstruction, which is commonly caused by stones, tumors, or infection. Choledocholithiasis is one of the most common disorder in pancreaticobiliary tract, and ERCP procedures, using ballooned double- lumen catheter, wired basket, and mechanical lithotripsy, found helpful especially in non- operated patients.
Other cause of obstruction is tumor, with papyllary cholangiocarcinoma being the most common, follow by pancreatic head tumors, whilst the incidence is increasing due to better sensitivity of developing diagnostic tools.
ERCP is undoubtedly advantageous in assisting physicians to diagnose and manage therapeutic measures, especially in pancreaticobilliar tract disorders. Hopefully this procedure could be continuously developed into further extent.1,2
METHODS
ERCP procedures were done during period of January 2008 until December 2010 in Radiology Department, Cipto Mangunkusumo General National Hospital, by using Phillips®
ERCP equipment. All the procedures were done
by gastroenterologist, Department of Internal Medicine in collaboration with Gastrointestinal Division of the Department of Radiology, University of Indonesia. The Indication, result and complications found within 30 days after the procedure was noted, the pertinent data were collected from medical records. In general indication of the ERCP were obstructive jaundice or gallstone pancreatitis. The ERCP was done as a guideline. At the time of ERCP, if found the billiary stone, we will attempt to perform the extraction of the stones. But if there were large or impacted stones that may be be difficult remove, we just only put biliary stenting. Endoscopic stent placement was performed if patients with malignant billiary obstruction.
RESULTS
During the period between January 2008 and December 2010, 129 ERCP procedures were done on patients presenting with jaundice. Data showed 63 procedures indicated by stone (52%) and 52 cases by tumor/mass (43%) and infection 7 cases (5%). Subjects of this study consist of 63 males (52%) and 59 females (48%), included in are 7 patients having ERCP 2 times.
Table 1. Demographic data of patients
Variables N (%)
Gender distribution
- Male 63 (52)
- Female 59 (48)
Age distribution
- < 30 yrs 8 (7)
- 30-39yrs 20 (16)
- 40-49yrs 30 (25)
- 50-59yrs 37 (30)
- > 60 yrs 27 (22)
ERCP Diagnosis
Figure 1. Subject diversity according to clinical diagnosis (n=122)
Table 2. Results of ERCP procedures (n= 129)
Results N %
Normal ERCP results 10 8
Abnormal ERCP results 96 74
Difficult cannulation (unable to go
through CBD) 23 18
Total 129 100
Table 3. Final outcome in patients with positive stone findings (n= 53)
Outcome of stone extraction N % Successful stone extraction (no remnants) 31 58
Stone remnants persisted 12 23
Stone retention 10 19
Total 53 100
Table 4. Stent placement result characteristics (n= 36) Outcome of stent placement N %
Proper placement in CBD 30 83
Proper placement in pancreatic duct 4 11
Extraneous CBD/Migration 2 5
Total 36 100
Other stent placement characteristics:
• Second stent placement: 2 cases
• Stent extraction: 4 cases (3 cases replaced)
• Double stent placement: 1 case of cholangiocarcinoma
• Wall stent placement: 1 case
Table 5. ERCP complications
Stent migration 2 cases (1 in papillary tumor and 1 in pancreatic head tumor)
Cracked basket 1 case due to large gallstone. Pieces of the crushed basket were removed during the next ERCP procedure and stent was deployed to handle the biliary obstruction. The large gallstone was subsquently removed Hemorrhage/
perforation Not found
A B
Figure 2. Male, 40 years old with pancreatic head tumor. (A) Muliple calcifications in pancreas. (B) Stent in Wirsungi duct
A B
Figure 3. Male, 55 years old with papillary tumor. (A) Plain photo: stent. (B) Cholangiography through gallbladder:
migration of stent from CBD.
Hepatoma
Duodenal tumor
Cholangiocarcinoma
Pancreatic head tumor
Pancreatitis
Klatskin’ tumor
Papillary tumor
Gallstones
Clinical diagnosis Indications of ERCP - Clinical diagnosis
Figure 4. Female, 59 years old, post-cholecystectomy. The patient still suffered from jaundice after stent insertion. In second ERCP, migration of stent was observed, and then a new stent was inserted into the CBD.
Two duodenal diverticulosis cases were coincidentally encountered in ERCP procedures done during the period. Radioopaque stones found in 2 cases (3%) out of 63 stone-indicated procedures and 61 cases characterized with radioluscent stones (97%). Most of the stones are radioluscent, although 20% of stones contain calcium carbonate hence appeared radioopaque.3
(no remnant), in 12 (19%) cases the stone mostly extracted but some remnants cannot be removed because of quantity and position of stone which are mostly located in left and right side of intra hepatic, only those which located in CBD can be removed completely. 43 (81%) the stones can removal, only 10 (19%) failed during examination. Baron TH and Harewoods GC7 reported 94.3% overall succesful stone removal.
Therefore, we tried procedure stent placement in those cases, included 2 more cases with stone failure removal. Total cases that treated by stent placement were 14 cases all. Endobiliary stents are used for palliative purposes to relieve symptoms of biliary obstruction. The patency duration of plastic stents is 2 to 4 months.
Metallic stents is longer (4 to 6 months) than plastic stents, but the survival for both devices are not different when stents occlusion are replaced with new stents.8
Another cause that mostly found in obstructive icterus case is neoplasma. Over 80% of malignant ductus biliary lead to carcinoma. The other tumor commonly found are papyllary tumor and small cell carcinoma, adenosa squamosa.
Melanoma maligna cases are rarely found, but rhabdomyosarcoma was been detected in pediatric patients. Data of prevalence pappyla vateri tumor in Indonesia still not found. Based on one research in French announced that pappyla vateri tumor was rarely found. They only had 111 cases in 20 years during 1976–1995 period, which were the incidence on male patients were higher than female patients (3.8 versus 2.7 per one million people).9
The incidence of cholangicarcinoma in United State are around 2000–3000 cases every year which is equivalent to 1–2 cases per 100.000 people.10 Of the total 129 neoplasm’s cases on this research revealed that 52 tumor
A B C
Figure 5. Female, 33 years old, stone in CBD. (A) Stone extraction in CBD, basket was broken and stone could not be extracted.
(B) Broken basket in CBD. (C) Extraction with new stent.
DISCUSSION
According to the results of the National Health and Nutrition Examination Survey (NHANES III), over 20 million people in the United State suffered from gallstone infection (based on USG results or review of gallstone surgery).4
The exact incidence of choledocholithiasis cases is still surely unknown, but there is assumption on 5-20% range of patient who treated by cholesistektomi commonly furthered having choledocholithiasis.5,6
This research have found that 63 patient with indicated by stone (49%) had treated with following ERCP procedures. The ERCP procedures has already perform in 53 cases, in 31 (49%) cases the stone had extracted completely
cases (43%) were diagnosed infecting billiary duct with mostly papilla valeri tumor found on 28 cases (54%), cholangio carsinoma (including Klatskin tumor 11 cases) on 16 cases (31%).
Other neoplasm that were also found with fewer number comprised pancreatic head tumor 4 cases (3.2%), duodenal tumor 2 cases (1.6%), and 1 hepatoma’s case (0.8%).
Another cause that lead patient to have ERCP treatment is post cholesistectomy syndrome. The treatment of post cholesistectomy syndrome needs ERCP procedure for observing and handling obstructive ductus billiari which is following on cholesistectomy procedure. In this research, 5 cases (4%) were having ERCP procedure.
Stent replacement on ERCP is for aiming billiary drainage which is interrupted by stone, neoplasm, or stenosis that is caused by complicated infection or post cholecystectomy. In this research, stent placement is implemented on 14 (39%) cases of stone, 6 (17%) cases of papilla tumor, 11 (31%) cases of cholangio carcinoma, 1 (3%) case of head of pancreatic tumor, and 4 (11%) cases of gallbladder infection. Salim S et al11 reported 53% patients succed in plastic stent placement in obstructive jaundice 6 in malignancy and 13 cases non malignancy.
(Figure 2)
About in range 8–10% case procedure, the migration of stent might be occur during stent placement on billiary duct, and mostly the stent will naturally excrete from gastrointestinal system. In several case rarely occur, stent get stuck or prick intestine membrane that causing perforation,. Migration can occur into the proximal duct or into the gut. Risk factors associated with proximal stent migration are malignant strictures, large stent diameter, and short stent length.10,11 On that case, endoscopy procedure is necessary on handling stent migration. However, if the procedure cannot be execute or stent location undetectable, then patient must be treat under observation to find acute abdomen symptom until stent can be completely evacuate from patient’s body. When patient’s body show an acute abdomen symptom, then mostly surgery procedure is needed.
According to this study, the migration occurred in 2 cases (5%); 1 case is papillary tumor and 1 case is pancreatic head tumor from 36 cases that perform stent placement had stent migration.14
(Figure 3, Figure 4)
Aside from its benefits, ERCP procedure also hcarries potential risks of complication side effect which is can reach until 10% from total procedure in hospital with professional paramedic and frequently using this procedure.14 Complication side effect that might be occurring is bleeding/perforation. In this research, bleeding and perforation was not found.
In this research, 2 cases of contrast extravasations out from ductus billiary, one case are caused by illness (hepatoma) and the other was caused by having previous cholesistectomy procedure. It was shows that ERCP was effective for evaluating rupture or leak on ductus billiary and solved the leakage with stent.
The crush basket incident during evacuating stone from ductus choledocus is rarely happens.
Kelly at al15 and Ryozawa at al16 report an unusual complication of ERCP with basket fracture and retention followed by recovery of the retained basket at second ERCP. In this report, 1 (1%) incident occurs during extracting a large and hard stone which is causing the basket crush.
Then, another basket was required to evacuate the remaining pieces of the stone. Stent placement was inserted to handle biliary obstruction. The stone cannot be removed because it cannot pass through the biliary duct and cannot be extracted by a lithotripter. Later success was obtained at the second attempt. (Figure 5)
CONCLUSION
The ERCP imaging procedure is very helpful in assisting clinicians to diagnose and manage therapeutic measures, especially in pancreaticobiliary tract disorders which need stone extraction and stent placement.
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