ENDOSCOPIC MANAGEMENT OF CHOLEDOCOLITHIASIS RELATED TO PERIAMPULLARY DUODENAL DIVERTICULA

M.E. GRIGORIU; R.V. COSTEA; Corina I. GRIGORIU; Florentina L FURTUNESCU

M.E. GRIGORIU “Carol Davila” University of Medicine and Pharmacy Bucharest
R.V. COSTEA “Carol Davila” University of Medicine and Pharmacy Bucharest
Corina I. GRIGORIU “Carol Davila” University of Medicine and Pharmacy Bucharest
Florentina L FURTUNESCU “Carol Davila” University of Medicine and Pharmacy Bucharest

Abstract

Aims: Periampullary duodenal diverticula is a subject still widely debated in the literature. Our study aimed to describe the characteristics and the clinical outcomes of a case series of subjects with periampullary duodenal diverticula and bile duct stones, receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP), by comparison to patients having only bile duct stones. Material and methods: 639 consecutive patients with bile duct stones have been investigated through ERCP during 2011 – 2016 in a single specialized center of gastrointestinal surgery. Periampullary duodenal diverticula (PADD)’s prevalence reached at 16.9% (n=108 cases). The patients with PADD have been compared to those without PADD, by personal characteristics, pathophysiological mechanisms incriminated in producing symptoms and therapeutic outcomes. Results: Patients with PADD showed a predominance of males, and a significantly older age. Most frequent abnormality was angulation of the terminal CBD group and jaundice occurred in a significantly higher proportion compared to non PADD group. The percentages of successful selective cannulation and sphincterotomy were significantly lower in the PADD group, even comparable to the literature; meanwhile mechanical lithotripsy was required in a higher proportion of cases. Main cause of failure of cannulation was the changed distal track of the duct. The frequency of postoperative complications was like patients without periampullary duodenal diverticula. Conclusions: Therapeutic endoscopic retrograde cholangiopancreatography is obviously a more difficult procedure in the presence of periampullary duodenal diverticula, due to the difficult access to the papilla and the common bile duct, but the success rate remains high even in such cases.

Author Biographies

M.E. GRIGORIU, “Carol Davila” University of Medicine and Pharmacy Bucharest

1^st Surgical Department

R.V. COSTEA, “Carol Davila” University of Medicine and Pharmacy Bucharest

2^nd Surgical Department

Corina I. GRIGORIU, “Carol Davila” University of Medicine and Pharmacy Bucharest

1^stDepartment of Obstetrics and Gynecology

References

1. Kirk AP, Summer eld JA. Incidence and significance of juxta papillary diverticula at endoscopic retrograde cholangiopancreatography. Digestion 1980; 20: 31-35.
2. Ozogul B, Ozturk G, Kisaoglu A, Aydinli B, Yildirgan M, Atamanalp SS. The clinical importance of different localizations of the papilla associated with juxta papillary duodenal diverticula. Can J Surg. 2014; 57(5): 337-341.
3. Lee BS, Ryu J, Lee SH, et al. Midazolam with meperidine and dexmedetomidine vs. midazolam with meperidine for sedation during ERCP: prospective, randomized, double-blinded trial. Endoscopy 2014; 46(4): 291-297.
4. Altonbary AY, Bahgat MH. Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation. World J Gastrointest Endosc. 2016; 25; 8(6): 282-287.
5. Trna J, Penka I, Buliková B, Zbořil V, Novotný I. Juxtapapillary duodenal diverticulum causing pancreatobiliary problems - case report and literature review. Rozhl Chir. 2016; 95 (7): 294-297.
6. Tomizawa M, Shinozaki F, Motoyoshi Y, Sugiyama T, Yamamoto S, Sueishi M. Association between juxtapapillary diverticulum and acute cholangitis determined using laboratory data. Clin Exp Gastroenterol. 2014; 7: 447-451.
7. Vaira D, Dowsett JF, Hateld AR, et al. Is duodenal diverticulum a risk factor for sphincterotomy? Gut 1989; 30: 939-942.
8. Mariani A., Di Leo1 M., Giardullo N., Giussani A., et al. Early precut sphincterotomy for difficult biliary access to reduce post-ERCP pancreatitis: a randomized trial. Endoscopy 2016; 48: 530-535.
9. Park CS, Park CH, Koh HR, et al. Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation. J Gastroenterol Hepatol. 2012; 27(9): 1480-1483.
10. Tyagi P, Sharma P, Sharma BC, Puri AS. Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography. Surg Endosc 2009; 23: 1342-1345.
11. Lobo DN, Balfour TW, Iftikhar SY. Periampullary diverticula: consequences of failed ERCP. Ann R Coll Surg Engl 1998; 80(5): 326-331.
12. Li X, Zhu K, Zhang L, Meng W, Zhou W, Zhu X, Li B. Periampullary diverticulum may be an important factor for the occurrence and recurrence of bile duct stones. World J Surg. 2012; 36(11): 2666-2669.
13. Ko KS, Kim SH, Kim HC, Kim IH, Lee SO. Juxtapapillary duodenal diverticula risk development and recurrence of biliary stone. J Korean Med Sci. 2012; 27(7): 772-776.
14. Parlak E, Suna N, Kuzu UB, et al. Diverticulum with Papillae: Does Position of Papilla Affect Technical Success? Surg Laparosc Endosc Percutan Tech. 2015; 25(5): 395-398.
15. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, Occhigrossi G, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with periampullary duodenal diverticula (PAD). Clin Ter. 2014; 165(4): 291-294.
16. Testoni P. A., Mariani A., Aabakken L., et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683.