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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 4  |  Page : 302-310

Endoscopic management and clinical outcomes of obstructive jaundice


1 Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
2 Department of Anaesthesia, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
3 Department of Radiology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
4 Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
5 Piedmont Physicians Gastroenterology, Georgia
6 Division of Gastroenterology/Hepatology, Froedtert and Medical College of Wisconsin Health Centers Clinics, Milwaukee, USA
7 Division of Gastroenterology/Hepatology, Warren Alpert Medical School of Brown University, Rhode Island, USA

Date of Submission29-Jul-2020
Date of Decision05-Sep-2020
Date of Acceptance08-Sep-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Dr. Olusegun Isaac Alatise
Department of Surgery, Division of Gastrointestinal/Surgical Oncology, Obafemi Awolowo University/Teaching Hospitals Complex, PMB 5538, Ile-Ife, Osun
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_242_20

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  Abstract 


Background: This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. Materials and Methods: We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. Results: A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). Conclusion: ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.

Keywords: Endoscopic retrograde cholangiopancreatography, gallstones, jaundice, malignant strictures, Nigeria


How to cite this article:
Alatise OI, Owojuyigbe AM, Omisore AD, Ndububa DA, Aburime E, Dua KS, Asombang AW. Endoscopic management and clinical outcomes of obstructive jaundice. Niger Postgrad Med J 2020;27:302-10

How to cite this URL:
Alatise OI, Owojuyigbe AM, Omisore AD, Ndububa DA, Aburime E, Dua KS, Asombang AW. Endoscopic management and clinical outcomes of obstructive jaundice. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 24];27:302-10. Available from: https://www.npmj.org/text.asp?2020/27/4/302/299913




  Introduction Top


In West Africa, the most common aetiology of biliary obstruction is a malignant stricture[1] (surgical intervention in the form of the palliative bypass has been the main modality of management primarily due to the unavailability of other options). Unfortunately, surgery is associated with significantly high perioperative mortality and morbidity.[2],[3] West and Central Africa data have reported mortality rates as high as 50%.[1],[3],[4],[5],[6],[7] This unacceptably high mortality is attributed to late patient presentation with associated co-morbidities such as hepatorenal syndrome and liver failure.[3]

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic technique for various pancreaticobiliary disorders.[8] Since its establishment in 1968, ERCP has significantly revolutionised the management of obstructive jaundice and significantly reduced the role of surgery.[9],[10] ERCP has both a diagnostic and therapeutic role in both malignant and benign pancreaticobiliary disorders. ERCP is commonly utilised in the management of choledocholithiasis, bile leak or malignant obstruction from pancreatic lesion or cholangiocarcinoma. ERCP serves as a bridge to surgery by providing immediate biliary decompression, thereby reducing the perioperative mortality associated with surgery.[11],[12] In a resource-limited setting with limitation of quality imaging, the cholangiogram serves as an important tool in the assessment and provides an opportunity for more precise diagnostic capability, including sampling for malignant evaluation. In settings where less invasive methods, including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) for diagnostic purposes, are readily available, ERCP is only indicated for a therapeutic or palliative purpose.[13] It has been suggested that facilities for standard ERCP procedures should be available at the community level because of the indications for the procedure.[14]

Three factors have limited the availability of ERCP in most West African countries. First, ERCP is a highly technical procedure requiring unique technical, cognitive and integrative skills.[6] The learning curve in many advanced endoscopy fellowship programmes is generally steep. In general, trainees require 150–200 cases to reach reasonable competence even for the basic biliary technique.[15] Second, the procedure is associated with significant morbidity and mortality. In the short term, about 10% of patients who had ERCP will have some complications such as pancreatitis, cholangitis, bleeding, and perforation, while overall 0.1 and 6% mortality rate has also been documented.[16],[17],[18],[19] Following endoscopic sphincterotomy, few post-ERCP patients may suffer repeated cholangitis and acute pancreatitis in the long term.[16] Third, one of the most common global indications for ERCP is stone diseases, which appears to be rare in West Africa, thus limiting exposure of such cases in training.[20] However, this paucity of diagnosed choledocholithiasis cases in the sub-region may be due to under-reporting and underdiagnosis.

Conventionally, training in ERCP has transitioned from an apprenticeship model to competency-based medical education.[6],[15] This process involves that a trainee must be taken through graded exposure to the procedure, starting from learning the passage of the duodenoscope and functions of various ERCP accessory tools, attempting cannulation, and finally, performing the entire ERCP procedure under the supervision of a trainer within a fixed period. As trainees become more proficient with the basic techniques, they can attempt therapeutic interventions. All these procedures are performed by trainees on patients during their clinical training.[21],[22] Some training centres have simulators to facilitate the skills transfer.[22] Unfortunately, no training opportunity for interested trainees exists in West Africa. Accessing training opportunities in developed centres is limited, with little or no hands-on training for very few. Given the urgent need for this rare skill set, we propose a reverse combination of apprenticeship and competence-based training model in which the trainer visits the local hospital to train local gastroenterologists a week in each quarter of the year. This study presents our initial experience of establishing an ERCP programme at an academic teaching hospital in Nigeria. We highlight the types of cases evaluated, procedures performed and clinical outcomes.


  Materials and Methods Top


Study setting

The study was a cross-sectional study carried out at the Gastrointestinal Endoscopy Unit of our hospital from March 2018 to February 2020. All participants signed informed consent as approved by the Ethics and Research Review Board of Obafemi Awolowo University Teaching Hospitals Complex (protocol number ERC/2019/01/08).

Study population

Consecutive patients who underwent therapeutic ERCP within the timeframe were enrolled in the study. The diagnosis of obstructive jaundice was based on the demonstration of direct hyperbilirubinaemia (>30 micromol/L) in association with dilated extra and/or intrahepatic biliary tree on pre-procedural imaging, which included a combination of abdominal ultrasound, computerised tomography scan, magnetic resonance imaging and/or MRCP. The clinical details and imaging features were reviewed at multidisciplinary meetings to assess the appropriateness of the referral and the pre-operative diagnosis. The multidisciplinary meeting is made of the Endoscopist (Surgeons/Physicians), Radiologists, Anaesthesiologists, Nurses, and their trainees. Patients with obstructive jaundice due to a mass in the head of the pancreas, gallbladder, or bile ducts are regarded to have a malignant process. Patients were excluded if they had hepatic encephalopathy or deranged clotting profile as measured by the prothrombin time/international normalised ratio.

Procedure

All the patients were admitted at least the night before the procedure. Any medical conditions, which could substantially increase the risk of the procedure, were assessed before and during admissions. Electrolyte derangements were corrected before the procedure. Clotting factor derangements were corrected with the use of Vitamin K and fresh frozen plasma as indicated. Antibiotics were administered prophylactically before all ERCPs using intravenous cefuroxime and metronidazole at the induction of anesthesia. The procedures were performed under general anesthesia. Sevoflurane was used in all the patients. Patients were placed in a semi-prone position for the procedure. In discussion with the anesthesiologist, patients with ascites were placed in a supine position. The procedures were performed using the Evis Exera II Videoduodenoscope Tjf-Q180V. C-arm was used for real-time fluoroscopic visualization of the biliary tree after injection of contrast agent into the biliary tree. The contrast agent, ScanluxR 370 mg/ml, which contains 755 mg/ml Iopamidol as the active substance, was diluted with normal saline in equal proportions. Wire-guided sphincter cannulation method was utilised in all the patients. After cannulation of the papilla with sphincterotome and opacification of the biliary tree, subsequent procedure interventions were determined by the findings. Procedure options performed included sphincterotomy, sphincteroplasty, balloon stone extraction, dilatation of stricture, brush biopsy, mechanical lithotripsy, and placement of the biliary stent, which includes plastic or metallic stent. Access papillotomy (previously described as pre-cut or needle knife papillotomy) was used sparingly in patients with difficult endoscopic biliary cannulation.

Post-procedural evaluation

All patients were closely monitored in the ward for 48 h and accessed for post-procedure complications. Antibiotics were continued for 24–48 h in individuals with concerns for incomplete biliary decompression post-procedure and discontinued when it was clear that the stent was draining adequately and no significant complication. Bilirubin levels were followed at 24 and 48 h after the procedure. Patients underwent a laparoscopic cholecystectomy as clinically indicated or were discharged when bilirubin was trending down. Patients with failed biliary cannulation were scheduled for repeat procedure within 48 h of the initial procedure. Those that had failed procedures were referred for percutaneous transhepatic cholangiography (PTC) with percutaneous transhepatic biliary drainage (PTBD) or surgical bypass.

Data collection and analysis

Collected data included demographics, clinical history, radiographic interpretation, procedural findings, and periprocedural laboratory data. The clinical data, including ERCP indications, duration of the procedure, the procedure performed, length of hospital stay, clinical course including complications, and outcomes were prospectively collected. The majority of the patients were referred from other hospitals. The referring doctors and/or the patients themselves were contacted to access the outcome of the procedure after 1 week. In this study, post-ERCP pancreatitis was defined as significant abdominal pain, which lasted >4 h after the procedure. Post-ERCP bleeding was defined and classified as immediate (haemorrhage at the time of sphincterotomy) or delayed (haemorrhage after sphincterotomy and manifested by melena, haematemesis, or hematochezia associated with a decrease in haemoglobin level) according to Cotton et al., classification.[23] The severity of bleeding was classified as mild (with endoscopic evidence of bleeding with a hemoglobin decrease <3 g/dl), moderate (require a transfusion of 4 units or less), severe (require more than four units of blood transfusion or intervention).

Data collected was analysed using the IBM SPSS Statistics for Windows, version 22. 0 Armonk, NY: IBM Corp. Categorical variables were presented as frequencies and in tables and charts. Continuous variables such as age were presented as mean with standard deviation and median for the duration of symptoms. Chi-square was used to assess the relationship between the procedure and the clinical outcome. The correlation coefficient was used to assess the relationship between the pre-operative and post-operative bilirubin levels.


  Results Top


A total of 177 patients were referred for ERCP, 146 patients had an ERCP performed for obstructive jaundice and 31 patients were excluded due to the wrong diagnosis on imaging, poor functional status, and wrong indication. The median age of the patients who had ERCP was 55 years, with a range from 8 to 83 years. There were 74 (50.7%) females with a male-to-female ratio approximately 1:1. The majority (94/146 [64.4%]) of patients were referred from the South-West, Nigeria [Figure 1].
Figure 1: Three-dimensional pie chart showing the distribution of patients from different geopolitical zones in Nigeria

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The most common referral diagnosis for ERCP was cancer of the head of the pancreas 56/146 (38.3%), followed by choledocholithiasis 29/146 (19.9%), cholangiocarcinoma 22/146 (15.1%), gallbladder cancer 11/146 (7.5%) [Table 1]. After the multidisciplinary review of all the clinical and radiological investigations, the pre-procedure diagnosis included cancer of the head of the pancreas in 41/146 (28.1%), choledocholithiasis in 28/146 (19.2%), cholangiocarcinoma in 24/146 (16.4%) and gallbladder cancer in 13/146 (8.9%). Overall, the malignant conditions at ERCP have seen 102/146 (69.9%) patients, while benign conditions were in 44/146 (30.1%) patients [Table 2]. Laboratory results revealed the hepatitis B surface antigen and hepatitis C virus antibody positivity in 3 (2.1%) and 2 (1.4%) patients, respectively. Three (2.1%) patients had HIV seropositivity. Clinical co-morbidities included diabetes mellitus in 51/146 (34.9%) patients and hypertension in 79/146 (54.1%) patients at presentation [Table 2].
Table 1: The referral diagnosis versus the preprocedure diagnosis in the patients who had endoscopic retrograde cholangiopancreatography (n=146)

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Table 2: Clinical and laboratory parameter (n=146)

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Overall, there was successful sphincter cannulation with technical and clinical success in 118/146 (80.8%) patients. Of the 118 we performed access papillotomy (needle knife sphincterotomy) were 18 (15.3%). Besides, 12/118 (10.2%) patients had successful repeat procedure within 48 h of the failed first attempt. Failed sphincter cannulation occurred in 11/146 (7.5%) patients while 17/146 (11.6)% of the cohort had duodenal, periampullary, or cancer of the head of the pancreas that has eroded into the duodenum, which either caused complete disruption of the papilla or complete occlusion of the second part of the duodenum [Figure 2]. All the patients with malignant lesions altering the ampulla anatomy had esophagogastroduodenoscopy and biopsy. If this group of patients was removed from the statistics, the overall technical and clinical success rose to 91.5%. As shown in [Table 3], of the 44 patients with benign indications, 39 patients had successful sphincter cannulation with a success rate of 88.6%. Similarly, of the 102 patients with malignant indications, 79 patients had successful sphincter cannulation, given the success rate in the malignant condition of 77.4%. When those with altered anatomy were excluded because of malignancy, the success rate was 92.9%.
Figure 2: Photograph of a patient with a peri-ampullary tumor that has destroyed the ampulla

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Table 3: Endoscopic retrograde cholangiopancreatography findings (n=146)

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The common ERCP findings in patients with malignant etiology included proximal bile stricture in 31/102 (30.4%), distal bile strictures in 30/102 (29.4%), periampullary cancer 20/102 (19.6%), and mid bile duct stricture in 9/102 (8.8%) [Table 3]. The common findings in patients with benign aetiology included choledocholithiasis in 33/44 (75%) [Figure 3] and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0) patients had choledochal cysts [Table 3].
Figure 3: Fluoroscopic image of a patient with common bile duct stones, biliary duct dilatation, and guidewire insitu

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Sphincterotomy was performed in 115/118 (97.5%) patients. Sphincterotomy was not performed in 3 (2.5%) patients who had deranged clotting profiles that were not controlled before ERCP. Sphincteroplasty was performed in 10/118 (6.8%) of patients. Sphincteroplasty was performed to aid biliary stone extraction in 8 of the patients and performed in 2 patients for tight malignant stricture around the ampulla to aid stent insertion. Biliary stents were placed in 81/118 patients. Of these, biliary strictures were dilated using a dilation catheter or balloon catheter to allow the placement of the stent in 8 (81) (9.9%) patients. Eighty-one patients out of a hundred and eighteen (68.6%) had biliary stent placement. Of these, the biliary tree was dilated to allow placement of the stent in 8/81 (9.9%) patients. Plastic stents were placed in 49/81 (60.5%) patients, while self-expanding metallic (SEM) stents were inserted in 32/81 (39.5%) patients. Two patients had concomitant pancreatic and biliary stents placement [Figure 4]. The indications for the insertion of the stents are shown in [Table 4]. Of the 28 patients who had distal obstructions, 13 patients had plastic stents placed while 15 patients had SEM stent placed.
Figure 4: Photograph of the biliary and pancreatic stent in one of the patients

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Table 4: Endoscopic retrograde cholangiopancreatography findings and the type of stents placed (n=81)

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Of the patients with choledocholithiasis, 31 patients had balloon stone extraction. This was sufficient to treat the choledocholithiasis in 26 patients at the first attempt, while seven patients required stent placement because of stone size [Table 4]. Plastic stents were removed within 2 months. The common bile duct stones were successfully extracted in 6 patients, while one was referred for common bile duct exploration because attempted mechanical lithotripsy failed.

Mean serum total bilirubin of patients with the stone disease before the procedure was 97.5 (128.7) μmol/L while the mean serum total bilirubin a week after the procedure was 20.1 (21.3) μmol/L. The difference was statistically significant (P = 0.015). For patients with distal strictures, the mean total bilirubin before and after the procedures were 253.2 (148.4) μmol/L and 56.5 (53.1) μmol/L, respectively, and the differences were statistically significant (P = 0.017) [Table 5].
Table 5: Pre-procedure and one-week post-procedure mean serum bilirubin of the patient who had endoscopic retrograde cholangiopancreatography

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Overall, 8/146 (5.5%) patients had post-ERCP pancreatitis which was mostly mild to moderate. Six of the patients had the stone disease while two patients had malignant bile duct strictures. Six of these patients were female 40 years old or younger. The pancreatitis was managed with bowel rest, analgesic, antibiotics, and intravenous infusions. Pre-procedural rectal indomethacin was administered in 6 of the patients with moderate pancreatitis. Three of the patients with proximal biliary strictures developed cholangitis. One patient had stent migration with recurrence of jaundice and one patient had post-sphincterotomy bleeding. The bleeding was moderate, requiring a transfusion of 2 pints of whole blood and 2 pints of fresh frozen plasma. We had 5 (3.4%) periprocedural mortality.


  Discussion Top


Our experience shows that skill for ERCP in the management of obstructive jaundice can be successfully transferred to a resource-constrained setting like Nigeria using the reverse combination of apprenticeship and competency-based training model. The success of the training programme and quality patient care, was made possible by the collaborative support of international partners, local multidisciplinary teams, including the administration and industrial partners who supported the endoscopic equipment and accessories. Though diagnostic ERCP was performed in Nigeria in the early 1990s,[1] the skill quickly disappeared due to brain drain at a time of economic instability in the country during the military era. It has been challenging to reintroduce ERCP despite the increasing need. Some of the earlier challenges included a lack of requisite equipment and complementary skill set needed to perform the procedures. Current programme success involved a partnership with local distributors for provision of the Olympus duodenoscope, which was further supported by the purchase of equipment by the institution in recognition of the dire need of ECRP programme based on referral volume and clinical outcome on one hand and procedure success and low complication rate on the other hand. The main challenge, as is the case with most resource-limited settings, was the acquisition of accessory tools. Our initial supply was primarily donations. As we expand the programme, we continue to explore opportunities for cost-effective accessories that would be affordable to the institution and patients.

Obstructive jaundice from malignant strictures is the most common indication for the ERCP in Nigeria.[1],[3] The etiology of the malignant strictures include cancer of the pancreas, cholangiocarcinoma, periampullary cancer, and gallbladder cancer. This finding corroborated the previous report from West and East Africa, showing malignant stricture as the most common cause of obstructive jaundice in the region.[1],[2],[4] Most patients with cancer presented at metastatic stages with severely deranged liver enzymes and clinical symptoms; hence, the endoscopic therapy was to palliate the patients.

The overall cannulation rate and completion of the intended treatment in the cohort was 81%. Seventeen patients among our cohort had no attempt at cannulation of the papilla because of significant alteration in the anatomy due to malignancy. These patients had esophagogastroduodenoscopy and biopsy done. The exclusion of these patients increased the cannulation rate in this study to 92%. The actual success rate for this study can be said to be 92%. The cannulation success rate is within the acceptable rate in most developed centres.[14],[17],[19],[24]

It should be noted that most of the failed cases were recorded in the early period of the training. The more cases performed by the local team, the more success we recorded. The previous report had shown that the successful cannulation rate increased to about 80% as the number of performed cases increased to 400 supervised procedures.[25] Post-training, most unsupervised operators attained an aggregated success rate of >96% when they performed about 300 procedures.[25],[26] Hence, the attainment of ≥80% successful deep biliary cannulation should be regarded as the standard for ERCP training programmes[25],[26],[27] With a cannulation rate of 92% within the short period of the commencement of this programme, it can be said that this innovative transfer of skill is a success.

Some of the reasons for failure include duodenal obstruction, a surgically altered anatomy, failed cannulation, and failed wire access across the stricture.[28],[29] All these factors are common in the setting of malignant strictures. Possible ways of dealing with such cases included the use of rendezvous technique, placement of stent through PTC, and endoscopic ultrasound (EUS). All these techniques are not currently available in our centre. Therefore, we recommend that new centers in West Africa interested in developing ERCP should work towards the simultaneous development of interventional radiological and EUS capacity.

ERCP related complications observed in our cohort were low and within the acceptable limit.[30],[31] The most common ERCP-related complications recorded was acute pancreatitis (5.5%). In general, the incidence of post-ERCP pancreatitis (PEP) reported in meta-analyses varies from 3.5% to 15%.[30],[31] Most of the patients who had PEP were female who had stone diseases and balloon clearance of the duct. Previous reviews have identified patient, procedure, and operator related factors as the factors responsible for the occurrence of PEP.[32],[33],[34] All our patients who had PEP responded to conservative management. Patients who we thought were at higher risk of PEP bases on previous reports were offered prophylactic rectal indomethacin. The use of rectal indomethacin is controversial. While some studies suggested its usefulness, some have refuted the assertion.[35],[36],[37],[38],[39] While more study is required to settle the claim and counterclaim, we advise on its prophylactic use, especially in young female patients undergoing ERCP for stone diseases.

Despite our aggressive nature at controlling the clotting indices of the patients before the procedure, one of our patients had post-sphincterotomy bleeding. The bleeding was classified as moderate. The index patient had sphincterotomy and the bleeding was observed during the procedure. Bleeding was stopped using a bipolar probe and injection of adrenalin. However, the patient started passing melaena stool a few hours after the procedure, which suggested a recurrence of the bleeding from the sphincterotomy site. Bleeding from the sphincterotomy site is the most common cause of post-ERCP bleeding. This can occur during or after the procedure. This is common in patients who are on anticoagulants. Post-ERCP bleeding occurs rarely following splenic injury, hepatic injury, and vascular injury and/or pseudoaneurysm following ERCP.[40] In addition, haemobilia may occur after ERCP, especially after stricture dilation, a biopsy of the biliary tree, and ablative biliary therapies.[41]

Five patients died within 72 h of the procedure. All these patients died of sedation-related adverse events. They also had metastatic disease with massive ascites and significant renal impairment before the procedure. A consideration in the pre-procedural evaluation is evaluating respiratory risk factors and possible drainage of ascites depending on co-morbidities, evaluation of risks, and benefits in performing the procedure. An experienced multidisciplinary team is prudent when initiating the programme. The experienced anaesthesiologist should be in attendance during the multidisciplinary meeting and pre-procedure planning.

This study revealed that patients with choledocholithiasis and distal biliary strictures benefit most from this procedure in terms of reduction in the serum bilirubin within the 1st week of the procedure. Most of our patients were referred from distant hospitals and it was difficult to monitor their serum bilirubin levels after the 1st week. ERCP is also useful in the setting of a malignant hilar stricture (MHS) for diagnosis by obtaining a sample for analysis and decompression with stent placement. MHS is generally classified using the Bismuth classification, which also serves as a guide for management. Generally, ERCP drainage methods may be more suitable for Types I and II hilar tumours, while Types III and IV hilar tumours may be more easily drained using PTBD.[42] ERCP has been linked with a higher incidence of cholangitis for patients having MHS more than type 2. Three of our patients with proximal hilar strictures had cholangitis. The cholangitis occurred within 2 weeks of the procedure, necessitating a re-admission of the patients in the hospital. They were managed with the use of antibiotics. It has been recommended that if the level of obstruction is at or above the hilum, extensive injection of contrast should be avoided to minimise the risk of post-procedural cholangitis because the entire biliary tree may not drain adequately.[43]

Biliary stenting was required in most of our patients with proximal and distal bile stricture and the majority of these patients had plastic stents. The recommendation for plastic stent removal or exchange is 3–6 months. Factors that impacted the type of stent used was the availability of the appropriate size and type. Lack of consumables was the greatest challenge as we increased the volume of cases. When compared with SEMSs, plastic stents were associated with more complications.[42] SEM is associated with longer patency and the cost is not significantly higher overall.[44] Even though SEMSs are more expensive than plastic stents, they lower the total medical expenses due to the reduced frequency of re-interventions.[44],[45] Furthermore, in patients with proximal strictures, SEMSs are associated with prolong overall survival.[45] However, when the overall survival of patients is judged to be short or in patients with some benign indication for the stent placement, the plastic stent should be used. Many endoscopists will prefer to use uncovered SEMs in a patient with intact gallbladder to avoid cholecystitis.[46] Four meta-analyses reported this outcome and found no increased risk of cholecystitis after insertion of covered versus uncovered SEMS.[42],[47],[48] It should also be noted that covered SEMs were associated with a lower risk of tumor ingrowth but a higher risk of stent migration, tumour overgrowth and sludge formation.[42]


  Conclusion Top


This study showed that ERCP can be successfully introduced in a resource-constrained setting. The key factor to the success of the programme was the multidisciplinary approach with collaboration between local and international teams. The training was expanded to include nurses and technicians alongside the endoscopists. The challenge of accessories remains; however, with increased volume, understanding of the need and quality patient care, we anticipate access to consumables. The next steps will involve organised expansion of the programme under the guidance of the Society of Gastroenterology and Hepatology in Nigeria with the involvement of experienced endoscopists and continued monitoring of clinical outcomes.

Acknowledgement

  1. Special appreciation to the nursing, radiographers and other support staff
  2. We are grateful to Boston Scientific for the donation of accessories used to train the Nigerian Endoscopists.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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