Introduction: A subgroup of patients with benign biliary (BD) and pancreatic duct (PD) strictures fail to resolve with ERCP stenting alone. Severe PD strictures may also preclude targeting of PD stones for intraductal lithotripsy. Data on cholangiopancreatoscopy-guided laser dissection (CPL) is limited. Our study aims to evaluate technical success, adverse events (AEs), and clinical efficacy.
Methods: Our endoscopy database was reviewed to identify CPL procedures. The technique entails the application of laser energy in three quadrants of the stenosis to improve luminal patency for PD stone targeting and/or PD/CBD dilation and stenting. Primary outcome: technical success defined as the ability to intervene or resolve the stricture of interest following CPL. Secondary outcome: stent-free survival defined as the time from stent removal without re-stenting. Kaplan-Meier analysis was performed to estimate median survival time using Stata (StataCorp, College Station, TX).
Results: Thirty patients (median age 61.5, 56.7% female) underwent CPL from 5/16 – 8/23 and had a median 3.5 (IQR 1-5) prior ERCPs to treat stricture(s) (Table 1). Median outer stent(s) diameter prior to CPL in BD was 8.5 Fr (IQR 7-10) and PD was 28.5 Fr (IQR 10-40). A total of 53 CPL’s were performed (median 1.0 per patient; IQR 1-2.25) for 49 strictures (median 1 per patient; IQR 1-2.5): 41 PD (83.7%; 15 head, 6 neck, 17 body, 3 tail) and 8 BD (16.3%; 2 common bile duct, 5 common hepatic duct, and 1 hilum). Technical success of CPL was 100%. Laser lithotripsy for PD stones was performed in 29/41 (70.7%). Adjunctive balloon dilation was done in 39/53 (73.6%) cases. Follow-up was 30.5 months (IQR 10.8-43.8) following index CPL. Stent-free trial has been attempted in 25 (83.3%) following a median of 1 CPL (IQR 1-2) and 2 ERCPs without CPL (IQR 1-3). Follow-up was available in 22 (88.0%). Reintervention with stenting occurred in 45.5% (n=10) with a median stent-free survival time of 37 months (95% CI 30-46; Figure 1). Five patients did not reach a stent-free trial: ongoing treatment (n=3), unrelated death (n=1), total pancreatectomy (n=1). AEs followed 10 (16.9%) CPLs: 6 chronic pancreatitis flare-ups (mild), 3 ED presentations, and 1 PD leak bridged with stenting.
Conclusions: 1) Cholangiopancreatoscopy-guided laser dissection has high technical success and an acceptable safety profile for the treatment of recalcitrant biliary and pancreatic duct strictures. 2) Pancreatoscopy-guided laser dissection increases lumen patency of downstream PD strictures to target difficult to access stones for intraductal laser lithotripsy. 3) The interval to reintervention with stenting in this complex patient population is more than three years, but nearly half may require repeat stenting. 4) Randomized studies comparing early CPL and stenting to stenting alone are needed.

Nicole Rueb

Appearances