Clinical Approach Strategy in Managing Complex Biliary Cases: Lesson Learnt from a Tertiary Referral Private Hospital

Cosmas Rinaldi Adithya Lesmana(1), Maria Satya Paramitha(2), Yulia Estu Pratiwi(3), Laurentius Adrianto Lesmana(4),


(1) - Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia - Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia - Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
(2) Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
(3) Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
(4) - Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia - Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
Corresponding Author

Abstract


Introduction: In the era of laparoscopic procedure, there are innovations on non-surgical management approaches for managing biliary tract disorders, such as therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and interventional endoscopic ultrasound (EUS). There is still no clear consensus yet in step-approach for managing difficult  biliary disorders. Method: A retrospective endoscopy database study was conducted. Complex biliary cases which included in this study, where multi-management approach is needed, biliary obstruction accompanied with cholangitis or biliary sepsis, difficult CBD stone, recurrent CBD stone, or advanced progressive malignant biliary obstruction. Results: Sixty-one subjects in this retrospective database study were considered as complex biliary cases. In this study, 16.4% of the subjects underwent combination of therapeutic ERCP and EUS in one session based on the complexity of the case; and 8.2% of the subjects underwent therapeutic ERCP with additional single operator cholangioscopy procedure. One subject underwent rendezvous ERCP procedure through percutaneous approach. Around 4.9% of the subjects underwent EUS-guided biliary drainage procedure. Conclusion: Complex biliary cases require a good clinical approach algorithm to decide which procedure comes first based on comprehensive evaluation consists of patient’s factor, expertise, cost, and the risk of complications.

 

Keywords: biliary tract; endoscopic retrograde cholangiography; endoscopic ultrasound; laparoscopic procedure


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