Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos)

Factors affecting complete stone removal and bile duct stone recurrence in patients with surgically altered anatomy treated by double-balloon endoscopy-assisted endoscopic retrograde cholangiography

OBJECTIVES

This study assessed factors influencing the complete removal and recurrence of bile duct stones in patients with surgically altered anatomy (SAA) undergoing double-balloon endoscopy-assisted endoscopic retrograde cholangiography (DBERC).

METHODS

A retrospective analysis of 289 patients with SAA treated for biliary stones with DBERC at Jichi Medical University Hospital (January 2007 to December 2022) was conducted. Evaluation of factors impacting complete stone removal was performed in 257 patients with successful bile duct cannulation. Logistic and Cox proportional hazards regression models were used to compute the odds ratios (ORs) and hazard ratios (HRs) at 95% confidence intervals (CIs).

RESULTS

Of 257 patients, 139 (54.0%) and 209 (81.3%) achieved initial and complete removal, respectively. Recurrence occurred in 55 (21.4%) patients. Factors associated with initial complete stone removal included cholangitis (P < 0.01, OR 0.48, 95% CI 0.27-0.83), number of stones (P < 0.01, OR 0.31, 95% CI 0.18-0.54), and largest stone diameter (P < 0.01, OR 0.37, 95% CI 0.20-0.67). The size of the largest stone was associated with complete removal (P = 0.01, OR 0.24, 95% CI 0.13-0.76). Recurrence was associated with cholangitis (P = 0.046, HR 0.54, 95% CI 0.29-0.99), congenital biliary dilatation (P = 0.01, HR 2.65, 95% CI 1.21-5.80), and number of stones (P = 0.02, HR 1.96, 95% CI 1.12-3.41).

CONCLUSIONS

Successful complete bile stone removal in patients with SAA depends on the stone diameter and number. Stone recurrence is influenced by the number of stones and history of congenital biliary dilatation.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Status of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: Systematic review and meta-analysis on biliary interventions

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is still challenging. Usefulness of single-balloon enteroscopy (SBE)-assisted ERCP has been increasingly reported. Short SBE is considered beneficial with a 152-cm working length and a 3.2-mm working channel. This has increased the variety of devices that can be used during ERCP procedures. The aim of this pooled analysis was to evaluate the efficacy of SBE-assisted ERCP in patients with surgically altered anatomy and elucidate the current status.

METHODS

This systematic review only involved biliary interventions which excluded pancreatic cases. Studies involving SBE-assisted ERCP in patients with Roux-en-Y gastrectomy, hepaticojejunostomy with Roux-en-Y, pancreaticoduodenectomy (Whipple or Child procedure), or Billroth II gastrectomy were analyzed. Enteroscopy, biliary cannulation, and procedural success were assessed by pooling data in a random-effect model, according to the degree of heterogeneity, to obtain a proportion with 95% confidence interval (CI). The outcomes observed for conventional and short SBE cases were also reported.

RESULTS

Overall, 1227 SBE-assisted ERCP procedures from 21 studies were included. The pooled enteroscopy, biliary cannulation, and procedural success rates were 86.6% (95% CI, 82.4-90.3%), 90% (95% CI, 87.1-92.5%), and 75.8% (95% CI, 71.0-80.3%), respectively. Adverse events occurred in 6.6% (95% CI, 5.3-8.2%) of the procedures. Although good outcomes were reported for short SBE-assisted ERCP, these should not be directly compared to the outcomes observed for conventional SBE, as they assume different backgrounds and include confounding variables.

CONCLUSIONS

Single-balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy on biliary interventions is effective.

Efficacy and Safety of Short-type Single Balloon Enteroscopy-assisted Peroral Direct Cholangioscopy Using an Ultra-slim Endoscope in Patients With Surgically Altered Anatomy

BACKGROUND

The efficacy and safety of peroral direct cholangioscopy (PDCS) in patients with surgically altered anatomy (SAA) are unclear. The present study aimed to evaluate the efficacy and safety of short-type single balloon enteroscope (s-SBE)-assisted PDCS using an ultra-slim endoscope in patients with SAA.

MATERIALS AND METHODS

We retrospectively analyzed 12 sessions of PDCS performed in 8 patients with surgically altered gastrointestinal or pancreatobiliary anatomy between November 2017 and September 2019 at our institution. Endoscopic retrograde cholangiopancreatography using s-SBE was initially performed. Subsequently, the s-SBE was exchanged for an ultra-slim endoscope through an overtube with an inflated balloon to perform PDCS. We analyzed the success rates and adverse events resulting from the procedure.

RESULTS

Six patients had biliary stones and 2 had biliary strictures. The types of reconstruction were Roux-en-Y choledochojejunostomy (n=5), Billroth II gastrectomy (n=2), and Roux-en-Y gastrectomy (n=1). Biliary insertion of the ultra-slim endoscope was successful in all 12 sessions. Biliary interventions included electronic hydraulic lithotripsy in 5 sessions, stone removal using basket catheter in 3 sessions, biopsy in 2 sessions, and diagnosis of no residual stones in 2 sessions. Complete stone removal was finally achieved in all 6 patients with biliary stones. Biliary strictures in 2 patients were diagnosed as adenocarcinoma following a biopsy. The adverse events were cholangitis of mild severity in 3 sessions.

CONCLUSION

S-SBE-assisted PDCS using an ultra-slim endoscope was useful and safe in patients with SAA, although care should be taken to avoid adverse events.

Endoscopic biliary therapy in the era of bariatric surgery

There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.

Peroral Cholangioscopy: How Technology and Imaging Have Changed ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is the minimally invasive standard of care for the treatment of several biliary and pancreatic pathologies. One of the limitations of this technique is the lack of endoluminal vision within the biliary tree or Wirsung's duct. This limits the diagnostic accuracy of the procedure and reduces the effectiveness of many treatments. Technological progress and the use of increasingly ergonomic and high-definition imaging equipment have led to the dissemination of peroral cholangioscopy (POC). Thanks to the high quality of video image resolution, POC could well be a powerful tool used to characterize malignant biliary strictures. It could also allow targeted biopsies or local treatments, hence reducing the risk of complications and increasing outcomes. The technological improvement of the last generation of POC is opening new horizons in the treatment of biliopancreatic pathologies, thereby contributing to refine and enhance the ERCP management of several diseases in the near future.

Endoscopic Balloon Dilation for Benign Bilioenteric Stricture: Outcomes and Factors Affecting Recurrence

BACKGROUND

Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD.

METHODS

Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated.

RESULTS

The study group comprised 55 patients (median age 72 years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78 years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1 year after endoscopic BD. The significant factors associated with recurrence within 1 year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6 months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88 years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001).

CONCLUSION

Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Endoscopic management of bile duct stones in patients with surgically altered anatomy

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.