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Khattak F, Khan A, Samiullah F. Comment on: "Feasibility of gallbladder lesion visualization using a novel ultrafine peroral cholangioscopy: A preliminary investigation". Dig Liver Dis 2024:S1590-8658(24)00823-5. [PMID: 38981788 DOI: 10.1016/j.dld.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024]
Affiliation(s)
| | - Ahmad Khan
- Khyber Medical College, Peshawar, Pakistan.
| | - Fnu Samiullah
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari, Karachi
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Tang RSY. Endoscopic evaluation of indeterminate biliary strictures: Cholangioscopy, endoscopic ultrasound, or both? Dig Endosc 2024; 36:778-788. [PMID: 38014445 DOI: 10.1111/den.14733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/26/2023] [Indexed: 11/29/2023]
Abstract
Accurate and timely diagnosis of biliary strictures can be challenging. Because the diagnostic sensitivity and accuracy of standard endoscopic retrograde cholangiopancreatography-based tissue sampling for malignancy are suboptimal, additional endoscopic evaluation by cholangioscopy and/or endoscopic ultrasound (EUS) is often necessary to differentiate between malignant and benign biliary strictures to guide clinical management. While direct visualization by cholangioscopy and/or high-resolution imaging by EUS are often the first step in the evaluation of an indeterminate biliary stricture (IDBS), tissue diagnosis by cholangioscopy-guided biopsy and/or EUS-guided fine-needle tissue acquisition is the preferred modality to establish a diagnosis of malignancy. Because each modality has its own strengths and limitations, selection of cholangioscopy and EUS is best guided by the biliary stricture location and local expertise. Artificial intelligence-assisted diagnosis, biopsy forceps with improved design, contrast-enhanced EUS, and dedicated fine-needle biopsy devices are recent technological advances that may further improve the diagnostic performance of cholangioscopy and EUS in patients with IDBS.
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Affiliation(s)
- Raymond S Y Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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4
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Shin IS, Moon JH, Lee YN, Kim HK, Chung JC, Lee TH, Yang JK, Cho YD, Park SH. Comparison of disposable digital single-operator cholangioscopy versus direct peroral cholangioscopy for the diagnosis of intraductal superficial lesions of the bile duct. Endoscopy 2024. [PMID: 38718833 DOI: 10.1055/a-2322-4657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Disposable digital single-operator cholangioscopy (D-SOC) and direct peroral cholangioscopy (D-POC) using an ultraslim endoscope are established POC modalities for the diagnosis and treatment of various biliary diseases. We compared the usefulness of D-SOC and D-POC for the diagnosis of intraductal superficial lesions of the bile duct (ISL-Bs). METHODS 38 consecutive patients with suspected biliary diseases who underwent both D-SOC and D-POC were enrolled. The primary outcome was ISL-B detection rate, and the secondary outcomes were technical success of POC and POC-guided forceps biopsy sampling (POC-FB), procedure time, visualization quality, and tissue adequacy. RESULTS D-SOC had a higher technical success rate than D-POC but the difference was not statistically significant (100% vs. 92.1%, P = 0.25). D-POC had a marginally higher ISL-B detection rate (34.2% vs. 28.9%, P = 0.68) and significantly higher visualization quality (P = 0.03). The mean (SD) procedure time was significantly shorter with D-SOC (11.00 [1.33] vs. 19.03 [2.95] minutes, P<0.001). The technical success rate of POC-FB and tissue adequacy did not differ between the two techniques (D-SOC vs. D-POC: 81.8% vs. 84.6%, P = 0.69 and 77.8% vs. 90.9%, P = 0.57, respectively). CONCLUSIONS Both POC systems were safe and useful for the detection, characterization, and diagnosis of minute ISL-Bs. While D-SOC displayed a shorter procedure time and a tendency for higher technical success rate, D-POC provided superior visualization quality, allowing detailed observation of the surface structure and microvascular patterns.
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Affiliation(s)
- Il Sang Shin
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of)
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of)
| | - Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of)
| | - Hee Kyung Kim
- Department of Pathology, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of)
| | - Jun Chul Chung
- Department of Surgery, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of)
| | - Tae Hoon Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea (the Republic of)
| | - Jae Kook Yang
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea (the Republic of)
| | - Young Deok Cho
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Seoul, Korea (the Republic of)
| | - Sang-Heum Park
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea (the Republic of)
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Tejido C, Puga M, Regueiro C, Francisco M, Rivas L, Sánchez E. Evaluation of the effectiveness and safety of single-operator cholangiopancreatoscopy with the SpyGlass™ system. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:170-178. [PMID: 37301507 DOI: 10.1016/j.gastrohep.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND STUDY AIMS The single-operator cholangiopancreatoscopy (SOCP) with the SpyGlass™ system is a endoscopy technique whose use has grown exponentially in recent years. The aims of this study were to evaluate the efficacy and safety of SOCP with SpyGlass™ and determine the factors related to the onset of adverse events (AEs). PATIENTS AND METHODS Retrospective study at a single tertiary institution with inclusion of all consecutive patients undergoing SOCP with SpyGlass™ from February-2009 to December-2021. No exclusion criteria were considered. A descriptive statistical analysis was performed. The factors associated with the existence of AE were analyzed using Chi-square and Student's t-test. RESULTS A total of 95 cases were included. The most common indications were biliary strictures (BS) evaluation (66.3%) or treatment of difficult common bile duct stones (27.4%). Technical and clinical success was attained in 98.9%. Single-session stone clearance was obtained in 84%. The AE rate was 7.4%. To detect malignancy in BS, optical diagnosis presents a sensitivity and specificity of 100% and 91.2%, respectively; while histology results were 36.4% and 100% respectively. A previous endoscopic sphincterotomy was associated with a lower rate of AEs (2.4% vs 41.7%; p<0.001). CONCLUSIONS SOCP with SpyGlass™ is a safe and effective technique to diagnose and treat pancreatobiliary pathology. The presence of sphincterotomy performed prior to the procedure could improve the technique's safety.
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Affiliation(s)
- Coral Tejido
- Department of Digestive Diseases, Complexo Hospitalario Universitario de Ourense, Ourense, Spain; Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
| | - Manuel Puga
- Department of Digestive Diseases, Complexo Hospitalario Universitario de Ourense, Ourense, Spain; Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain.
| | - Cristina Regueiro
- Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
| | - María Francisco
- Department of Digestive Diseases, Complexo Hospitalario Universitario de Ourense, Ourense, Spain; Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
| | - Laura Rivas
- Department of Digestive Diseases, Complexo Hospitalario Universitario de Ourense, Ourense, Spain; Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
| | - Eloy Sánchez
- Department of Digestive Diseases, Complexo Hospitalario Universitario de Ourense, Ourense, Spain; Grupo de Investigación en Oncología Digestiva (GIODO), Instituto de Investigación Sanitaria Galicia Sur, Ourense, Spain
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Uribe Rivera AK, Seeliger B, Saldivar CA, Houghton E, Rodríguez F, Acquafresca P, Palermo M, Giménez ME. Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope. Surg Endosc 2023; 37:7774-7783. [PMID: 37580582 DOI: 10.1007/s00464-023-10337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/23/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The length of conventional single-use cholangioscopes poses a challenge for percutaneous or laparoscopic approaches for direct visualization of the biliary tract. The aim of this retrospective observational clinical study was to assess the use of a dedicated percutaneous short single-operator cholangioscope (PSSOC) for diagnosis and treatment of benign or malignant biliary diseases. METHODS Retrospective analysis of a prospectively maintained database including all consecutive patients undergoing percutaneous transhepatic cholangioscopy with the PSSOC between 06/2021 and 01/2023. RESULTS Forty patients were included (22F/18 M, age 58.7 ± 16.7 years). The diagnostic and therapeutic management plan was based on procedural findings. Indications were bile duct obstruction associated with complex anatomy (n = 13), choledocholithiasis (n = 11), suspected malignant stenosis of the biliary tract (n = 11), biliary stent placement (n = 2) and removal (n = 1), and failed endoscopic retrograde cholangiopancreatography (n = 2). The cholangioscopies were diagnostic (n = 5), therapeutic (n = 20) or both simultaneously (n = 15). The most frequent procedures were electrohydraulic lithotripsy (n = 25) and biopsy sampling (n = 12). Complications occurred in 7 cases (17.5%), including cholangitis (n = 4, B2), pleural perforation (n = 1, B2), portal bleeding (n = 1, B3), and Tako-Tsubo syndrome (n = 1, B3), classified according to the Society of Interventional Radiology classification. Intraprocedural visual diagnosis was confirmed by the histopathologic result in 11/12 patients in which biopsies were performed (91.7%). PSSOC was relevant to avoid surgery in 2 patients (5%) with indeterminate strictures, allowing to rule out malignancy and treat the lithiasis. CONCLUSIONS Direct visualization of the biliary tract enabled targeted biopsies for histopathological diagnosis. The visual and histopathological diagnoses were concordant in all but one case. Percutaneous cholangioscopy with a dedicated PSSOC allows to optimize identification and treatment of complex biliary disease including biliary lithiasis while assessing bile duct patency. The clinical use of the novel PSSOC system was safe and effective and could prevent surgical exploration in select patients.
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Affiliation(s)
- A K Uribe Rivera
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina.
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.
| | - B Seeliger
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- Department of Visceral and Digestive Surgery, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - C A Saldivar
- Dr. Eduardo Liceaga, General Hospital, Mexico City, Mexico
| | - E Houghton
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - F Rodríguez
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - P Acquafresca
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - M Palermo
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - M E Giménez
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Yadlapati S, Mulki R, Sánchez-Luna SA, Ahmed AM, Kyanam Kabir Baig KR, Peter S. Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup. World J Gastroenterol 2023; 29:5198-5210. [PMID: 37901449 PMCID: PMC10600956 DOI: 10.3748/wjg.v29.i36.5198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.
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Affiliation(s)
- Sujani Yadlapati
- Department of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, IN 46202, USA
| | - Ramzi Mulki
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Sergio A Sánchez-Luna
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Ali M Ahmed
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | | | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Arnelo U, Valente R, Scandavini CM, Halimi A, Mucelli RMP, Rangelova E, Svensson J, Schulick RD, Torphy RJ, Fagerström N, Moro CF, Vujasinovic M, Matthias Löhr J, Del Chiaro M. Intraoperative pancreatoscopy can improve the detection of skip lesions during surgery for intraductal papillary mucinous neoplasia: A pilot study. Pancreatology 2023; 23:704-711. [PMID: 37336668 DOI: 10.1016/j.pan.2023.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Intraoperative pancreatoscopy is a promising procedure that might guide surgical resection for suspected main duct (MD) and mixed type (MT) intraductal papillary mucinous neoplasms (IPMNs). The aim of the present study was to assess the diagnostic yield and clinical impact of intraoperative pancreatoscopy in patients operated on for MD and MT-IPMNs. METHODS This is a retrospective cohort study. Patients undergoing surgery for suspected MD or MT-IPMN underwent intraoperative pancreatoscopy and frozen section analysis. In all patients who required extended resection due to pancreatoscopic findings, we compared the final histology with the results of the intraoperative frozen section analysis. RESULTS In total, 46 patients, 48% females, mean age (range) 67 years (45-82 years) underwent intraoperative pancreatoscopy. No mortality or procedure related complications were observed. Pancreatoscopy changed the operative course in 30 patients (65%), leading to extended resections in 20 patients (43%) and to parenchyma sparing procedures in 10 patients (22%). Analyzing the group of patients who underwent extended resections, 7 (35%) displayed lesions that needed further surgical treatment (six high grade dysplasia and one with G1 pancreatic neuroendocrine tumor) and among those 7, just 1 (14%) would have been detected exclusively with histological frozen section analysis of the transection margin. The combination of both pancreatoscopy and frozen section analysis lead to 86% sensitivity and 92% specificity for the detection of pathological tissue in the remnant pancreas. CONCLUSION Intraoperative pancreatoscopy is a safe and feasible procedure and might allow the detection of skip lesions during surgery for suspect MD-involving IPMNs.
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Affiliation(s)
- Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Raffaella M Pozzi Mucelli
- Department of Radiology Huddinge, Karolinska University Hospital, O-huset 42, 14186, Stockholm, Sweden; Division of Radiology, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Section for Upper Abdominal Surgery at Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niklas Fagerström
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Carlos Fernández Moro
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Huddinge, Sweden; Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Huddinge, Sweden
| | - Miroslav Vujasinovic
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Deng X, Wang J, Mou T, Pan L, Du C, Wu Q. Case report: Single-operator peroral cholangioscopy system (SpyGlass) diagnosis of an extrahepatic biliary cystadenoma (video). Front Med (Lausanne) 2023; 10:1175034. [PMID: 37425323 PMCID: PMC10327893 DOI: 10.3389/fmed.2023.1175034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/17/2023] [Indexed: 07/11/2023] Open
Abstract
Biliary cystadenoma is a type of rare liver cystic tumor. Intrahepatic biliary cystadenomas are the most common, while extrahepatic biliary cystadenomas are rarely seen. Biliary cystadenoma tends to occur in middle-aged to older women and there is a lack of specific preoperative diagnostic markers. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. Herein, we report a patient in whom a space-occupying lesion was found in the bile duct by SpyGlass, and who later underwent radical surgery. The pathology report indicated that the final diagnosis was biliary cystadenoma. SpyGlass cholangioscopy may be a novel and effective diagnostic method for biliary cystadenoma.
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Affiliation(s)
- Xin Deng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jingwen Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tong Mou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Long Pan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengyou Du
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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10
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Chiang CH, Chen KC, Devereaux B, Chung CS, Kuo KC, Lin CC, Lin CK, Wang HP, Chen KH. Precise mapping of hilar cholangiocarcinoma with a skip lesion by SpyGlass cholangioscopy: A case report. World J Gastrointest Surg 2023; 15:965-971. [PMID: 37342860 PMCID: PMC10277946 DOI: 10.4240/wjgs.v15.i5.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/07/2023] [Accepted: 04/07/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Cholangiocarcinoma (CC) is a very aggressive cancer with a poor prognosis. As surgery is the only curative therapy, preoperative evaluation of the tumor extent is essential for surgical planning. Although high-quality image modalities such as computed tomography and magnetic resonance imaging have been used extensively in preoperative evaluation, the accuracy is low. To obtain precise localization of tumor spread arising from the hilar region preoperatively, the development of an acceptable imaging modality is still an unmet need.
CASE SUMMARY A 52-year-old female presented to our emergency department with jaundice, abdominal pain, and fever. Initially, she was treated for cholangitis. Endoscopic retrograde cholangiopancreatography with the cholangiogram showed long segment filling defect in the common hepatic duct with dilatation of bilateral intrahepatic ducts. Transpapillary biopsy was performed, and the pathology suggested intraductal papillary neoplasm with high-grade dysplasia. After treatment of cholangitis, contrasted-enhanced computed tomography revealed a hilar lesion with undetermined Bismuth-Corlette classification. SpyGlass cholangioscopy showed that the lesion involved the confluence of the common hepatic duct with one skip lesion in the posterior branch of the right intrahepatic duct, which was not detected by previous image modalities. The surgical plan was modified from extended left hepatectomy to extended right hepatectomy. The final diagnosis was hilar CC, pT2aN0M0. The patient has remained disease-free for more than 3 years.
CONCLUSION SpyGlass cholangioscopy may have a role in precision localization of hilar CC to provide surgeons with more information before the operation.
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Affiliation(s)
- Cheng-Han Chiang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Xin-Tai General Hospital, New Taipei 242063, Taiwan
| | - Kuan-Chih Chen
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Herston 4029, Queensland, Australia
| | - Chen-Shuan Chung
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Kuei-Chang Kuo
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Chien Chu Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Cheng-Kuan Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 10002, Taiwan
| | - Kuo-Hsin Chen
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
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Shin J, Oh CH, Dong SH. Single-operator Cholangioscopy Guided Lithotripsy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 80:163-168. [DOI: 10.4166/kjg.2022.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jungha Shin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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Sljivic I, Trasolini R, Donnellan F. Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones. Endosc Int Open 2022; 10:E1193-E1200. [PMID: 36118645 PMCID: PMC9473834 DOI: 10.1055/a-1873-0884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background and study aims Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.
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Affiliation(s)
- Igor Sljivic
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Roberto Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard University, Cambridge, Massachusetts, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Shin IS, Moon JH, Lee YN, Kim HK, Lee TH, Yang JK, Cha SW, Cho YD, Park SH. Efficacy of narrow-band imaging during peroral cholangioscopy for predicting malignancy of indeterminate biliary strictures (with videos). Gastrointest Endosc 2022; 96:512-521. [PMID: 35469893 DOI: 10.1016/j.gie.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Direct peroral cholangioscopy (POC) can be useful when combined with narrow-band imaging (NBI) to explore the etiologies of indeterminate biliary strictures. We evaluated the efficacy of NBI compared with that of conventional white-light imaging (WLI) during POC diagnosis of indeterminate biliary strictures. METHODS Consecutive patients with indeterminate biliary strictures were enrolled from 2016 to 2019. The primary outcome was diagnostic accuracy, and secondary outcomes were technical success, adverse events, and visualization quality when predicting malignancy. RESULTS Seventy-one patients underwent direct POC under NBI during targeted biopsy sampling. The strictures were successfully explored and adequate biopsy samples obtained in 67 of 71 patients (94.4%). In terms of visual impression, WLI and NBI afforded 75.0% and 87.5% sensitivity, 82.9 and 91.4% specificity, and 82.8 and 91.3% accuracy, respectively. The areas under the WLI and NBI receiver-operating characteristic curves were .80 and .96 (P = .01). Under NBI, the visualization quality of surface structures, microvessels, and lesional margins was higher than that under conventional WLI (P < .05). CONCLUSIONS Direct POC under NBI effectively and accurately predicts malignancies of indeterminate biliary strictures. NBI effectively illuminated surface structures, microvessels, and lesional margins.
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Affiliation(s)
- Il Sang Shin
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Hee Kyung Kim
- Department of Pathology, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Tae Hoon Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Jae Kook Yang
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Sang-Woo Cha
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Young Deok Cho
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
| | - Sang-Heum Park
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Cheonan, and Seoul, Korea
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Digital single-operator cholangioscopy in diagnostic and therapeutic bilio-pancreatic diseases: A prospective, multicenter study. Dig Liver Dis 2022; 54:1243-1249. [PMID: 35597763 DOI: 10.1016/j.dld.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Digital single-operator cholangioscopy (D-SOC) is an endoscopic procedure that is increasingly used for the management of bilio-pancreatic diseases. We aimed to investigate the efficacy and safety of D-SOC for diagnostic and therapeutic indications. METHODS This is a multicenter, prospective study(January 2016-June 2019) across eighteen tertiary centers. The primary outcome was procedural success of D-SOC. Secondary outcomes were: D-SOC visual assessment and diagnostic yield of SpyBite biopsy in cases of biliary strictures, stone clearance rate in cases of difficult biliary stones, rate of adverse events(AEs) for all indications. RESULTS D-SOC was performed in 369 patients (201(54,5%) diagnostic and 168(45,5%)therapeutic). Overall, procedural success rate was achieved in 360(97,6%) patients. The sensitivity, specificity, PPV, NPV and accuracy in biliary strictures were: 88,5%, 77,3%, 83,3%, 84,1% and 83,6% for D-SOC visual impression; 80,2%, 92,6%, 95,1%, 72,5% and 84,7% for the SpyBite biopsy, respectively. For difficult biliary stones, complete duct clearance was obtained in 92,1% patients (82,1% in a single session). Overall, AEs occurred in 37(10%) cases.The grade of AEs was mild or moderate for all cases, except one which was fatal. CONCLUSION D-SOC is effective for diagnostic and therapeutic indications.Most of the AEs were minor and managed conservatively, even though a fatal event has happened that is not negligible and should be considered before using D-SOC.
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Kawashima H, Ohno E, Ishikawa T, Mizutani Y, Iida T, Yamamura T, Kakushima N, Furukawa K, Nakamura M. Endoscopic management of perihilar cholangiocarcinoma. Dig Endosc 2022; 34:1147-1156. [PMID: 35377509 DOI: 10.1111/den.14317] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/25/2022] [Accepted: 04/01/2022] [Indexed: 02/08/2023]
Abstract
Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector-row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe-based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self-expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography-guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC.
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Affiliation(s)
- Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Wu X, Wu S, Tang S. Endoscopic nasobiliary drainage-based saline-injection ultrasound: an imaging technique for remnant stone detection after retrograde cholangiopancreatography. BMC Gastroenterol 2022; 22:318. [PMID: 35761194 PMCID: PMC9238265 DOI: 10.1186/s12876-022-02394-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 06/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background The purpose of this retrospective study aimed to assess the accuracy of detection of remnant common bile duct (CBD) stones by injecting saline through endoscopic nasobiliary drainage (ENBD) tubes under transabdominal ultrasound (US) guidance. Method Stone extraction and ENBD are regularly achieved through endoscopic retrograde cholangiopancreatography (ERCP) in patients with CBD stones. At 1–3 days thereafter, routine US studies were performed and repeated, using ENBD tubal saline injections (20–100 mL). Results A total of 302 patients underwent standard ERCP stone extractions in conjunction with occlusion cholangiograms, routine US testing, and ENBD-based saline-injection US exams. By occlusion cholangiogram, remnant stones were suspected in 31 (10.3%) patients in total of 302, and 26 (83.8%) were verified as true positives (sensitivity, 50.9%; specificity, 98.0%). Routine US studies proved suspicious in 13 (4.3%) patients in total of 302, and 12 (92.3%) were verified as true positives (sensitivity, 23.5%; specificity, 99.6%). Using ENBD-based saline-injection US, suspected stones were identified in 50 (16.6%) patients in total of 302, and 46 (92%) were verified as true positives (sensitivity, 90.1%; specificity, 98.4%). The sensitivity of ENBD-based saline-injection US significantly surpassed that of occlusion cholangiogram (p < 0.001) and routine US (p < 0.001). Conclusion Detection of remnant CBD stones via ENBD-based saline-injection US is a valid, inexpensive, and repeatable means of patient screening that is non-invasive, radiation-free, and dynamically informative. This may help improve the accuracy of detecting remnant CBD stones after ERCP. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02394-8.
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17
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Mony S, Ghandour B, Raijman I, Manvar A, Ho S, Trindade AJ, Benias PC, Zulli C, Jacques J, Ichkhanian Y, Zuchelli T, Ghanimeh MA, Irani S, Canakis A, Sanaei O, Szvarca D, Zhang L, Bejjani M, Akshintala V, Khashab MA. An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy. Endosc Int Open 2022; 10:E898-E904. [PMID: 35692911 PMCID: PMC9187392 DOI: 10.1055/a-1794-0331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background and study aims The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.
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Affiliation(s)
- Shruti Mony
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Isaac Raijman
- Greater Houston Gastroenterology, Houston, Texas, United States
| | - Amar Manvar
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, New York City, New York, United States
| | - Sammy Ho
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, New York City, New York, United States
| | - Arvind J. Trindade
- Division of Gastroenterology and Hepatology, Hofstra-Northwell School of Medicine, Manhasset, New York, United States
| | - Petros C. Benias
- Division of Gastroenterology and Hepatology, Hofstra-Northwell School of Medicine, Manhasset, New York, United States
| | - Claudio Zulli
- Division of Gastroenterology and Hepatology, Hospital of Salerno, G. Fucito Center, Mercato San Severino, Italy
| | - Jérémie Jacques
- Department of Endoscopy and Gastroenterology, Limoges Dupuytren Hospital, Lyon, France
| | - Yervant Ichkhanian
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Tobias Zuchelli
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, United States
| | | | - Shayan Irani
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew Canakis
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Daniel Szvarca
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Linda Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Venkata Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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Baroud S, Sahakian AJ, Sawas T, Storm AC, Martin JA, Abu Dayyeh BK, Topazian MD, Levy MJ, Roberts LR, Gores GJ, Petersen BT, Chandrasekhara V. Impact of trimodality sampling on detection of malignant biliary strictures compared with patients with primary sclerosing cholangitis. Gastrointest Endosc 2022; 95:884-892. [PMID: 34871554 DOI: 10.1016/j.gie.2021.11.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Malignant biliary strictures can be difficult to diagnose, with up to 20% considered indeterminate after initial tissue sampling. This study aimed to determine the performance characteristics of transpapillary biopsy sampling (TPB) and fluorescence in situ hybridization (FISH) in isolation or in combination with standard brush cytology (BC) in patients who received trimodality sampling for biliary strictures. METHODS This single-center retrospective cohort study included patients with biliary strictures undergoing ERCP with trimodality sampling between September 2014 and April 2019. Performance characteristics for each diagnostic test alone and in combination were calculated. RESULTS Two hundred four patients underwent trimodality biliary sampling, including 104 (51.0%) with malignancy. The diagnostic sensitivity for malignancy with BC (17.3%) significantly improved with dual modality (BC+FISH, 58.7%; BC+TPB, 40.4%) or trimodality sampling (68.3%; P < .001 for all comparisons). Trimodality sampling improved diagnostic sensitivity for malignancy compared with BC+FISH (P = .002) and BC+TPB (P < .001). There was no statistically significant difference in the sensitivity of trimodality sampling in detecting cholangiocarcinoma (79.7%) compared with pancreatic cancer (62.5%; P = .1). Among 57 patients with primary sclerosing cholangitis (PSC), the sensitivity of detecting biliary malignancy (n = 20) was 20% for BC and significantly improved with the addition of FISH (80%; P < .001) but not with TPB (35.0%; P = .25). Trimodality sampling did not further improve diagnostic sensitivity (85%) over BC+FISH (80%) for malignancy in the setting of PSC (P = 1). CONCLUSIONS Trimodality sampling improves the diagnostic sensitivity for the detection of malignant biliary strictures with no significant difference in sensitivity for cholangiocarcinoma compared with pancreatic cancer. However, in patients with PSC, trimodality sampling was not superior to BC+FISH.
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Affiliation(s)
- Serge Baroud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander J Sahakian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarek Sawas
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Despite advances in noninvasive techniques for imaging the pancreaticobiliary system, several disease processes including indeterminate biliary strictures as well as neuroendocrine tumors, inflammatory pseudotumors, and complex cysts of the pancreas remain difficult to characterize. New endoscopic imaging technologies have emerged to address these challenges. Cholangioscopy and intraductal ultrasound (IDUS) are powerful tools to characterize subtle biliary concretions and strictures. Confocal Laser Endomicroscopy (CLE) and Optical Coherence Tomography (OCT) are emerging approaches for the most difficult biliary lesions. Contrast harmonic endoscopic ultrasound (CH-EUS), elastography, and 3D-EUS are improving the approach to subtle pancreatic lesions, particularly in the context of indeterminate tissue sampling. Pancreatoscopy, pancreatic IDUS, and intracystic CLE hold promise to further improve the assessment of pancreatic cysts. We aim to comprehensively review the emerging clinical evidence for these innovative endoscopic imaging techniques.
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Single-operator peroral pancreatoscopy in the preoperative diagnostics of suspected main duct intraductal papillary mucinous neoplasms: efficacy and novel insights on complications. Surg Endosc 2022; 36:7431-7443. [PMID: 35277769 PMCID: PMC9485081 DOI: 10.1007/s00464-022-09156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/18/2022] [Indexed: 11/20/2022]
Abstract
Background Distinguishing intraductal papillary mucinous neoplasms (IPMNs) from other pancreatic cystic lesions is essential since IPMNs carry the risk of becoming malignant. Differentiating the main pancreatic duct involving IPMNs (MD-IPMNs) through conventional imaging is deficient. Single-operator peroral pancreatoscopy (SOPP) represents a promising method offering additional information on suspected lesions in the pancreatic main duct (MD). We aimed to determine the role of SOPP in the preoperative diagnostics of suspected MD-IPMNs and identify factors contributing to SOPP-related complications. Materials and Methods In this primarily retrospective study, SOPPs were performed at three high-volume centers on suspected MD-IPMNs. Primary outcome was the clinical impact of SOPP to subsequent patient care. Additionally, we documented post-SOPP complications and analyzed several assumed patient- and procedure-related risk factors. Results One hundred and one (101) SOPPs were performed. Subsequent clinical management was affected due to the findings in 86 (85%) cases. Surgery was planned for 29 (29%) patients. A condition other than IPMN explaining MD dilatation was found in 28 (28%) cases. In 35 (35%) cases, follow-up with MRI was continued. Post-SOPP pancreatitis occurred in 20 (20%) patients and one of them was fatal. A decrease in odds of post-SOPP pancreatitis was seen as the MD diameter increases (OR 0.714 for 1.0 mm increase in MD diameter, CI 95% 0.514–0.993, p = 0.045). Furthermore, a correlation between lower MD diameter values and higher severity post-SOPP pancreatitis was seen (TJT = 599, SE = 116.6, z = − 2.31; p = 0.020). History of pancreatitis after endoscopic retrograde cholangiopancreatography was a confirmed risk factor for post-SOPP pancreatitis. Conclusions between complications and other risk factors could not be drawn. Conclusion SOPP aids clinical decision-making in suspected MD-IPMNs. Risk for post-SOPP pancreatitis is not negligible compared to non-invasive imaging methods. The risk for pancreatitis decreases as the diameter of the MD increases.
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Digital Single-operator Cholangioscopy (DSOC) Improves Interobserver Agreement (IOA) and Accuracy for Evaluation of Indeterminate Biliary Strictures: The Monaco Classification. J Clin Gastroenterol 2022; 56:e94-e97. [PMID: 32040050 DOI: 10.1097/mcg.0000000000001321] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Visual characteristics seen during digital single-operator cholangioscopy (DSOC) have not been validated. The aim of this 2-phase study was to define terminology by consensus for the visual diagnosis of biliary lesions to develop a model for optimization of the diagnostic performance of DSOC. MATERIALS AND METHODS In phase 1 (criteria identification), video-cholangioscopy clips were reviewed by 12 expert biliary endoscopists, who were blinded to the final diagnosis. Visual criteria were consolidated into the following categories: (1) stricture, (2) lesion, (3) mucosal features, (4) papillary projections, (5) ulceration, (6) abnormal vessels, (7) scarring, (8) pronounced pit pattern.During the second phase (validation), 14 expert endoscopists reviewed DSOC (SpyGlass DS, Boston Scientific) clips using the 8 criteria to assess interobserver agreement (IOA) rate. RESULTS In phase 1, consensus for visual findings were categorized into 8 criteria titled the "Monaco Classification." The frequency of criteria were: (1) presence of stricture-75%, (2) presence of lesion type-55%, (3) mucosal features-55%, (4) papillary projections-45%, (5) ulceration-42.5%, (6) abnormal vessels-10%, (7) scarring-40%, and (8) pronounced pit pattern-10%. The accuracy on final diagnosis based on visual impression alone was 70%.In phase 2, the IOA rate using Monaco Classification criteria ranged from slight to fair. The presumptive diagnosis IOA was fair (κ=0.31, SE=0.02), and overall diagnostic accuracy was 70%. CONCLUSIONS The Monaco classification identifies 8 visual criteria for biliary lesions on single-operator digital cholangioscopy. Using the criteria, the IOA and diagnostic accuracy rate of DSOC is improved compared with prior studies.
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22
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Fukuhara S, Iwasaki E, Kayashima A, Machida Y, Tamagawa H, Kawasaki S, Horibe M, Hori S, Abe Y, Kitago M, Ogata H, Kanai T. Endoscopic Diagnosis of Biliary Stricture Combined with Digital Cholangioscope: A Case Series. Healthcare (Basel) 2021; 10:healthcare10010012. [PMID: 35052176 PMCID: PMC8775675 DOI: 10.3390/healthcare10010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022] Open
Abstract
The endoscopic diagnosis of biliary tract lesions is applied as a non-invasive method; however, its diagnostic accuracy is not yet high. Moreover, digital cholangioscopy is used for directly visualizing the inside of the bile duct, resulting in a more precise biopsy. We present the case series of the outcomes of diagnosis using digital cholangioscopy in patients who underwent cholangioscopy for the evaluation of biliary stenosis in our department between January 2014 and March 2021. The controls were those who underwent a biopsy for biliary stenosis with conventional endoscopic retrograde cholangiopancreatography (ERCP). Background data for each case were collected, and the clinical outcomes by biopsy were evaluated, focusing on the accuracy of the diagnosis. Cholangioscopy was performed in 15 cases, while a conventional biopsy by ERCP was performed in 172 cases. Nine of 15 cases (60.0%) were diagnosed with cholangiocarcinoma. The number of specimens obtained through conventional ERCP and cholangioscopy was 2.5 ± 1.3 and 3.3 ± 1.5, respectively (p = 0.043). The diagnostic accuracy of conventional ERCP and cholangioscopy were 65.7% (113 of 172 cases) and 100%, respectively, which was significantly higher in the group with cholangioscopy. Digital cholangioscopy is useful when the diagnosis of the biliary stricture using the conventional ERCP method is difficult.
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Affiliation(s)
- Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.F.); (H.O.)
- National Hospital Organization Tokyo Medical Center, Division of Gastroenterology and Hepatology, Tokyo 152-8902, Japan;
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
- Correspondence: ; Tel.: +81-3-5363-3790
| | - Atsuto Kayashima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Hiroki Tamagawa
- National Hospital Organization Tokyo Medical Center, Division of Gastroenterology and Hepatology, Tokyo 152-8902, Japan;
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.F.); (H.O.)
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
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Contreras-Omaña R, Velarde-Ruiz Velasco JA, Castro-Narro GE, Trujillo-Benavides O, Zamarripa-Dorsey F, Reyes-Dorantes AA, Muñoz-Espinosa L, Aiza-Haddad I, Castillo-Barradas M, Cerda-Reyes E, Cisneros-Garza LE, Flores-Calderón J, García-Jiménez ES, Higuera-de-la-Tijera MF, Lira-Pedrín MA, Marquez-Guillén E, Moctezuma-Velázquez C, Moreno-Alcántar R, Noyola-Cedillo SG, Pérez-Hernández JL, Ramos-Gómez MV, Remes-Troche JM, Rizo-Robles MT, Rodríguez-Hernández H. Approach to the patient with cholestasis and jaundice syndrome. Joint AMH, AMG, and AMEG scientific position statement. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 87:80-88. [PMID: 34866042 DOI: 10.1016/j.rgmxen.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/14/2021] [Indexed: 11/17/2022]
Abstract
The term cholestasis refers to bile acid retention, whether within the hepatocyte or in the bile ducts of any caliber. Biochemically, it is defined by a level of alkaline phosphatase that is 1.67-times higher than the upper limit of normal. Cholestatic diseases can be associated with an inflammatory process of the liver that destroys hepatocytes (hepatitis), withjaundice (yellowing of the skin and mucus membranes, associated with elevated serum bilirubin levels), or with both, albeit the three concepts should not be considered synonymous. Cholestatic diseases can be classified as intrahepatic or extrahepatic, depending on their etiology. Knowing the cause of the condition is important for choosing the adequate diagnostic studies and appropriate treatment in each case. A complete medical history, together with a thorough physical examination and basic initial studies, such as liver ultrasound and liver function tests, aid the clinician in deciding which path to follow, when managing the patient with cholestasis. In a joint effort, the Asociación Mexicana de Hepatología (AMH), the Asociación Mexicana de Gastroenterología (AMG) and the Asociación Mexicana de Endoscopia Gastrointestinal (AMEG) developed the first Mexican scientific position statement on said theme.
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Affiliation(s)
- R Contreras-Omaña
- Centro de Estudio e Investigación en Enfermedades Hepáticas (CEIHE), Pachuca, Hidalgo, Mexico.
| | | | | | | | | | | | - L Muñoz-Espinosa
- Centro de Hepatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - I Aiza-Haddad
- Clínica de Enfermedades Hepáticas, Hospital Ángeles Lomas, Mexico City, Mexico
| | - M Castillo-Barradas
- Hospital de Especialidades CMN La Raza, IMSS Hospital Ángeles Lindavista, Mexico City, Mexico
| | | | | | - J Flores-Calderón
- Servicio de Gastropediatría, UMAE Hospital de Pediatría CMN Siglo XXI IMSS, Mexico City, Mexico
| | - E S García-Jiménez
- Hospital Civil de Guadalajara "Fray Antonio Alcalde", Guadalajara, Jalisco, Mexico
| | - M F Higuera-de-la-Tijera
- Servicio de Gastroenterología, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - M A Lira-Pedrín
- Hospital Centro Médico del Prado, Tijuana, Baja California, Mexico
| | | | | | | | - S G Noyola-Cedillo
- Centro Médico del Noreste, Clínica 25 IMSS, Monterrey, Nuevo León, Hospital Ángeles Torreón, Coahuila, Mexico
| | - J L Pérez-Hernández
- Hospital Central Sur de Alta Especialidad Petróleos Mexicanos, Mexico City, Mexico
| | - M V Ramos-Gómez
- Servicio de Gastroenterología, CMN 20 de Noviembre, ISSSTE Mexico City, Mexico
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - M T Rizo-Robles
- UMAE Hospital de Especialidades CMN La Raza IMSS, Mexico City, Mexico
| | - H Rodríguez-Hernández
- Facultad de Medicina y Nutrición, Universidad Juárez del Estado de Durango, Durango, Mexico
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Dietrich CF, Bekkali NL, Burmeister S, Dong Y, Everett SM, Hocke M, Ignee A, On W, Hebbar S, Oppong K, Sun S, Jenssen C, Braden B. Controversies in ERCP: Technical aspects. Endosc Ultrasound 2021; 11:27-37. [PMID: 34677144 PMCID: PMC8887038 DOI: 10.4103/eus-d-21-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
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Affiliation(s)
- Christoph F Dietrich
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China; Johann Wolfgang Goethe University, Frankfurt/Main, Germany; Department of Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Noor L Bekkali
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Germany
| | - Andre Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Wei On
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Srisha Hebbar
- University Hospitals of North Midlands, United Kingdom
| | - Kofi Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Christian Jenssen
- Krankenhaus Märkisch-Oderland, Department of Internal Medicine, Strausberg; Brandenburg Institute for Clinical Ultrasound (BICUS) at Medical University Brandenburg, Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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Use of peroral cholangioscopy to screen for neoplastic bile duct lesions in patients with bile duct stones (with videos). Gastrointest Endosc 2021; 94:776-785. [PMID: 33865838 DOI: 10.1016/j.gie.2021.03.997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although cholangiocarcinomas (CCAs) can be diagnosed using several modalities, the detection of early-stage cancers remains unsatisfactory. We explored whether peroral cholangioscopy (POC) could be used to screen for neoplastic bile duct lesions including CCAs in patients with bile duct stones. METHODS Two hundred seven patients who underwent endoscopic removal of bile duct stones were enrolled between August 2010 and July 2018. The primary outcome was the detection rate of intraductal neoplastic biliary lesions by direct POC. Secondary outcomes were the technical success rates of direct POC and POC-guided forceps biopsy sampling (POC-FB), the diagnostic accuracy of the direct POC findings, adverse events, and the number needed to screen to detect a neoplastic bile duct lesion. RESULTS Direct POC was successful in 199 of 207 patients (96.1%). Mild cholangitis developed in 2 patients (1.0%) and was treated conservatively. Of the 199 successfully performed POCs, 31 patients (15.6%) exhibited abnormal intraductal mucosal lesions. The technical success rate of POC-FB was 90.3% (28/31 patients). The pathologic diagnoses after POC-FB were CCAs (n = 4), intraductal papillary neoplasms of the bile duct (IPN-B) (n = 2), an adenoma with dysplasia (n = 1), and benign lesions (n = 21). Direct POC correctly distinguished non-neoplastic from neoplastic bile duct lesions in 91.6% of patients. Curative surgical resection was performed for the 5 patients with CCAs or IPN-B. The number needed to screen to detect a neoplastic bile duct lesion was 29.6. CONCLUSIONS Direct POC using a dedicated, ultraslim upper endoscope usefully screens for neoplastic bile duct lesions including CCAs in selected patients with bile duct stones.
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Sanders DJ, Bomman S, Krishnamoorthi R, Kozarek RA. Endoscopic retrograde cholangiopancreatography: Current practice and future research. World J Gastrointest Endosc 2021; 13:260-274. [PMID: 34512875 PMCID: PMC8394185 DOI: 10.4253/wjge.v13.i8.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
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Affiliation(s)
- David J Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Dollhopf M, Schmetkamp H. Endoscopic management of difficult common bile duct stones. Minerva Gastroenterol (Torino) 2021; 68:144-153. [PMID: 34142521 DOI: 10.23736/s2724-5985.21.02876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. EVIDENCE ACQUISITION A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS). EVIDENCE SYNTHESIS This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones. CONLCLUSIONS For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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Affiliation(s)
- Markus Dollhopf
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany
| | - Henning Schmetkamp
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -
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Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones - A prospective study from a tertiary care centre in Eastern India. Arab J Gastroenterol 2021; 22:111-114. [PMID: 34120850 DOI: 10.1016/j.ajg.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/22/2021] [Accepted: 05/18/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5-15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones. PATIENTS AND METHODS Consecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications. RESULTS During the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up. CONCLUSION LL is a highly effective and safe procedure with minimal and transient complications.
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A narrative review on endopancreatic interventions: an innovative access to the pancreas. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Yoshida M, Naitoh I, Hayashi K, Jinno N, Hori Y, Natsume M, Kato A, Kachi K, Asano G, Atsuta N, Sahashi H, Kataoka H. Four-Step Classification of Endoscopic Transpapillary Gallbladder Drainage and the Practical Efficacy of Cholangioscopic Assistance. Gut Liver 2021; 15:476-485. [PMID: 33402544 PMCID: PMC8129659 DOI: 10.5009/gnl20238] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/05/2020] [Accepted: 09/17/2020] [Indexed: 12/22/2022] Open
Abstract
Background/Aims Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.
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Affiliation(s)
- Michihiro Yoshida
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Naruomi Jinno
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Makoto Natsume
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akihisa Kato
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kenta Kachi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Go Asano
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Naoki Atsuta
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hidenori Sahashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Munot K, Raijman I, Khan V, Gandle C, Shahid M, Liu Y, Patel K, Wheeler TM, Othman MO. Aspiration fluid cytology during single operator cholangioscopy with targeted biopsy to improves the diagnostic yield in indeterminate biliary strictures. Diagn Cytopathol 2021; 49:768-772. [PMID: 33755354 DOI: 10.1002/dc.24741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/28/2021] [Accepted: 03/08/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Sensitivities of various sampling methods to detect malignant biliary strictures remain suboptimal. Irrigation during digital single operator cholangioscopy (dSOC) is done routinely for visualization of the duct. The aim of this study was to evaluate improvement of the sensitivity for detecting malignant biliary strictures when adding aspiration fluid cytology (AFC) from the irrigated fluid during cholangioscopy to cholangioscopic biopsy (CBx). METHODS We conducted a retrospective analysis of patients at a tertiary medical center who underwent CBx for evaluation of their biliary strictures. We included patients who had aspiration of fluid from the bile duct after CBx and were sent for cytology from January 2017 to October 2017. Diagnosis was made on the basis of final pathology or follow-up over 9 months. RESULTS Fifty-six patients had CBx obtained, out of which 35 patients had AFC in conjunction. Twenty-two (62%) patients were male and the average age was 65 years. Considering atypical cells as benign, the sensitivity, specificity, positive and negative predictive values (PPV, NPV) for CBx were 62.5%, 100%, 100%, and 76% respectively. When CBx combined with AFC, the above statistics went up to 81.25%, 100%, 100%, and 86.36% respectively. When atypical cells were considered malignant, the sensitivity, specificity, PPV and NPV for CBx were 81.25%, 84.21%, 81.25%, 84.21% and increased to 93.75%, 78.94%, 78.94%, and 93.75% respectively after adding AFC results. CONCLUSION For patients with biliary stricture, addition of AFC dSOC guided biopsies, significantly improves the sensitivity for detecting malignancy.
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Affiliation(s)
- Khushboo Munot
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Isaac Raijman
- Gastroenterology Service, Department of Medicine, Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Vinshi Khan
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Cassandra Gandle
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Marwah Shahid
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Yan Liu
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kalpesh Patel
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Gastroenterology Service, Department of Medicine, Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Thomas M Wheeler
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed O Othman
- Gastroenterology Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Gastroenterology Service, Department of Medicine, Baylor St Luke's Medical Center, Houston, Texas, USA
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Alvarez chica LF, Rico-Juri JM, Carrero-Rivera SA, Castro-Villegas F. Coledocolitiasis y exploración laparoscópica de la vía biliar. Un estudio de cohorte. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar.
Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal.
Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %.
Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.
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Choe JW, Kim SY, Lee DW, Hyun JJ, Ahn KR, Yoon I, Jung SW, Jung YK, Koo JS, Yim HJ, Lee SW. Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy. Gastrointest Endosc 2021; 93:608-615. [PMID: 32598960 DOI: 10.1016/j.gie.2020.06.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. METHODS A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. RESULTS Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10 mm, cholesterol stone, maximum diameter of CBD >15 mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10 mm, and EML were related to postoperative CBD stones after cholecystectomy. CONCLUSIONS Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.
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Affiliation(s)
- Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Seung Young Kim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dong-Won Lee
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ke Ryun Ahn
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ik Yoon
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Woo Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sang Woo Lee
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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Oh CH, Dong SH. Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy. Korean J Intern Med 2021; 36:235-246. [PMID: 32972127 PMCID: PMC7969058 DOI: 10.3904/kjim.2020.425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/16/2022] Open
Abstract
The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
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Du C, Chai N, Linghu E, Li H, Feng X, Wang X, Tang P. Diagnostic value of SpyGlass for pancreatic cystic lesions: comparison of EUS-guided fine-needle aspiration and EUS-guided fine-needle aspiration combined with SpyGlass. Surg Endosc 2021; 36:904-910. [PMID: 33650000 DOI: 10.1007/s00464-021-08347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS No study has evaluated the diagnostic value of SpyGlass by comparing SpyGlass results and non-SpyGlass results. In this retrospective study, we aimed to compare the diagnostic value of EUS-guided fine-needle aspiration (EUS-FNA) and EUS-FNA combined with SpyGlass to evaluate whether SpyGlass is valuable for increasing the diagnostic yield of EUS-FNA. METHODS From April 2015 to April 2020, 251 patients suspected of having pancreatic cystic lesions (PCLs) by imaging techniques who then underwent EUS-FNA were retrospectively enrolled. Only 98 patients who underwent surgical resection with a pathological diagnosis of pancreatic cystic lesion (PCL) were studied. The diagnostic performance outcomes were compared between the EUS-FNA group (EUS-FNA alone, n = 40) and the SpyGlass group (EUS-FNA combined with SpyGlass, n = 58) to assess the value of SpyGlass in diagnosing PCLs. RESULTS There were 71 females and 27 males with an overall mean age of 47.6 years. The median diameter of the PCLs was 42.2 mm (range, 11.4-100.0 mm). Approximately 37 cysts were localized in the head/neck of the pancreas, while 61 in the body/tail. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the EUS-FNA group were 96.4% (27/28), 83.3% (10/12), 93.1% (27/29), 90.9% (10/11) and 92.5% (37/40), while those in the SpyGlass group were 100% (54/54), 75% (3/4), 98.2% (54/55), 100% (3/3) and 98.3% (57/58), respectively. The diagnostic accuracy rate in the SpyGlass group was higher than that in the EUS-FNA group; however, no significant difference was found between the two groups (P = 0.368). The diagnostic accuracy of evaluating specific cyst types in the EUS-FNA group was 85% (34/40), similar to that in the SpyGlass group (85.0% vs 84.5%, P = 0.944). CONCLUSION SpyGlass seems less valuable for the diagnosis of PCLs when EUS and EUS-FNA have been performed by experienced endoscopists.
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Affiliation(s)
- Chen Du
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China.
| | - Huikai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
| | - Xiuxue Feng
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
| | - Xiangdong Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Haidian District, No. 28 of Fuxing Road, Beijing, 100853, China
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Martins FP, Seleti SMR, Contini ML, DE Paulo GA, Ferrari AP. IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT? ARQUIVOS DE GASTROENTEROLOGIA 2021; 57:347-353. [PMID: 33237212 DOI: 10.1590/s0004-2803.202000000-67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 07/31/2020] [Indexed: 09/28/2023]
Abstract
BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.
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Percutaneous transhepatic cholangioscopy using a single-operator cholangioscope (pSOC), a retrospective, observational, multicenter study. Surg Endosc 2021; 35:6724-6730. [PMID: 33398561 DOI: 10.1007/s00464-020-08176-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Percutaneous cholangioscopy (PC) is more complex and invasive than a transpapillary approach, with the need for a large percutaneous tract of 16 French (Fr) on average in order to advance standard percutaneous cholangioscopes. The aim of this study was to investigate whether percutaneous single-operator cholangioscopy (pSOC) using the SpyGlass™ DS system is feasible, safe, and effective in PC for diagnostic and therapeutic indications. MATERIALS AND METHODS The data of 28 patients who underwent pSOC in 4 tertiary referral centers were retrospectively analyzed. Technical and clinical success for therapeutic procedures was assessed as well as diagnostic accuracy of pSOC-guided biopsies and visualization. Adverse events and the required number and size of dilatations were reviewed. RESULTS 25/28 (89%) patients had a post-surgical altered anatomy. The average number of percutaneous dilatations prior to pSOC was 1.25 with a mean dilatation size of 11 French. Histopathology showed a 100% accuracy. Visual impression showed an overall accuracy of 96.4%. Technical and clinical success was achieved in 27/28 (96%) of cases. Adverse events occurred in 3/28 (10.7%) cases. CONCLUSION pSOC is a feasible, safe, and effective technique for diagnostic and therapeutic indications. It may be considered an alternative approach in clinical cases where gastrointestinal anatomy is altered. It has the potential to reduce peri-procedural adverse events and costs. Prospective randomized-controlled trials are necessary to confirm the previously collected data.
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Martinez NS, Trindade AJ, Sejpal DV. Determining the Indeterminate Biliary Stricture: Cholangioscopy and Beyond. Curr Gastroenterol Rep 2020; 22:58. [PMID: 33141356 DOI: 10.1007/s11894-020-00797-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Indeterminate biliary strictures (IDBS) continue to be an area of frustration for clinicians. Standard endoscopic retrograde cholangiopancreatography (ERCP) with conventional brush cytology and/or forceps biopsy has a low sensitivity for distinguishing benign from malignant biliary strictures. A delay in diagnosis of malignancy has consequences for subsequent therapy or surgery. In this article, we review current and emerging technologies that may aid in this diagnostic dilemma. RECENT FINDINGS Several technologies have been utilized in IDBS to establish a diagnosis which include peroral cholangioscopy, confocal laser endomicroscopy, endoscopic ultrasound with fine needle aspiration, intraductal ultrasound, optical coherence tomography, fluorescence in situ hybridization, next generation sequencing, integrated molecular pathology, and DNA-image cytometry. While cholangioscopy and confocal laser endomicroscopy have become standards of care in expert centers for the evaluation of patients with IDBS, there are several endoscopic and molecular modalities that may also aid in establishing a diagnosis. Further head-to-head prospective diagnostic studies as well as cost-efficacy studies are needed.
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Affiliation(s)
- Nichol S Martinez
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Arvind J Trindade
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Divyesh V Sejpal
- Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.
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Wen LJ, Chen JH, Xu HJ, Yu Q, Liu K. Efficacy and Safety of Digital Single-Operator Cholangioscopy in the Diagnosis of Indeterminate Biliary Strictures by Targeted Biopsies: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:E666. [PMID: 32887436 PMCID: PMC7555631 DOI: 10.3390/diagnostics10090666] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Biliary strictures are frequently encountered in clinical practice. The determination of their nature is often difficult. This study aims to systematically evaluate the efficacy and safety of the second generation of digital single-operator cholangioscopy (SpyGlass DS, DSOC) in indeterminate biliary strictures (IBDS) through biopsies. METHODS All relative studies published in Medline, the Cochrane Library, Web of Science, and EMBASE were included. The diagnostic tests for IBDS were compared to the surgical histology, autopsy, or long-term clinical follow-up. The methodological quality of the included studies was evaluated by the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS-2). RESULTS A total of 11 studies, which involved 356 patients diagnosed through biopsies, were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.74 (95% CI: 0.67-0.80), 0.98 (95% CI: 0.95-1.00), 10.52 (95% CI: 5.45-20.32), 0.31 (95% CI: 0.23-0.41), and 65.18 (95% CI: 26.79-158.61), respectively. The area under the curve (AUC) was 0.9479, and the pooled adverse event rate was 7%. The sensitivity and specificity in the heterogeneity analysis were I2 = 48.1% and I2 = 25.4%, respectively. CONCLUSION SpyGlass DS is a safe and effective technique for IBDS. However, future randomized trials are needed to determine optimal number of biopsies.
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Affiliation(s)
- Li-Jia Wen
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Jun-Hong Chen
- College of Clinical Medicine, Jilin University, Changchun 130021, China;
| | - Hong-Ji Xu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Qiong Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun 130021, China;
| | - Kai Liu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
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Bang JY, Sutton B, Navaneethan U, Hawes R, Varadarajulu S. Efficacy of Single-Operator Cholangioscopy-Guided Lithotripsy Compared With Large Balloon Sphincteroplasty in Management of Difficult Bile Duct Stones in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:2349-2356.e3. [PMID: 32057976 DOI: 10.1016/j.cgh.2020.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/23/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although single-operator cholangioscopy (SOC)-guided lithotripsy and large balloon sphincteroplasty (LBS)-based techniques are effective rescue measures, the ideal approach to management of difficult bile duct stones is unclear. We conducted a randomized trial to compare the effectiveness of SOC-guided lithotripsy and LBS-based approaches for endoscopic management of difficult bile duct stones. METHODS Patients with difficult bile duct stones who failed retrieval using balloon or basket were randomly assigned to groups that received SOC-guided laser lithotripsy (SOC-LL, n = 33) or LBS (n = 33), from June 2016 through August 2018. When assigned treatment was unsuccessful, patients underwent mechanical lithotripsy before crossing over to the other group. The main outcome was treatment success, defined as ability to clear the duct in 1 session. Secondary outcomes were adverse events and treatment costs. RESULTS A higher proportion of patients in the SOC-LL group had treatment success (93.9%) than in the LBS group (72.7%; P = .021). On multiple logistic regression analysis, treatment success was significantly associated with use of SOC-LL (odds ratio [OR], 8.7; 95% CI, 1.3-59.3; P = .026), stone to extrahepatic bile duct ratio of 1 or less (OR, 28.8; 95% CI, 1.2-687.6; P = .038), and lack of a tapered bile duct (OR, 26.9; 95% CI, 1.3-558.2; P = .034). There was no significant difference between groups in adverse events (9.1% in the SOC-LL group vs 3.0% in the LBS group, P = .61) or overall treatment cost ($16,684 in the SOC-LL group vs $10,626 in the LBS group; P = .097). CONCLUSIONS In a randomized trial of patients with difficult bile stones that cannot be cleared by standard maneuvers, SOC-guided lithotripsy leads to duct clearance in a significantly higher proportion of patients than LBS-particularly when stone size exceeds the diameter of the extrahepatic bile duct. Adjunct lithotripsy might be required in patients with tapered distal bile duct, because LBS alone is less likely to be successful. ClinicalTrials.gov no: NCT00852072.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | | | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida.
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Fujita A, Nakahara K, Michikawa Y, Morita R, Suetani K, Sato J, Igarashi Y, Araki R, Ikeda H, Matsunaga K, Watanabe T, Itoh F. Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal. BMC Gastroenterol 2020; 20:285. [PMID: 32831030 PMCID: PMC7446213 DOI: 10.1186/s12876-020-01428-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background Recent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP. Methods We retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP. Results The rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19–9.88; P = 0.02). Conclusions When removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.
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Affiliation(s)
- Akashi Fujita
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - Yosuke Michikawa
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryo Morita
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Keigo Suetani
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Junya Sato
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yosuke Igarashi
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryuichiro Araki
- Community Health Science Center, Saitama Medical University, Saitama, Japan
| | - Hiroki Ikeda
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kotaro Matsunaga
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tsunamasa Watanabe
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Fumio Itoh
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Aly FZ, Mostofizadeh S, Jawaid S, Knapik J, Mukhtar F, Klein R. Effect of single operator cholangioscopy on accuracy of bile duct cytology. Diagn Cytopathol 2020; 48:1230-1236. [PMID: 32770823 DOI: 10.1002/dc.24553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/05/2020] [Accepted: 06/29/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This is the first study to evaluate the accuracy of bile duct brushings since the introduction of single operator cholangioscopy SpyGlass DS system in 2015. The primary aim of our study was to compare the accuracy of cytology brushings against biopsies obtained at endoscopic retrograde cholangiopancreatography (ERCP) and cholangioscopy. METHOD A retrospective search for bile duct brushing specimens was performed and the charts reviewed. The gold standard for definitive diagnosis of malignancy was surgical tissue or compelling clinical evidence of malignancy. Definite negative diagnosis relied on lack of clinical/imaging features of malignancy on follow-up. RESULTS There was no significant difference in diagnostic accuracy of cytology specimens obtained at different procedures. Overall sensitivity for all methods was 59%, specificity 90% and accuracy of 82%. Notably, all four false-positive cases except for one were from patients with primary sclerosing cholangitis or primary biliary sclerosis. There was no significant difference in sensitivity or specificity between biopsies procured by the two methods. The combined biopsy sensitivity for all modalities was 44% with a specificity of 100%. There was 70% concordance between cytology and biopsy cases. The overall specificity and sensitivity of the combined cytology and biopsy result was 85% and 65.3%, respectively. Ranking of factors that predict clinical diagnosis shows cytology results to surpass other parameters including pancreatic mass, age and stenosis length. Similarly, the presence of two cell populations and three-dimensional clusters was not nearly as predictive of malignancy as single malignant cells. CONCLUSION Biliary brush cytology specimens performed better than biopsies irrespective of whether they are procured during ERCP or cholangioscopy. The combination of cytology and biopsy had the best accuracy than either one alone.
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Affiliation(s)
- Fatima Zahra Aly
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sayedamin Mostofizadeh
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Salmaan Jawaid
- Department of Gastroenterology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jacquelyn Knapik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Faisal Mukhtar
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert Klein
- Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona, USA
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Palermo M, Fendrich I, Ronchi A, Obeid J, Gimenez M. Laparoscopic Common Bile Duct Exploration Using a Single-Operator Cholangioscope. J Laparoendosc Adv Surg Tech A 2020; 30:989-992. [PMID: 32707008 DOI: 10.1089/lap.2020.0534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Gallbladder stones are a very common disease, with a prevalence of 21.9% in Argentina. The incidence of common bile duct stones (CBDS) varies with age and with the clinical presentation; ∼3%-10% of patients with gallbladder lithiasis have concomitant choledocholithiasis. In the past decades, the development of ultrasound and magnetic resonance cholangiography and endoscopic ultrasound has expanded for the preoperative diagnosis of gallbladder lithiasis. Materials and Methods: We describe the step-by-step technique using the single-operator cholangioscope (pSOC) (SpyGlass™ Discover; Boston Scientific, Natick, MA) under laparoscopic guidance, in a patient with huge stones in the bile duct that was treated with a choledocotomy. Results: The patient underwent the procedure well and the closure of the bile duct was with a primary suture. The current devices, standard cholangioscopes or bronchoscopes, only have a two-way deflection. This problem might be solved with the introduction of a new pSOC device (SpyGlass Discover; Boston Scientific). Conclusion: In conclusion, the combination of laparoscopy and pSOC is a feasible, safe, and effective technique for the treatment of CBDS, and may be considered as an alternative approach in clinical cases where gastrointestinal anatomy is altered or when endoscopic retrograde cholangio-pancreatography (ERCP) failed. pSOC has the potential to reduce peri-procedural adverse events and costs.
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Affiliation(s)
- Mariano Palermo
- Division of Minimally Invasive Surgery, DAICIM Foundation, Buenos Aires, Argentina
| | - Ivan Fendrich
- Division of General Surgery, Hospital J.B. Iturraspe, Santa Fe, Argentina
| | - Antonela Ronchi
- Division of Minimally Invasive Surgery, DAICIM Foundation, Buenos Aires, Argentina.,Division of General Surgery, Hospital J.B. Iturraspe, Santa Fe, Argentina
| | - Jorge Obeid
- Division of General Surgery, Hospital J.B. Iturraspe, Santa Fe, Argentina
| | - Mariano Gimenez
- Division of Minimally Invasive Surgery, DAICIM Foundation, Buenos Aires, Argentina
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Galetti F, Moura DTHD, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGHD. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2020; 33:e1491. [PMID: 32609255 PMCID: PMC7325696 DOI: 10.1590/0102-672020190001e1491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. AIM To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. METHODS Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. RESULTS Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). CONCLUSIONS For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
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Affiliation(s)
- Facundo Galetti
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil.,Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Igor Braga Ribeiro
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Mateus Pereira Funari
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Martin Coronel
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Amit H Sachde
- Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Vitor Ottoboni Brunaldi
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tomazo Prince Franzini
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Dumonceau JM, Delhaye M, Charette N, Farina A. Challenging biliary strictures: pathophysiological features, differential diagnosis, diagnostic algorithms, and new clinically relevant biomarkers - part 1. Therap Adv Gastroenterol 2020; 13:1756284820927292. [PMID: 32595761 PMCID: PMC7298429 DOI: 10.1177/1756284820927292] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/16/2020] [Indexed: 02/04/2023] Open
Abstract
It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed.
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Affiliation(s)
- Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi
University Hospitals, Chaussée de Bruxelles 140, Charleroi, 6042,
Belgium
| | - Myriam Delhaye
- Department of Gastroenterology,
Hepatopancreatology and GI Oncology, Erasme University Hospital, Brussels,
Belgium
| | - Nicolas Charette
- Department of Gastroenterology, Charleroi
University Hospitals, Charleroi, Belgium
| | - Annarita Farina
- Department of Medicine, Geneva University,
Geneva, Switzerland
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Gerges C, Beyna T, Tang RSY, Bahin F, Lau JYW, van Geenen E, Neuhaus H, Reddy DN, Ramchandani M. Response. Gastrointest Endosc 2020; 91:1215-1217. [PMID: 32327122 DOI: 10.1016/j.gie.2020.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/31/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Christian Gerges
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Raymond S Y Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Farzan Bahin
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - James Y W Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Erwin van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Horst Neuhaus
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video). Gastrointest Endosc 2020; 91:1105-1113. [PMID: 31778656 DOI: 10.1016/j.gie.2019.11.025] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Accurately diagnosing indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy sampling under direct cholangioscopic vision might be superior to standard ERCP techniques such as brushing or biopsy sampling. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP workup improves the diagnostic yield in patients with indeterminate biliary strictures. METHODS Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (control arm [CA]) or DSOC visualization and DSOC-guided biopsy sampling (study arm [SA]). This was a prospective, international, multicenter trial with a procedure-blinded pathologist. RESULTS The first sample sensitivity of DSOC-guided biopsy samples was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P < .01). The sensitivity of visualization (SA 95.5% vs CA 66.7%, P = .02) and overall accuracy (SA 87.1% vs CA 65.5%, P = .05) were significantly higher in the SA compared with the CA, whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms. CONCLUSIONS DSOC-guided biopsy sampling was shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathologic diagnosis of indeterminate biliary strictures. (Clinical trial registration number: NCT03140007.).
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Cholangioscopy Biopsies Improve Detection of Cholangiocarcinoma When Combined with Cytology and FISH, but Not in Patients with PSC. Dig Dis Sci 2020; 65:1471-1478. [PMID: 31571103 DOI: 10.1007/s10620-019-05866-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy (SOC) has been suggested to be a cost-effective strategy for the detection of cholangiocarcinoma (CCA). The aim of this study is to compare the performance characteristics of SOC-guided biopsies and transpapillary biopsies with standard sampling techniques for the detection of CCA. METHODS A retrospective cohort study of patients undergoing SOC between 1/2007 and 10/2018 at a single academic center was performed. Demographic, procedural, and outcomes data were recorded and analyzed using STATA 14.0. Sensitivity comparison between diagnostic tests was performed using exact McNemar test exclusively among patients with CCA. Two-sided p value < 0.05 was considered statistically significant. RESULTS Ninety-two patients were included; 36 (39.1%) with primary sclerosing cholangitis (PSC), 41 (44.6%) with CCA, and median follow-up was 15.1 months. In the overall cohort, brush cytology demonstrated a sensitivity of 44.7% and increased with the addition of FISH (56.8%; p = 0.12), FISH with SOC-guided biopsy (71.4%; p = 0.03), and FISH with transpapillary biopsy (64.5%; p = 0.01). However, in patients with PSC, there was no significant improvement in sensitivity with the addition of SOC-guided biopsy or transpapillary biopsy in addition to FISH when compared to brush cytology. There was no difference in the rates of overall adverse events (14% vs. 23.2%; p = 0.27) or infection (3% vs. 4%; p = 0.83) in patients with and without PSC. CONCLUSIONS SOC-guided and transpapillary biopsies improve sensitivity for the detection of cholangiocarcinoma in combination with other ERCP-based techniques compared to brush cytology alone. However, while safe, these modalities do not significantly improve the sensitivity for the detection of malignancy in PSC patients.
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Determining the Indeterminate in Biliary Strictures. Clin Gastroenterol Hepatol 2020; 18:300-301. [PMID: 31568841 DOI: 10.1016/j.cgh.2019.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023]
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Hülagü S, Şirin G. Biliyer Darlık ve Zor Biliyer Taş Tedavisinde Yeni Nesil Dijital Kolanjiyoskopi Kullanımı. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2020. [DOI: 10.30934/kusbed.656893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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