Initial evaluation of a duodenoscope modified to allow guidewire fixation during ERCP

Conventional endoscopic retrograde cholangiopancreaticography vs the Olympus V-scope system

AIM

To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP).

METHODS

Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naïve patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient's clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test.

RESULTS

Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m(2), 159-5039 cGy/m(2) vs 1296 cGy/m(2), 202.2-6421 cGy/m(2), P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires.

CONCLUSION

ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

Refinement of ERCP by using the Olympus V-scope system with a 0.025 in. compatible and complete fixable Visiglide(®) guidewire

AIM

Prospective evaluation of the new 0.025 in. Visiglide(®) guidewire to facilitate endoscopic retrograde cholangiopancreaticography using the Olympus V-scope.

MATERIALS AND METHODS

Interventional endoscopic retrograde cholangiopancreaticography was performed in 9 patients with the Olympus V-scope and the 0.025 in. Visiglide(®) guidewire (VS group), whilst 9 other patients underwent endoscopic retrograde cholangiopancreaticography with a conventional Olympus duodenoscope using 0.035 in. conventional guidewires (controls). Exchange time of accessories, X-ray time, dose and endoscopic retrograde cholangiopancreaticography examination time were investigated.

RESULTS

The VS group showed a significantly lower exchange time of endoscopic retrograde cholangiopancreaticography accessories (9; 4-10s, p<0.0001) than controls (29; 19-44s). The Visiglide(®) guidewire was complete fixable by the elevator in 35/36 instrument exchanges (97%) compared to 16/31 exchanges (52%) using conventional guidewires.

LIMITATIONS

Single-centre study, small patient numbers, two investigators.

CONCLUSIONS

Endoscopic retrograde cholangiopancreaticography using the Olympus V-scope with the new 0.025 in. Visiglide(®) guidewire enables a 3-fold faster exchange of accessories due to a nearly complete fixation of the guidewire.

Duodenoscopic treatment of recurrent common bile duct stones: an analysis of 440 cases

AIM: To analyze the indications and contraindications for duodenoscopy in the treatment of recurrent common bile duct stones.

METHODS: A total of 449 patients with recurrent common bile duct stones diagnosed by type-B ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography were analyzed in this study. Based on the presence of bile duct stricture and intrahepatic bile duct stones or not, the size and number of recurrent stones, and past treatment history, the possibility of success of duodenoscopic treatment was evaluated to select appropriate minimally invasive procedures.

RESULTS: Of 449 patients included, 440 underwent duodenoscopic treatment, and of them 335 patients received duodenoscopic stone removal. The success rate of stone removal was 96.7% (324/335). The average length of hospital stay for patients undergoing duodenoscopic stone removal was 5.43 d ± 1.86 d, and the incidence of complications was 6.6% (22/335). Postoperative evaluation of the biliary tract showed that 317 patients were in good condition.

CONCLUSION: Duodenoscopy has the advantages of minimal invasiveness and short hospital stay in the treatment of recurrent bile duct stones. Etiological treatment can help reduce the recurrence rate of bile duct stones.

Prospective randomized blinded comparison of a short-wire endoscopic retrograde cholangiopancreatography system with traditional long-wire devices

BACKGROUND

Short-wire endoscopic retrograde cholangiopancreatography (ERCP) systems are perceived to carry advantage over traditional long-wire devices. To date, this potential advantage has not been well documented, and gastroenterologists are confronted in everyday practice with the dilemma of choosing a particular system without the benefit of having objective comparative data.

AIMS

The aim of this study was to compare the performance characteristics of the Fusion ERCP short-wire system with traditional long-wire devices.

METHODS

This is a prospective, blinded, randomized, controlled trial. Patients with a clinical indication for ERCP were randomized to undergo the procedure with the Fusion short-wire system or long-wire devices. All procedures were done by one experienced endoscopist who was blinded to the outcomes of the study. The person recording the outcomes was an independent observer not involved in the procedure and was blinded to the study hypothesis. The main outcome was device exchange time. Secondary outcomes included stent insertion time, total procedure time, fluoroscopy time, cannulation time, successful cannulation of the desired duct, and complications.

RESULTS

A total of 71 patients were enrolled. The short-wire system provided for significantly faster mean device exchange time (125 versus 177 s; P = 0.05) and stent insertion time (135 versus 254 s; P < 0.001) as compared with the long-wire system. A trend towards shorter total procedure time, fluoroscopy time, and cannulation time was noted with the short-wire system but did not reach statistical significance. Successful cannulation of the desired duct was achieved in all patients. Post-ERCP pancreatitis occurred in one patient in the short-wire and in two patients in the long-wire group.

CONCLUSIONS

This short-wire system provides for significantly shorter device exchange and stent insertion times compared with traditional long-wire devices.

ERCP wire systems: The long and the short of it

Guidewires are routinely used at the time of endoscopic retrograde cholangiopancreatography (ERCP) to gain and maintain access to the desired duct and aid in the advancement of various devices. Limitations of the traditional long-wire systems have led to the introduction of three proprietary short-wire systems. These systems differ in many respects but share two main principles: They lock a shorter wire in position to allow advancement or removal of various devices without displacement of the wire and they all allow for physician control of the wire. In this comprehensive review, we describe the key features of the three currently available short-wire systems: RX, Fusion and V systems. We also focus on the potential benefits and drawbacks that accompany the short-wire concept as a whole and each specific system in particular. Although the available data are limited, it appears that the use of the short-wire systems lead to reduced procedure, fluoroscopy and device exchange times, decreased sedation requirements, improved wire stability and increased endoscopist control of the wire. Furthermore, the physician-controlled wire-guided cannulation has the potential to decrease ampullary trauma and the rate of post-ERCP pancreatitis. The short guidewire systems appear to be an improvement over the traditional long-wire systems but further studies directly comparing the two approaches are needed.

Intraprocedural steps to enhance efficiency

This section focuses on intraprocedural steps that can improve endoscopic efficiency. Contributors to procedural efficiency and inefficiency are considered. The limitations to enhancing efficiency are presented. Strategies for incorporating contributors to efficiency including techniques, technologies, accessories, and attitudes are presented.