Endoscopic sphincterotomy of the ampulla of Vater

Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

All-in-one sphincterotome with high rotation performance and freely bendable blade for endoscopic sphincterotomy in patients with surgically altered anatomy (a case series with video)

A new type of sphincterotome released to the market recently has high rotation performance and a freely bendable blade. It is devised to be singly capable of accommodating not only normal anatomy but also cases with surgically altered anatomy. This study was undertaken for clinical evaluation of the usefulness of this new sphincterotome. Eight cases in a reconstructed intestine for which cannulation or endoscopic sphincterotomy (EST) had been performed were extracted from 32 cases for which endoscopic retrograde cholangiopancreatography-related procedures were performed using the sphincterotome developed during November 2023 through February 2024. The cases were investigated retrospectively. Among these, EST was applied to six cases. Cannulation was performed using the developed sphincterotome in the native papilla in four cases. The primary endpoints were the success rate of cannulation in surgically altered anatomy and the success rate of EST. Secondary endpoints were complications and usability for operators. Usability for operators was evaluated by questionnaire for several items on a 5-point scale. EST was conducted successfully in all six cases subjected to EST. Mild hemorrhage was observed in one case (17%) as an adverse event after EST. Deep cannulation to the native papilla with the developed sphincterotome was conducted successfully in three cases (75.0%). Evaluation results by operators were 4.4 ± 0.55 for rotation performance, 4.00 ± 0.63 for incision performance, 4.29 ± 0.49 for deep cannulation performance, and 4.07 ± 0.19 for overall evaluation. In conclusion, this developed sphincterotome might be very useful for EST and cannulation in cases with surgically altered anatomy.

Post-ERCP clearance of bile duct stones: should the gallbladder be left in-situ?

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has become the gold standard management for patients who present with common bile duct stone (CBDS). Although laparoscopic cholecystectomy is generally recommended for patients who have CBDS clearance, there is still a significant proportion of patients who are managed expectantly. Our study aimed to evaluate the outcomes of expectant management (EM) versus prophylactic cholecystectomy after initial endoscopic removal of CBDS.

METHOD

We performed a retrospective review of all patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019. Patients were further classified into young or elderly group using age 60 years as the cut-off. Primary outcomes measured biliary-related complications in each interventional group whereas secondary outcomes measured all-cause mortality.

RESULTS

136 patients (51.3%) had EM whereas 129 patients (48.7%) were initially planned for LC. There was 20.6% of recurrence of biliary events in EM group as compared to 3.9% in LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. Overall complications of LC group was low (5.4%) with nil operative-related mortality. However, there was a significant higher proportion of elderly patients in EM group in comparison to LC group (88.2% vs 31%) and 51.4% of EM group died during follow-up period with only one biliary-related death.

CONCLUSION

Prophylactic cholecystectomy should be recommended for patients who have undergone ERCP clearance of CBDS. A watch-and-wait approach may be justified for elderly populations who are not ideal surgical candidates and a follow-up duration of up to 2 years is recommended.

Combinatorial Effects of Terpene, Chenodeoxycholic Acid, and Ursodeoxycholic Acid on Common Bile Duct Stone Recurrence and Gallbladder Stone Dissolution

Background: Ursodeoxycholic acid (UDCA), chenodeoxycholic acid (CDCA) plus UDCA (C&U), and terpene are widely administered to prevent common bile duct (CBD) stone recurrence and dissolve gallbladder (GB) stones. We evaluated and compared the combined effects of these agents on CBD stone recurrence and GB stone resolution. Methods: This study included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at six referral centers, retrospectively. A total of 940 patients who underwent cholecystectomy before or after CBD stone removal by ERCP were evaluated to assess CBD stone recurrence (the CBD recurrence cohort), and 98 patients with GB stones were assessed by abdominal or endoscopic ultrasonography before and 6 months after ERCP to evaluate GB stone resolution (GB cohort). Patients were divided into no-medication, single-agent treatment (UDCA, C&U, or terpene), or dual-agent treatment (terpene plus UDCA or C&U) groups for the analysis. Results: In the CBD recurrence cohort, baseline characteristics were similar in the three groups. CBD stone recurrence rates were 41.5%, 12.7%, and 9.8% in the no-medication, single-agent, and dual-agent groups, respectively (p < 0.001), and the recurrence rate was significantly lower for those administered C&U plus terpene (5.2% vs. 13.2%, p = 0.002). In the GB cohort, baseline characteristics were also similar in the groups. GB stone resolution rates of >30% were observed in 5.3%, 14.3%, and 34.8% of patients in the no-medication, single-agent, and dual-agent groups, respectively (p = 0.028). Conclusions: C&U plus terpene was significantly more effective for preventing CBD stone recurrence and achieving GB stone resolution than no medication or single agents.

Current Gallstone Treatment Methods, State of the Art

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Application of a New Hemostatic Clip to Prevent Delayed Bleeding After Endoscopic Sphincterotomy: A Propensity Score-matched Analysis

BACKGROUND AND AIM

Delayed bleeding after endoscopic sphincterotomy (ES) is a serious adverse event of endoscopic retrograde cholangiopancreatography. The aim of this study is to evaluate the effect of prevent delayed bleeding of hemostatic clip (Sureclip) after ES.

METHODS

Consecutive patients diagnosed with common bile duct stones with a high risk of delayed bleeding who received ES from January 1, 2013, to July 31, 2022, were analyzed retrospectively. A 1:1 propensity score-matching analysis and logistic regression analysis were used. The patients were allocated into the hemostatic clip and control groups. The rate of delayed bleeding, hyperamylasemia, pancreatitis, and hemostatic clip closing the bile duct or pancreatic duct by mistake were compared between the 2 groups.

RESULTS

Overall, 161 and 232 patients were allocated to the control and hemostatic clip groups, respectively, propensity score matching created 120 matched pairs. The rate of delayed bleeding was significantly lower in the hemostatic clip group than in the control group (1.67% vs. 7.5%, P =0.031). After adjusting for confounding factors, logistic regression showed hemostatic clip was associated with decreased odds of delayed bleeding (0.134, 95% CI: 0.025-0.719). No case of hemostatic clip closing the bile duct or pancreatic duct by mistake occurred in the hemostatic clip group. No significant differences were observed in postoperative hyperamylasemia and pancreatitis between the 2 groups.

CONCLUSIONS

This study indicated that the prophylactic application of a hemostatic clip is associated with a significantly reduced rate of delayed bleeding after ES in high-risk patients. This approach did not increase the risk of adverse event.

History of the Interventional Pancreaticobiliary Endoscopy

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.

Role of endoscopy in hepatology

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

Needle-Knife Fistulotomy Versus Needle-Knife Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP.

Methods

We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate.

Results

Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I2 = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed.

Conclusions

Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.

ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes

Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Optimal dilation duration of 10 mm diameter balloons after limited endoscopic sphincterotomy for common bile duct stones: a randomized controlled trial

Limited endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) is widely used. However, the optimal duration of small balloon dilation in choledocholithiasis remains controversial. We aimed to determine the optimal duration for 10 mm diameter balloon dilation after limited EST in choledocholithiasis. In this randomized controlled clinical trial, 320 patients were randomly assigned to receive small balloon dilation (10 mm in diameter) for 1 min (n = 160) or 3 min (n = 160) after deep bile duct cannulation. No significant difference in success rate of stone extraction between the two groups was observed. The incidence of post-ERCP pancreatitis (PEP) was higher in the 1 min group (10.6%) than in the 3 min group (4.4%) (P = 0.034). The logistic regression analysis showed that guidewire into the pancreatic duct, cannulation time > 5 min and 1 min balloon dilation were independent risk factors for PEP. There were no significant differences in other post-ERCP adverse events such as acute cholangitis, bleeding, perforation, etc. between the two groups. In conclusion, 3 min in duration was determined to be the optimal dilation condition for the removal of common bile duct stones.

My 40-Year Encounter with ERCP: A Saga of Service, Syndromes, and Solutions

Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, Ascaris lumbricoides, was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.

Face and content validity of a biological papilla designed for the Boškoski-Costamagna ERCP simulator

BACKGROUND AND AIMS

A biological papilla made of chicken heart tissue, incorporated into the Boškoski-Costamagna ERCP Trainer simulator, was recently designed to allow training in sphincterotomy. This study aimed to evaluate the face and content validity of this tool.

METHOD

Participants from 2 groups (nonexperienced and experienced [<600 or >600 lifetime ERCPs, respectively]) were invited to perform standardized assignments on the model: sphincterotomy and precut for both groups and papillectomy for the experienced group. Following these assignments, all participants filled out a questionnaire to rate their appreciation of the realism of the model, and experienced endoscopists were also asked to evaluate its didactic value using a 5-point Likert scale.

RESULTS

A total of 19 participants were included (nonexperienced, n = 10; experienced, n = 9). Parameters regarding the realism of the tool in terms of general appearance, sphincterotomy, precut, and papillectomy were overall considered realistic (4 of 5), with good agreement rates in terms of overall realism between groups. Experienced operators reported the highest realism for "positioning the scope and needle-knife in the field of view" and "during precut," "cutting in small increments during precut," and "controlling the scope during papillectomy," and they highly agreed that this papilla should be included for training novice and intermediate trainees in sphincterotomy, precut, and papillectomy.

CONCLUSIONS

Our results show good face validity and excellent content validity of this biological papilla combined with the Boškoski-Costamagna ERCP Trainer. This new tool provides a useful, inexpensive, versatile, and easy tool for training regarding sphincterotomy, precut, and papillectomy. Future studies should explore whether including this model in real-life training improves the learning curve of endoscopy trainees.

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

OBJECTIVES

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones.

METHODS

We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram.

RESULTS

The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success.

CONCLUSIONS

PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate.

KEY POINTS

• PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

A Case of Spurting Bleeding After Endoscopic Papillary Balloon Dilation

A 58-year-old male with acute cholangitis due to a common bile duct stone underwent endoscopic retrograde cholangiopancreatography for stone removal with endoscopic papillary balloon dilation (EPBD) due to his high bleeding risk owing to maintenance dialysis and antiplatelet and anticoagulant medications. He had a history of stone removal using an EPBD. The stone was removed; however, the patient subsequently developed spurting bleeding and underwent endoscopic hemostasis. Despite the subsequent mild pancreatitis, he recovered with conservative management. While EPBD is considered a low-risk procedure for bleeding, caution should still be exercised due to the possibility of massive postprocedural bleeding.

National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea

Background/Aims

This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea.

Methods

The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021.

Results

The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively.

Conclusions

Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones.

Comparison of one-stage treatment versus two-stage treatment for the management of patients with common bile duct stones: A meta-analysis

Background

Cholelithiasis is a frequently occurring disease in clinic. Due to changes in people's living environments, dietary habits and the aging population, cholelithiasis incidence is increasing. Currently, laparoscopic cholecystectomy (LC) is the preferred treatment for gallbladder stones, but the surgical method for patients with choledocholithiasis is controversial. An endoscopic retrograde cholangiopancreatography (pERCP) is performed preoperatively, followed by LC as the general treatment method. However, pERCP still has some disadvantages, such as prolonged hospital stay, increased incidence of postoperative pancreatitis, and increased duration of anesthesia. Therefore, intraoperative endoscopic retrograde cholangiopancreatography (iERCP) is proposed.

Objective

To compare the efficacy and safety of one-stage treatment and two-stage treatment for the management of patients with cholecystolithiasis and choledocholithiasis.

Search strategy

PubMed, Embase, Web of Science, and Cochrane databases were searched through October 2022. The search terms include cholangiolithiasis/bile duct stones/calculi, endoscopic retrograde cholangiopancreatography/ERCP, endoscopic sphincterotomy/EST, laparoendoscopic rendezvous (LERV), and laparoscopic cholecystectomy/LC.

Selection criteria

For the treatment of patients with cholecystolithiasis and choledocholithiasis in adults, randomized controlled trials (RCTs) comparing LC with iERCP vs. pERCP followed by LC were conducted.

Data collection and analysis

Data extraction and quality assessment were performed by two reviewers. We used Revman version 5.3 to analyze the collected data. The trials were grouped according to the evaluation results such as the overall mortality rate, overall morbidity rate, clearance rate of choledocholithiasis, incidence of pancreatitis, the length of hospitalization, and the length of operation.

Results

9 RCTs (950 participants) were included in this meta-analyses. The overall morbidity rate in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.57, 95% CI = 0.41-0.79, p = 0.0008). The clearance rate of choledocholithiasis in LC + iERCP group was almost the same as that in LC + pERCP group (RR: 1.03, 95% CI = 0.98-1.08, p = 0.28). The incidence of pancreatitis in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.29, 95% CI = 0.13-0.67, p = 0.004). The length of operation of the LC + iERCP group seems to be similar to that of the LC + pERCP group (MD: 16.63 95% CI = -5.98-39.24, p = 0.15). LC + iERCP group has a shorter length of hospitalization than that in LC + pERCP group (MD: -2.68 95% CI = -3.39--1.96, p < 0.00001). LC + iERCP group has lower postoperative second ERCP rate than that in LC + pERCP group (RR: 0.13, 95% CI = 0.03-0.57, p = 0.006).

Conclusion

Our study suggest that LC + iERCP may be a better option than LC + pERCP in the management of patients with both cholecystolithiasis and choledocholithiasis. This procedure can reduce the overall incidence of postoperative complications, especially the occurrence of postoperative pancreatitis. It could shorten the length of hospital stay, reduce postoperative second ERCP rate.

Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance

INTRODUCTION

To develop a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions.

METHODS

This study included patients with CBD stones who underwent ERCP at Pattani Hospital between August 2017 and December 2021. Retrospective cohort data was collected and patients were categorized into two groups: bile duct stones successfully treated by endoscopic biliary sphincterotomy and extraction compared to the former method combined with EPLBD. We explored potential predictors using multivariable logistic regression. The chosen logistic coefficients were transformed into a scoring system based on risk with internal validation via bootstrapping procedure.

RESULTS

Among the 155 patients who had successful endoscopic therapy for bile duct stones, there were 79 (50.97%) cases of endoscopic biliary sphincterotomy, EPLBD and extraction versus 76 (49.03%) cases without EPLBD. The factors used to derive a scoring system included the size of CBD stones >15 mm, the difference between the stone and distal CBD diameter >2mm, distal CBD arm length <36 mm and stone shape. The score-based model's area under ROC was 0.88 (95% CI: 0.83, 0.93). For clinical use, the range of scores from 0 to 16, was divided into two subcategories based on CBD stone removal difficulty requiring EPLBD to derive the PPV. For scores <5 and ≥ 5, the PPV was 23.40 (p <0.001) and 93.44 (p <0.001) respectively. The Bootstrap sampling method indicated a prediction ability of 0.88 (AuROC, 95% CI: 0.83, 0.94).

CONCLUSION

This scoring system has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

Risk of post-sphincterotomy bleeding in patients with thrombocytopenia

Background

Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Objective

The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES.

Design

Retrospective observational cohort study.

Methods

Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review.

Results

A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not.

Conclusion

In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.

Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis

Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).

Endoscopic sphincterotomy vs papillary large balloon dilation vs combination modalities for large common bile duct stones: a network meta-analysis

Background and study aims  The optimal technique for removal of large common bile duct (CBD) stones (≥ 10 mm) during endoscopic retrograde cholangiopancreatography (ERCP) remains unclear. We aimed to perform a comparative analysis between different endoscopic techniques. Methods  Adhering to PRISMA guidelines, a stringent search of the following databases through January 12, 2021, were undertaken: PubMed/Medline, Embase, Web of Science, and Cochrane. Randomized controlled trials comparing the following endoscopic techniques were included: (1) Endoscopic sphincterotomy (EST); (2) Endoscopic papillary large balloon dilation (EPLBD); and (3) EST plus large balloon dilation (ESLBD). Stone clearance rate (SCR) on index ERCP was the primary outcome/endpoint. Need for mechanical lithotripsy (ML) and adverse events were also evaluated as secondary endpoint. Random effects model and frequentist approach were used for statistical analysis. Results  A total of 16 studies with 2545 patients (1009 in EST group, 588 in EPLBD group, and 948 patients in ESLBD group) were included. The SCR was significantly higher in ESLBD compared to EST risk ratio [RR]: 1.11, [confidence interval] CI: 1.00-1.24). Lower need for ML was noted for ESLBD (RR: 0.48, CI: 0.31-0.74) and EPLBD (RR: 0.58, CI: 0.34-0.98) compared to EST. All other outcomes including bleeding, perforation, post-ERCP pancreatitis, stone recurrence, cholecystitis, cholangitis, and mortality did not show significant difference between the three groups. Based on network ranking, ESLBD was superior in terms of SCR as well as lower need for ML and adverse events (AEs). Conclusions  Based on network meta-analysis, ESLBD seems to be superior with higher SCR and lower need for ML and AEs for large CBD stones.

The impact of endoscopic sphincterotomy incision size on common bile duct stone recurrence: A propensity score matching analysis

BACKGROUND/PURPOSE

The aim of this study is to clarify the relation between the incision size for endoscopic sphincterotomy (EST) and common bile duct stone (CBDS) recurrence.

METHODS

Patients who underwent elective endoscopic treatment for CBDS between January 2013 and December 2017 were enrolled, excluding those who met the exclusion criteria. The clinical characteristics were investigated using propensity score matching analysis.

RESULTS

A total of 243 patients were investigated. Propensity scores were calculated using multinomial logistic regression with five relevant variables (age, gender, follow-up time, maximum stone size, and bile duct diameter), which led to extraction of 188 cases to compose cohorts of the small and medium EST incision groups. The CBDS recurrence rate was 17.0% in the small incision group and 6.4% in the medium incision group. Multivariate analysis identified the medium incision as an independent predictor of CBDS recurrence (hazard ratio 0.350, 95% confidence interval 0.133-0.922, P = .034). The CBDS non-recurrence rate of the medium incision group was significantly higher than that of the small incision group (log-rank test P = .019).

CONCLUSIONS

Our findings suggest that the CBDS recurrence rate was lower in EST with medium incision size than with small incision size.

Outcomes of balloon vs basket catheter for clearance of choledocholithiasis: a systematic review and meta-analysis

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay for treatment of choledocholithiasis. It is unclear whether balloon or basket catheters are better for extraction of stones ≤ 10 mm in size. We performed a meta-analysis of studies comparing rates of complete stone extraction and adverse events after ERCP using balloon vs basket catheters for bile duct stones ≤ 10 mm in size. Methods  Cochrane database, PubMed, Web of Science, and Embase were searched from inception to October 2021. Randomized control trials comparing outcomes of balloon vs basket catheter were included. Data extraction of articles was carried out by two authors using predefined inclusion criteria. Metanalysis was carried out using the Revman 5.4.1. software using a random-effects model. Results  Three studies with a total of 508 patients were included in the final analysis. For common bile duct stones ≤ 10 mm, balloon catheters had higher complete stone clearance rates than basket catheters (relative risk 1.1, confidence interval 1.03, 1.18, P  = 0.006). Heterogeneity among studies was low (Tau ²  = 0.0; P  = 0.47, I ²  = 0 %). There was no difference in the rate of complications. Conclusions  Meta-analysis of three studies indicates that balloon catheters have a higher success rate compared to basket catheters for complete stone extraction for choledocholithiasis ≤ 10 mm with no significant difference in the rate of complications.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Características morfológicas de la papila duodenal y su relación con complicaciones poscolangiopancreatografía retrógrada endoscópica en un hospital de Perú

Introducción: existen diversos factores de riesgo para presentar complicaciones poscolangiopancreatografía retrógrada endoscópica (CPRE), uno de los recientemente estudiados es la morfología de la papila duodenal. Objetivos: evaluar la asociación entre las características morfológicas de la papila duodenal y las complicaciones pos-CPRE en pacientes atendidos en el servicio de gastroenterología de un hospital de referencia de Perú. Métodos: estudio prospectivo y analítico que incluyó a 138 pacientes en los que se realizó CPRE, estableciendo relación entre el tipo de papila duodenal según la clasificación endoscópica propuesta por Haraldsson y colaboradores, y las complicaciones pos-CPRE de hasta 1 mes de seguimiento. Resultados: se incluyeron 138 pacientes, 93 mujeres (68,42 %) y 45 varones (31,58 %), con una edad promedio de 51,46 años. El tipo 1 se asoció con menor dificultad en la canulación con un odds ratio (OR): 0,42 (intervalo de confianza [IC]: 0,20-0,88). El tipo 4 presentó significativamente mayor tiempo de canulación (6,83 minutos). La tasa de pancreatitis pos-CPRE fue de 2,9 %; de sangrado, 1,45 %, y de perforación, 0,72 %. La perforación presentó asociación estadísticamente significativa con el tipo de papila (p = 0,009). El tipo 2 presentó mayores tasas de pancreatitis (9,09 %) y perforación (9,09 %) pos-CPRE. Conclusión: el tipo de papila duodenal se asocia significativamente con perforación pos-CPRE. El tipo 2 presentó tasas más altas de complicaciones.

Outcome of Digital Cholangioscopy and Laser Lithotripsy for Impacted Biliary Stones

Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct.

Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications.

Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient.

Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.

Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.

Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.

Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Endoscopic Management of Complex Biliary Stones

Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.

The therapeutic effect of balloon dilatation with different duration for biliary duct calculi: A network meta-analysis

Objective:

To systematically evaluate the application effect of endoscopic papillary balloon dilatation (EPBD) with different balloon dilatation duration for biliary duct calculi, and find the most appropriate dilatation duration for EPBD using a network meta-analysis.

Materials and Methods:

PubMed, Embase and Cochrane Library databases were searched for relevant randomised controlled trials (RCTs) published up to August 2020. Node split, consistency and inconsistency models analysis were all conducted in network meta-analysis.

Results:

Eighteen RCTs with 2256 participants were finally analysed. EPBD was divided into four categories based on balloon dilatation duration, including EPBD (P0.5), EPBD (>0.5, ≤1), EPBD (1, ≤2) and EPBD (>2, ≤5). Compared with EPBD (>0.5, ≤1), EPBD (>2, ≤5) had a lower risk of early complications (odds ratio [OR] = 0.23, 95% credible interval [CI] = 0.05–0.96) and post-endoscopic procedure pancreatitis (PEP) (OR = 0.17, 95% CI = 0.03–0.72). Endoscopic sphincterotomy (EST) tended to have less need for mechanical lithotripsy (OR = 0.37, 95% CI = 0.16–0.88) and PEP (OR = 0.26, 95% CI = 0.08–0.71) than EPBD (>0.5, ≤1). EPBD (>2, ≤5) was the safest endoscopic procedure with respect to early complications (surface area under cumulative ranking curves [SUCRA] = 79.0) and PEP (SUCRA = 85.3). In addition, EPBD (>2, ≤5) and EST had the highest probability of being the best (SUCRA = 82.6) and the worst (SUCRA = 10.8), respectively, regarding late complications.

Conclusion:

EPBD and EST are two methods used to treat uncomplicated choledocholithiasis (stone diameter <10 mm and stone number <3). The extension of balloon dilatation duration has no significant influence on successful stone removal in the first endoscopic session or preventing the need for mechanical lithotripsy. However, it can reduce the risk of early complications, especially PEP. What's more, EPBD seems to have less late complications compared with EST, and the effect of prolonged balloon dilatation duration on late complications still needs to be further explored. Therefore, 2–5 min is the recommended dilatation duration range for EPBD using balloon with ≤10 mm diameter. Further research based on a specific population and with a longer follow-up time are needed.

Effects of antithrombotic therapy on bleeding after endoscopic sphincterotomy: A systematic review and meta-analysis

Background and study aims  Bleeding is a common complication of following endoscopy sphincterotomy (EST), and antithrombotic therapy use during the procedure often increases risk of it. Although several guidelines have been released regarding the use of antithrombotic agents during EST, many issues about it remain controversial. We carried out a systematic review and meta-analysis to evaluate the effect of antithrombotic medication on the risk of EST bleeding. Methods  A structured literature search was carried out in Web of Science, EMBASE, PubMed, and Cochrane Library databases. RevMan 5.2 was used for meta-analysis to investigate the rate of post-EST bleeding. Results  Seven retrospective articles were included. Compared with patients who had never taken antithrombotic drugs, patients who discontinued antithrombotic drugs 1 day before the procedure had a significantly increased risk of post-EST bleeding (OR, 1.95; 95 %CI, 1.57-2.43), particularly for severe bleeding (OR, 1.83; 95 %CI, 1.44-2.34). In addition, compared with patients who discontinued antithrombotic therapy for at least 1 day, patients who continued taking antithrombotic drugs did have an increased risk of post-EST bleeding (OR, 0.70; 95 %CI, 0.40-1.23). Conclusions  The use of antithrombotic drugs may increase the bleeding rate of EST, but discontinuing therapy 1 day before endoscopy does not significantly reduce the bleeding rate.

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal

BACKGROUND

Stone removal using endoscopic papillary large balloon dilation (EPLBD) is extremely effective. However, limited research exists regarding the risk factors for perforation of the duodenal papilla and bile duct, which may be fatal.

AIMS

We aimed to investigate the risk factors for perforation during EPLBD + stone removal.

METHODS

We included patients who underwent EPLBD + stone removal at four medical facilities between January 2008 and December 2018. We retrospectively analyzed the risk factors for perforation and their relationship between overdilation and adverse events. Overdilation was defined as a ratio of the balloon diameter to the diameter of the bile duct that exceeded 100%. The diameter of the distal bile duct was measured using the diameter of the intrapancreatic bile duct at a point 10 mm toward the liver from the narrow distal segment on a cholangiogram.

RESULTS

We included 310 patients (177 males; median age: 79 years [range: 46-102 years]). Perforation occurred in five patients (1.6%). Multivariate analysis indicated that no surrounding-pancreas (half or less of the circumference of the intrapancreatic bile duct was surrounded by the pancreatic parenchyma) was a significant risk factor (perforation rate: 8.3%, p = 0.011, odds ratio: 12.7 [95% confidence interval: 1.8-90.5]). No significant difference was found between the overdilation and non-overdilation groups regarding the occurrence of pancreatitis, bleeding, and cholangitis. Perforation rate in patients with no surrounding pancreas + overdilation was 16.7% (2/12). Patients with perforation underwent conservative therapy, which improved their conditions.

CONCLUSIONS

EPLBD + stone removal should be avoided in patients with no surrounding pancreas. Overdilation is not a risk factor for adverse procedural events; however, it should be limited in patients with surrounding pancreas.

Endoscopic Applications of Near-Infrared Photoimmunotherapy (NIR-PIT) in Cancers of the Digestive and Respiratory Tracts

Near-infrared photoimmunotherapy (NIR-PIT) is a newly developed and promising therapy that specifically destroys target cells by irradiating antibody-photo-absorber conjugates (APCs) with NIR light. APCs bind to target molecules on the cell surface, and when exposed to NIR light, cause disruption of the cell membrane due to the ligand release reaction and dye aggregation. This leads to rapid cell swelling, blebbing, and rupture, which leads to immunogenic cell death (ICD). ICD activates host antitumor immunity, which assists in killing still viable cancer cells in the treated lesion but is also capable of producing responses in untreated lesions. In September 2020, an APC and laser system were conditionally approved for clinical use in unresectable advanced head and neck cancer in Japan, and are now routine in appropriate patients. However, most tumors have been relatively accessible in the oral cavity or neck. Endoscopes offer the opportunity to deliver light deeper within hollow organs of the body. In recent years, the application of endoscopic therapy as an alternative to surgery for the treatment of cancer has expanded, providing significant benefits to inoperable patients. In this review, we will discuss the potential applications of endoscopic NIR-PIT, especially in thoracic and gastrointestinal cancers.

ERCP in critically ill patients is safe and does not increase mortality

ABSTRACT

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.

Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

INTRODUCTION

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

AREAS COVERED

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

EXPERT OPINION

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

[Comparison of Clinical Performance and Safety between Domestic New Pull-type Triple-lumen Sphincterotome and Conventional Sphincterotome: A Prospective Multicenter Trial]

Background/Aims

Sphincterotomes are essential for endoscopic sphincterotomy (EST) and can also be used for cannulation in ERCP. A domestic new pull-type sphincterotome (Optimos™, Taewoong, Goyang, Korea) provides acceptable technical feasibility and safety, but there are no comparison results. Thus, this study compared the clinical performance and safety of Optimos™ sphincterotome to a conventional sphincterotome (CleverCut3™, Olympus, Tokyo, Japan) in patients who underwent ERCP.

Methods

From April 2021 to July 2021, a randomized prospective comparative study was conducted on 104 consecutive patients who underwent ERCP in three medical centers. The primary endpoint was the clinical performance and safety of sphincterotomes during ERCP.

Results

One hundred and four patients were assigned randomly to the Optimos™ group (n=51) or CleverCut3™ group (n=53). All demographic characteristics did not differ between the groups except the BMI. The technical success rate for cannulation, performance of EST, and total procedure time were similar in the two groups. The adverse events did not differ, even though two cases of post-ERCP pancreatitis occurred in CleverCut3™. On the other hand, in questionnaire analysis, CleverCut™ showed a better user's convenience (median [interquartile range] 4.0 [3.0-4.0] vs. 3.0 [3.0-4.0], p=0.013) and manipulability (median [interquartile range], 4.0 [3.0-4.0] vs. 3.0 [3.0-4.0], p=0.039) than Optimos™, even though the other profiles did not reveal any differences.

Conclusions

New domestic pull-type sphincterotome can offer comparable clinical performance and safety profiles to conventional sphincterotome, but it needs refinements to increase the user's convenience and manipulability. Further improvement and innovation will be required to advance domestic medical devices.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938-3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

Combined surgical and intraoperative endoscopic rescue of a biliary incarcerated balloon dilator: a successful rescue in a fortunate patient

Background

Endoscopic papillary balloon dilatation (EPBD) is the second proposed maneuver for the endoscopic retrieval of common bile duct stones after endoscopic sphincterotomy (EST). Being less traumatic, EPBD is acknowledged for fewer procedure-related complications compared to (EST).

Case presentation

We present a 55-year-old lady, who was referred to the pancreato-biliary division, Gastrointestinal Endoscopy Unit, National Liver Institute, Menoufia University, for endoscopic management of a high likelihood of choledocholithiasis. Unfortunately, during the procedure, the balloon dilator was incarcerated inside the common bile duct (CBD) with failure of all endoscopic extraction trials. Because of the resultant cholangio-pancreatitis, the incarcerated inflated balloon had to be removed immediately. Open surgical rescue of the case in conjunction with the intraoperative endoscopic biliary stent deployment had made it possible to save the patient.

Conclusion

This case is one of the few reports of incarcerated balloon dilator during EPBD and failure of endoscopic retrieval, with subsequent acute pancreatitis/hepato-cholangitis, and gall bladder mucocele. Despite being a critical surgical candidate and owing to the attentive timely surgical intervention collaborated with the intra-operative endoscopic management, the case was fortunate.

DOES AGE INFLUENCE IN ENDOSCOPIC THERAPEUTIC SUCCESS ON THE BILIARY TRACT?

BACKGROUND

Retrograde endoscopic cholangiopancreatography (ERCP) effectively treats biliary and pancreatic disorders. Its indications are limited and precise, since its misuse delays adequate treatment, increases costs and to patient´s adverse events.

AIM

To compare clinical, radiological and exploratory characteristics in relation to therapeutic success in patients undergoing ERCP in relation to age.

METHOD

421 patients who underwent the method were retrospectively studied; those who were not able to access the duodenal papilla were excluded. The patients were divided into two age groups: <60 years (group 1) and >60 years (group 2), and the variables of gender, examination indications, radiological findings, therapeutic success, diagnosis and the occurrence of immediate adverse events were analyzed.

RESULTS

177 patients were allocated to group 1 and 235 to group 2. The main indication found in both groups was choledocholithiasis. In group 2, the number of cases of acute cholangitis (p=0.001), biliary stenosis (p=0.002) and papilla cancer (p=0.046) was higher. In this group, urgent indication for ERCP was higher (p=0.042), as well as the diagnosis of biliary tract dilatation (p<0.001). The placement of prostheses was the most common procedure performed in both groups, but the greatest number of patients in absolute quantity occurred in group 2. In group 1, the success in catheterization and the chance of achieving clearing of the biliary tract was significantly higher in compared to group 2 (p=0.016, OR=2.1).

CONCLUSION

The success of catheterization and complete clearance of the bile duct was significantly higher in the group of young patients.

Controversies in ERCP: Technical aspects

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.

Endoclip papillaplasty restores sphincter of Oddi function: Pilot study

OBJECTIVES

Endoscopic sphincterotomy (EST) damaged the sphincter of Oddi (SO) function. This study aimed to explore the feasibility and efficacy of endoclip papillaplasty in restoring SO function.

METHODS

This prospective pilot study included consecutive patients with choledocholithiasis (stone size ≥10 mm) who underwent large-EST for stone removal, followed by endoclip papillaplasty, between May 2018 and March 2019.

RESULTS

Thirty patients were enrolled in this trail. Overall, 80% of the patients had a SO basal pressure of >10 mmHg after endoclip papillaplasty. Manometric parameters, including SO basal pressure, phasic wave contraction amplitude, phasic waves per minute, recovered after endoclip papillaplasty (P > 0.05). There were no significant differences in the manometric parameters of SO between healing grades A and B. Six patients developed mild post-endoscopic retrograde cholangiopancreatography pancreatitis, including three that had pancreatic stenting. Bile duct stone recurrence developed in 3.3% of the patients (1/30) during an 18-month follow-up.

CONCLUSIONS

Endoclip papillaplasty might restore SO function and possibly prevented biliary stone and cholangitis recurrence.

Percutaneous Management of Biliary Stones

Bile duct stone disease is the most common causes of nonmalignant bile duct obstructions. The range of common bile duct stone formation in patients with cholecystectomy is 3 to 14.7%. Hepatolithiasis, although endemic in some parts of the world, is a rare disease that is difficult to manage. Endoscopic intervention is accepted as the first-line management of common bile duct stones. However, when the bile duct cannot be cannulated for various reasons, the endoscopic procedure fails. In this circumstance, percutaneous approach is an alternative technique for the nonsurgical treatment of bile duct stones. This article reviews the indications, technique, outcomes, and complications of the percutaneous treatment of bile duct stone disease.

Efficacy of endoscopic large balloon dilation extended for 2 minutes in bile duct stone removal: A multicenter retrospective study

BACKGROUND/PURPOSE

There is no evidence regarding the optimal balloon dilation time during endoscopic papillary large balloon dilation (EPLBD). The study aim was to evaluate the efficacy of 2-minute extended balloon dilation for EPLBD.

METHODS

Two hundred and five patients who underwent EPLBD during endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones at three tertiary centers were included in the analysis. Clinical outcomes and the adverse events were compared between the 0-minute group (n = 94, balloon deflated immediately after waist disappearance) and the 2-minute group (n = 111, balloon dilation maintained for 2 minutes after waist disappearance). The risk factors of post-ERCP pancreatitis (PEP) after EPLBD were assessed.

RESULTS

There were no significant differences in the stone removal rates and hospitalization periods between the two groups. However, the total ERCP procedure time was significantly shorter in the 2-minute group (40.6 vs 48.9 min, P = .03). The incidence of PEP was 7.4% in the 0-minute group and significantly lower at 0.9% in the 2-minute group (P = .04). Multivariate analysis identified without 2-minute extended EPLBD as a significant risk factor of PEP (OR: 9.9, P = .045).

CONCLUSIONS

Extension of EPLBD for 2 minutes helped prevent PEP and shortened the procedure time.

Comparison of intraoperative endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy for treating gallstones and common bile duct stones: a systematic review and meta-analysis

BACKGROUND

This study aimed to compare the efficacy and safety of laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC-IntraERCP) and laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (LC-LCBDE) to determine which one-stage therapeutic strategy provides better outcomes for patients with gallstones and common bile duct stones.

METHODS

Cochrane Library, EMBASE, PubMed, and Web of Science databases were searched to identify eligible articles from the database inception to September 2020. The revised Cochrane risk of bias tools for randomized trials (RoB-2) and non-randomized interventions (ROBINS-I) was used to assess the quality of the included studies. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. The primary outcomes consisted of surgical success, retained stones, and overall postoperative complications, while secondary outcomes included postoperative bleeding, postoperative pancreatitis, postoperative bile leakage, conversion to laparotomy, and operative time.

RESULTS

Eight studies (four RCTs and four Non-RCTs with high quality) with 2948 patients were included. No significant difference was seen between the two groups regarding surgical success, overall postoperative complications, conversion to laparotomy, and operative time. The meta-analysis demonstrated that in the LC-IntraERCP group, the rate of retained stones (OR 0.51, 95% CI 0.28-0.91) and postoperative bile leakage were lower (OR 0.25, 95% CI 0.09-0.69), while in the LC-LCBDE group, postoperative bleeding (OR 5.24, 95% CI 1.65-16.65) and postoperative pancreatitis (OR 4.80, 95% CI 2.35-9.78) decreased.

CONCLUSIONS

LC-IntraERCP and LC-LCBDE exhibited similar efficacies when surgical success rate, overall postoperative complications, conversion to laparotomy, and operative time were compared. However, LC-IntraERCP is probably to be more effective in terms of lowering the rate of retained stones.

Cracking Difficult Biliary Stones

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.