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Petersen BD, Nørregaard C, Krøijer R, Floyd A, Ploug M. Laparoscopic-Assisted ERCP in Gastric Bypass Patients-No Stones Left Unturned: A Single Center Retrospective Cohort Study. Obes Surg 2024; 34:2999-3004. [PMID: 38839634 PMCID: PMC11289228 DOI: 10.1007/s11695-024-07268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE The long-term need for biliary duct intervention following Roux-en-Y gastric bypass surgery (RYGB) is uncertain. We investigated the rate of laparoscopic assisted retrograde cholangiopancreatography (LAERCP) following RYGB. Also, the pre-LAERCP diagnostic workup together with the true rate of choledocholithiasis in patients with or without prior cholecystectomy was investigated. MATERIALS AND METHODS Retrospective cohort study of RYGB and LAERCP performed at the Hospital South West Jutland, University Hospital of Southern Denmark, from 1 January 2013 to 31 May 2022. RESULTS One percent of patients (n = 13) with a history of RYGB (n = 1363) underwent LAERCP at our facility during a median follow-up of 60.6 months. The stone extraction rate was 66.7% in patients with in situ gallbladder and 12.5% in patients with prior cholecystectomy. Cannulation of the common bile duct was achieved in 96.7% of cases. Postoperative complications were observed in 22.6% of the cases. CONCLUSION Approximately 1% of RYGB patients needed LAERCP during a median follow-up of 5 years. In patients with a history of cholecystectomy, the LAERCP rate of stone extraction was very low (12.5%).
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Affiliation(s)
- B D Petersen
- Department of Surgical Gastroenterology, Hospital South West Jutland, Region of Southern Denmark, Finsensgade 35, Skolebakken 141, 6705, Esbjerg, Denmark.
| | - C Nørregaard
- Department of Surgery, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense, Denmark
| | - R Krøijer
- Department of Surgical Gastroenterology, Hospital South West Jutland, Region of Southern Denmark, Finsensgade 35, Skolebakken 141, 6705, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - A Floyd
- Department of Surgical Gastroenterology, Hospital South West Jutland, Region of Southern Denmark, Finsensgade 35, Skolebakken 141, 6705, Esbjerg, Denmark
| | - M Ploug
- Department of Surgical Gastroenterology, Hospital South West Jutland, Region of Southern Denmark, Finsensgade 35, Skolebakken 141, 6705, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Chon HK, Kim KH, Song TJ, Ahn DW, Lee ES, Lee YN, Lee YS, Jeon TJ, Park CH, Cho KB, Lee DW, Park JS, Yoon SB, Chung KH, Lee J, Choi M. Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea. Gut Liver 2024; 18:564-577. [PMID: 38462478 PMCID: PMC11249929 DOI: 10.5009/gnl230427] [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: 10/19/2023] [Accepted: 11/22/2023] [Indexed: 03/12/2024] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea.
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Affiliation(s)
- Hyung Ku Chon
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
- Institute of Wonkwang Medical Science, Iksan, Korea
| | - Ki-Hyun Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Won Ahn
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eaum Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Tae Joo Jeon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Chang Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang Hyun Chung
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
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Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open 2023; 11:E588-E598. [PMID: 37564727 PMCID: PMC10410689 DOI: 10.1055/a-2085-4565] [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: 02/14/2023] [Accepted: 04/19/2023] [Indexed: 08/12/2023] Open
Abstract
Background and study aims Endoscopist techniques affect biliary cannulation success and the risk of adverse events during endoscopic retrograde cholangiopancreatography (ERCP). This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods Practicing endoscopists were sent an anonymous 28-question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD, respectively, before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut NKTs and likelihood of prophylactic PD stent ( P <0.001 for both). Conclusions A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques; however, almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic PD stent placement, factors known to be associated with cannulation success and adverse outcomes.
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Affiliation(s)
- Abdul Kouanda
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Alexis Bayudan
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Azhar Hussain
- Medicine, Ameer-ud-Din Medical College of PGMI, Lahore, Pakistan
| | - Patrick Avila
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Faisal Kamal
- Gastroenterology, University of Tennessee Health Science Center, Memphis, United States
| | - Muhammad Khalid Hasan
- Center for Interventional Endoscopy, Florida Hospital Orlando, Orlando, United States
| | - Sun-Chuan Dai
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Craig Munroe
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | | | - Mustafa A Arain
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
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4
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Miyaguchi K, Mizuide M, Tanisaka Y, Fujita A, Jinushi R, Hiromune K, Ogawa T, Saito Y, Tashima T, Mashimo Y, Imaeda H, Ryozawa S. Distinguishing the papilla of Vater during biliary cannulation using texture and color enhancement imaging: A pilot study. DEN OPEN 2023; 3:e125. [PMID: 35898835 PMCID: PMC9307722 DOI: 10.1002/deo2.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/09/2022] [Accepted: 04/28/2022] [Indexed: 01/22/2023]
Abstract
Objectives Understanding the exact morphology of the bile duct opening is important for determining the success of bile duct cannulation. Texture and color enhancement imaging (TXI) has been reported to enhance slight changes in color tone and structure that are difficult to see with white light imaging. This study investigated whether TXI mode1 could improve papillary recognition by trainees inexperienced in endoscopic retrograde cholangiopancreatography. Methods We included 31 patients with naive papilla of Vater at a single institution in the study. Trainee endoscopists (n = 4) evaluated and identified the papilla according to the Inomata classification using white light imaging and TXI. The degree of agreement with the evaluation of supervising physicians (n = 4) was examined using the McNemar test. Results In the trainee group, the kappa coefficient agreements were κ = 0.346 and κ = 0.754 for white light imaging and TXI, respectively. When further evaluated, the separate and septal types of papilla groups showed an increased concordance rate in one of the four trainees (76.67%–96.67%, p = 0.031, respectively). Moreover, comparison for two‐group evaluation showed an increased kappa coefficient in two of four trainees (0.34–0.92, p = 0.010, 0.45–0.92, p = 0.024). Conclusions Observation of the duodenal papilla using TXI improved papillary differentiation and suggested the potential of TXI as a clinical tool. Further study of this method is necessary; it is expected to help reduce cannulation time and the incidence of pancreatitis.
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Affiliation(s)
- Kazuya Miyaguchi
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan.,Department of Gastroenterology Saitama Medical University Saitama Japan
| | - Masafumi Mizuide
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Yuki Tanisaka
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Akashi Fujita
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Katsuda Hiromune
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Tomoya Ogawa
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Yoichi Saito
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Tomoaki Tashima
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Yumi Mashimo
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
| | - Hiroyuki Imaeda
- Department of Gastroenterology Saitama Medical University Saitama Japan
| | - Shomei Ryozawa
- Department of Gastroenterology Saitama Medical University International Medical Center Saitama Japan
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Maruta S, Sugiyama H, Ogasawara S, Sugihara C, Ouchi M, Kan M, Yamada T, Miura Y, Nagashima H, Takahashi K, Kusakabe Y, Ohyama H, Okitsu K, Ohno I, Mikata R, Sakai Y, Tsuyuguchi T, Kato J, Kato N. "Salvage techniques" are the key to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography. Sci Rep 2022; 12:13627. [PMID: 35948566 PMCID: PMC9365799 DOI: 10.1038/s41598-022-17809-5] [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: 12/07/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Although the efficacy and safety of salvage techniques for biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) have been reported, few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with native papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, cannulation success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate using standard technique alone was 62.8%, which increased to 94.3% including salvage techniques. Salvage techniques were frequently required in patients with long oral protrusions (OR 2.38; 95% CI 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Salvage techniques may help to overcome many difficult biliary cannulation cases.
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Affiliation(s)
- Shikiko Maruta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan.
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan.,Translational Research and Development Center, Chiba University Hospital, Chiba, Japan
| | - Chihei Sugihara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Toshihito Yamada
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yoshifumi Miura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yuko Kusakabe
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Koichiro Okitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Rintaro Mikata
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yuji Sakai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | | | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
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6
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Wang X, Luo H, Tao Q, Ren G, Wang X, Liang S, Zhang L, Chen L, Shi X, Guo X, Pan Y. Difficult biliary cannulation in ERCP procedures with or without trainee involvement: a comparative study. Endoscopy 2022; 54:447-454. [PMID: 34087945 DOI: 10.1055/a-1523-0780] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The 5-5-1 criteria (> 5 minutes - 5 cannulation attempts - 1 unintended pancreas duct cannulation) were proposed by the European Society of Gastrointestinal Endoscopy to define difficult biliary cannulation. However, the criteria may be inappropriate for trainee-involved procedures. We developed criteria for difficult cannulation in trainee-involved procedures. METHODS Patients undergoing biliary cannulation with or without trainee involvement were eligible. Procedures that might be too easy (e. g. fistula) or too difficult (e. g. altered anatomy) were excluded. The primary outcome was difficult cannulation, defined as cannulation time, attempts, or inadvertent pancreatic duct (PD) cannulation exceeding the 75 % percentile of each variable. Propensity score matching (PSM) analysis was used. RESULTS After PSM, there were 1596 patients in each group. Trainee-involved procedures had longer median (interquartile range [IQR]) cannulation time (7.5 [2.2-15.3] vs. 2.0 [0.6-5.2] minutes), and more attempts (5 [2-10] vs. 2 [1-4]) and inadvertent PD cannulation (0 [0-2] vs. 0 [0-1]) vs. procedures without trainee involvement (all P < 0.001). The 15-10-2 criteria for difficult cannulation were proposed for trainee-involved cannulation and the 5-5-1 criteria were nearly confirmed for cannulation without trainee involvement. The proportions of difficult cannulation using these respective criteria were 35.5 % (95 % confidence interval [CI] 33.2 %-37.9 %) and 31.8 % (95 %CI 29.5 %-34.2 %), respectively (odds ratio 1.18 [95 %CI 1.02-1.37]). Incidences of post-ERCP pancreatitis following difficult cannulation were comparable (7.8 % [95 %CI 5.7 %-10.3 %] vs. 9.8 % [95 %CI 7.4 %-12.8 %], respectively). CONCLUSION By using the 75 % percentiles as cutoffs, the proposed 15-10-2 criteria for difficult cannulation could be appropriate in trainee-involved procedures.
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Affiliation(s)
- Xu Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qin Tao
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Long Chen
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xin Shi
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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7
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Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm. Medicina (B Aires) 2022; 58:medicina58030331. [PMID: 35334507 PMCID: PMC8951173 DOI: 10.3390/medicina58030331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.
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8
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Guzmán-Calderón E, Martinez-Moreno B, Casellas JA, Aparicio JR. Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1758-E1767. [PMID: 34790542 PMCID: PMC8589559 DOI: 10.1055/a-1534-2388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/16/2021] [Indexed: 10/27/2022] Open
Abstract
Background and study aims Approximately 11 % of biliary cannulations are considered difficult. The double guidewire (DGW-T) and transpancreatic sphincterotomy (TPS) are two useful techniques when difficult cannulation exists and the main pancreatic duct is unintentionally accessed. We carried out a systematic review and meta-analysis to evaluate the effectiveness and security of both DGW-T and TPS techniques in difficult biliary cannulation. Methods We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. Were included all RCT which showed a comparison between TPS and DGW in difficult biliary cannulation. Endpoints computed were successful cannulation rate, median cannulation time, and adverse events rate. Results Four studies were selected (4 RCTs). These studies included 260 patients. The mean age was 64.79 ± 12.99 years. Of the patients, 53.6 % were men and 46.4 % were women. The rate of successful cannulation was 93.3 % in the TPS group and 79.4 % in the DGW-T group ( P = 0.420). The rate of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) was lower in patients who had undergone TPS than DGW-T (TPS: 8.9 % vs DGW-T: 22.2 %, P = 0.02). The mean cannulation time was 14.7 ± 9.4 min in the TPS group and 15.1 ± 7.4 min with DGW-T ( P = 0.349). Conclusions TPS and DGW are two useful techniques in patients with difficult cannulation. They both have a high rate of successful cannulation; however, the PEP was higher with DGW-T than with TPS.
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Affiliation(s)
- Edson Guzmán-Calderón
- Gastroenterology Unit of Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru,Universidad Peruana de Ciencias Aplicadas (UPC),Gastroenterology Unit of Angloamericana Clinic – Lima, Perú
| | - Belen Martinez-Moreno
- Gastroenterology Unit of Hospital General Universitario de Alicante, Alicante, Spain
| | - Juan A. Casellas
- Gastroenterology Unit of Hospital General Universitario de Alicante, Alicante, Spain
| | - José Ramón Aparicio
- Gastroenterology Unit of Hospital General Universitario de Alicante, Alicante, Spain
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9
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Pawa R, Pleasant T, Tom C, Pawa S. Endoscopic ultrasound-guided biliary drainage: Are we there yet? World J Gastrointest Endosc 2021; 13:302-318. [PMID: 34512878 PMCID: PMC8394188 DOI: 10.4253/wjge.v13.i8.302] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/14/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.
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Affiliation(s)
- Rishi Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Troy Pleasant
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Chloe Tom
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, United States
| | - Swati Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
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Lee YS. When is the Optimal Timing of a Rescue Technique for Selective Biliary Cannulation During Endoscopic Retrograde Cholagiopancreatography? THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021. [DOI: 10.4166/kjg.2021.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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11
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Op den Winkel M, Schirra J, Schulz C, De Toni EN, Steib CJ, Anz D, Mayerle J. Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla. Dig Dis 2021; 40:85-96. [PMID: 33684915 DOI: 10.1159/000515692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure. SUMMARY Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.
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Affiliation(s)
- Mark Op den Winkel
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Schirra
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Christian J Steib
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - David Anz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
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12
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Rejeski J, Hines M, Jones J, Conway J, Mishra G, Evans J, Pawa R. Outcomes of precut sphincterotomy techniques in cases of difficult biliary access. Frontline Gastroenterol 2020; 12:113-117. [PMID: 33613942 PMCID: PMC7873550 DOI: 10.1136/flgastro-2019-101380] [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: 12/05/2019] [Revised: 01/17/2020] [Accepted: 02/17/2020] [Indexed: 02/04/2023] Open
Abstract
GOALS Our study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre. BACKGROUND Complication rates rise with increasing number of failed attempts at biliary cannulation; therefore, early precut sphincterotomy (PS) has been recommended. Selecting the ideal method for PS can be challenging and there is a paucity of data to help guide this decision. STUDY We performed a retrospective analysis over 37 months of endoscopic retrograde cholangiopancreatography (ERCP) experience at a single institution. We identified all ERCPs performed and stratified based on the presence of PS; if PS occurred, a thorough chart review was performed to identify success and complication rates. Patients received guideline-driven management for post-ERCP pancreatitis including rectal indomethacin and pancreatic duct stenting when appropriate. RESULTS We identified 1808 ERCP procedures performed during this time. Successful biliary cannulation was achieved in 1748 cases, yielding a success rate of 96.7% (Grades I-IV ERCP difficulty/complexity). PS was required in 232 cases (12.8%); we identified 88 TPS cases and 114 needle-knife precut sphincterotomy (NKPS) cases. Complications following PS procedures occurred in 9.1% of TPS patients and 11.4% of NKPS patients. Success rates for TPS and NKPS were 97.7% and 81.6%, respectively-a statistically significant difference (p<0.001). CONCLUSION This data supports TPS as a safe and effective option for biliary access in difficult cannulation settings when performed by experienced advanced endoscopists.
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Affiliation(s)
- Jared Rejeski
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Marc Hines
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Jason Jones
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Jason Conway
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Girish Mishra
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - John Evans
- Section of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Rishi Pawa
- Section on Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
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13
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Hatamaru K, Kitano M. EUS-guided biliary drainage for difficult cannulation. Endosc Ultrasound 2020; 8:S67-S71. [PMID: 31897382 PMCID: PMC6896436 DOI: 10.4103/eus.eus_60_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.
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Affiliation(s)
- Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Transpapillary Biliary Cannulation is Difficult in Cases with Large Oral Protrusion of the Duodenal Papilla. Dig Dis Sci 2019; 64:2291-2299. [PMID: 30746630 DOI: 10.1007/s10620-019-05510-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/29/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary cannulation failure is a major problem during endoscopic retrograde cholangiopancreatography. It remains unclear how duodenal papilla morphology affects biliary cannulation. Therefore, we proposed a new classification system for the duodenal papilla based on oral protrusion pattern (ratio of the length of the oral protrusion to the transverse diameter of the papilla) and papilla pattern. AIMS To retrospectively compare biliary cannulation results with regard to classification and operator experience. METHODS We analyzed 589 naïve major duodenal papillae. Our classification system comprised oral protrusion pattern, classified as small (Protrusion-S), regular (Protrusion-R), or large (Protrusion-L), and the papilla pattern, classified as annular (Papilla-A), unstructured (Papilla-U), longitudinal (Papilla-LO), isolated (Papilla-I), or gyrus (Papilla-G). Intra-evaluator concordance and the results of biliary cannulation were analyzed. RESULTS The following oral protrusion pattern classifications were observed: Protrusion-S, 11.7%; Protrusion-R, 77.9%; and Protrusion-L, 10.4%. The following papilla patterns were observed: Papilla-A, 67.1%; Papilla-U, 7.0%; Papilla-LO, 7.5%; Papilla-I, 1.2%; Papilla-G, 15.6%; and unclassified, 1.7%. Intra-evaluator concordance value (Fleiss kappa) was 0.788 for oral protrusion pattern and 0.750 for papilla pattern. A logistic regression analysis of cannulations performed by an experienced endoscopist identified Protrusion-L as a significant risk factor for difficult cannulation (odds ratio 2.956; 95% confidence interval 1.115-7.84; p = 0.029). Multivariate analysis confirmed Protrusion-L as an independent risk factor for difficult biliary cannulation (odds ratio 3.772; 95% confidence interval 1.359-10.464; p = 0.011). CONCLUSIONS We propose a new general classification system for the duodenal papilla. Protrusion-L is a significant risk factor for difficult biliary duct cannulation.
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Mariani A, Segato S, Anderloni A, Cengia G, Parravicini M, Staiano T, Tontini GE, Lochis D, Cantù P, Manfredi G, Amato A, Bargiggia S, Bernasconi G, Lella F, Berni Canani M, Beretta P, Ferraris L, Signorelli S, Pantaleo G, Manes G, Testoni PA, Prada A, Iiritano E, Lesinigo E, Mezzi GS, de Nucci G. Prospective evaluation of ERCP performance in an Italian regional database study. Dig Liver Dis 2019; 51:978-984. [PMID: 30718203 DOI: 10.1016/j.dld.2018.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prospective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare. AIM To assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice. METHODS Prospective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered. RESULTS 38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed. CONCLUSIONS The procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting.
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Affiliation(s)
- Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Simone Segato
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | | | - Marco Parravicini
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria, Ospedale di Circolo di Varese, Varese, Italy
| | - Teresa Staiano
- Digestive Endoscopy and Gastroenterology Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Italy
| | | | - Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Guido Manfredi
- Gastroenterology and Digestive Endoscopy Department, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Arnaldo Amato
- Department of Gastroenterology Unit, Valduce Hospital, Como, Italy
| | | | - Giordano Bernasconi
- Gastroenterology and Digestive Endoscopy Unit, Busto Arsizio Hospital, Busto Arsizio, Varese, Italy
| | - Fausto Lella
- Gastroenterology and Digestive Endoscopy Unit, Policlinico San Pietro, Bergamo, Italy
| | - Marcella Berni Canani
- Digestive Endoscopy and Gastroenterology Unit, ASST Vimercate, Monza e Brianza, Italy
| | - Paolo Beretta
- Gastroenterology and Digestive Endoscopy Unit, ICCS, Milan, Italy
| | - Luca Ferraris
- Gastroenterologia ed Endoscopia Digestiva ASST Valleolona PO, Gallarate, Varese, Italy
| | - Sergio Signorelli
- Gastroenterology and Gastrointestinal Endoscopy Unit, ASST, Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Pantaleo
- UniSR-Social.Lab [Research Methods], Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpiero Manes
- Department of Gastroenterology and Digestive Endoscopy, ASST Rhodense Garbagnate Milanese, Milano, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Prada
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Italy
| | - Elena Iiritano
- Gastroenterology and Digestive Endoscopy Department, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Enrico Lesinigo
- Gastroenterology and Digestive Endoscopy Unit, Busto Arsizio Hospital, Busto Arsizio, Varese, Italy
| | - Gianni Santo Mezzi
- Digestive Endoscopy and Gastroenterology Unit, ASST Vimercate, Monza e Brianza, Italy
| | - Germana de Nucci
- Department of Gastroenterology and Digestive Endoscopy, ASST Rhodense Garbagnate Milanese, Milano, Italy
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Abbarh S, Seleem M, Al Balkhi A, Al Mtawa A, Al Khathlan A, Qutub A, Al Sayari K, Al Otaibi N, AlEid A, Al Ghamdi A, Al Lehibi A. ERCP quality indicators: The experience of a high-volume tertiary care center in Saudi Arabia. Arab J Gastroenterol 2019; 20:32-37. [PMID: 30872134 DOI: 10.1016/j.ajg.2019.01.005] [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] [Received: 10/16/2018] [Accepted: 01/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically demanding and high-risk procedures performed by GI endoscopists. Therefore, guidelines or position statements on various aspects of quality indicators, safety indicators and credentialing for ERCP have been developed by gastroenterology associations. In this paper, we evaluate the ERCP quality in a single, high-volume, tertiary care center in Saudi Arabia using a number of measures commonly stated by these organizations, and compare the experience of that center to the previously-published standards in this regard. PATIENTS AND METHODS This is a descriptive, retrospective chart review of a consecutive sample taken over 12 continuous months (July 2016-June 2017). Data collected included demographic characteristics, and technical/clinical details from three time periods: preprocedure, intraprocedure, and postprocedure. Measurement parameters were all taken from the ASGE/ACG guidelines. Data was represented by the percentage of which each indicator was achieved, and the 95% proportion confidence intervals (CIs) when needed. RESULTS From July 2016 to June 2017, 281 ERCP procedures were performed. An outstanding majority of them (95.7%) was done for therapeutic purposes, whereas 4.3% were diagnostic procedures. The sample included 206 patients, of whom 83 (40.3%) were males. The age of the participants ranged between 11 and 101 years (mean age ± SD; 51 ± 19). The quality of ERCP at the center in which the study was done met the performance targets stated by the ASGE/ACG for almost all indicators. Adverse events reported in our series were lower than previous studies for pancreatitis and perforation, and slightly higher in the incidence of bleeding, cholangitis, and death. CONCLUSION In a single, high-volume, tertiary care center in Saudi Arabia, the quality of ERCP met the performance targets stated by the ASGE/ACG for almost all indicators.
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Affiliation(s)
- Shahem Abbarh
- Almaarefa University, College of Medicine and Surgery, Riyadh, Saudi Arabia
| | - Mostafa Seleem
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia
| | - Areej Al Balkhi
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia
| | - Abdullah Al Mtawa
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Abdullah Al Khathlan
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Adel Qutub
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Khalid Al Sayari
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Nawaf Al Otaibi
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Ahmad AlEid
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Ahmad Al Ghamdi
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
| | - Abed Al Lehibi
- King Fahad Medical City, Department of Gastroenterology and Hepatology, Riyadh, Saudi Arabia.
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Tang Z, Yang Y, Yang Z, Meng W, Li X. Early precut sphincterotomy does not increase the risk of adverse events for patients with difficult biliary access: A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. Medicine (Baltimore) 2018; 97:e12213. [PMID: 30200135 PMCID: PMC6133433 DOI: 10.1097/md.0000000000012213] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The present study was conducted to investigate whether early precut sphincterotomy (EPS) itself increases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), bleeding, and perforation, or improves the overall success rates of biliary cannulation. METHODS Four electronical databases were searched systematically for randomized controlled trials (RCTs) reporting the incidence of adverse events for difficult biliary access (DBA) between EPS groups and persistent cannulation attempts (PCA). The primary endpoint was the incidence of PEP. Secondary outcomes were the incidence of bleeding and perforation, and the overall success rates of biliary cannulation. The Mantel-Haenszel method was used to pool data on the outcomes into random-effect models. Heterogeneity, sensitivity, and stratified analyses were performed with Review Manager 5.3. Furthermore, we performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint and secondary outcomes. RESULTS Seven RCTs (999 patients with DBA of 10450, 9.5%) were included. The incidence of PEP was significantly lower in EPS groups than PCA (risk ratio [RR] = 0.57, 95% confidence interval [CI] 0.36, 0.92, P = .02). Furthermore, TSA (TSA-adjusted 95% CI 0.30-0.82, P = .0061) and subgroup analysis stratified by the fellow involvement in initial cannulation before randomization, technique of precut, and the definition of DBA confirmed this finding. Success rates of overall cannulation (RR = 1.00, P = .94), bleeding (RR = 1.22, P = .58), and perforation (RR = 1.59, P = .32) were similar in both groups; however, the results of TSA could not confirm these findings. CONCLUSION Both the quality and the quantity of evidence supporting, compared with PCA, EPS itself do not increase the risk of PEP for DBA patients. Moreover, subgroup analysis demonstrated that EPS can significantly decrease the risk of PEP when it is performed by qualified staff endoscopists with using needle-knife fistulutomy earlier for patients with DBA.
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Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | - Zhangfu Yang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital,Fudan University, and Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Shanghai
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The first Hospital of Lanzhou University, Lanzhou
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The second department of General Surgery, The first Hospital of Lanzhou University, Lanzhou, China
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18
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Katzarov AK, Dunkov ZI, Popadiin I, Katzarov KS. How to measure quality in endoscopic retrograde cholangiopancreatography (ERCP). ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:265. [PMID: 30094251 DOI: 10.21037/atm.2018.05.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called "Quality measures" which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist. Further research is required regarding quality measures improvement and information exchange in the global ERCP quality network.
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Affiliation(s)
| | - Zdravko Ivanov Dunkov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Ivan Popadiin
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Krum Sotirov Katzarov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
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19
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Alberca de Las Parras F, López-Picazo J, Pérez Romero S, Sánchez Del Río A, Júdez Gutiérrez J, León Molina J. Quality indicators for endoscopic retrograde cholangiopancreatography. The procedure of endoscopic retrograde cholangiopancreatography. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:658-666. [PMID: 30071737 DOI: 10.17235/reed.2018.5652/2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The goal of the project encompassing the present paper is to propose useful quality procedures and indicators in order to improve quality in digestive endoscopy units. In this third part outcome procedures and indicators are suggested for endoscopic retrograde cholangiopancreatography (ERCP). First, a diagram of pre- and post-ERCP steps was developed. A group of experts in healthcare quality and/or endoscopy, under the shelter of the Spanish Society of Digestive Diseases (Sociedad Española de Patología Digestiva - SEPD), carried out a qualitative review of the literature regarding quality indicators for ERCP. Then, a paired analysis was used for the selection of identified references. A total of six specific indicators, apart from the common indicators already described, were identified, all of them process indicators (two pre-procedure and four post-procedure). Evidence quality was analyzed for each indicator using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) classification.
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Affiliation(s)
| | - Julio López-Picazo
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
| | - Shirley Pérez Romero
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
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20
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Borges AC, Almeida PCD, Furlani SMT, Cury MDS, Pleskow DK. ERCP PERFORMANCE IN A TERTIARY BRAZILIAN CENTER: FOCUS ON NEW RISK FACTORS, COMPLICATIONS AND QUALITY INDICATORS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 31:e1348. [PMID: 29947682 PMCID: PMC6049994 DOI: 10.1590/0102-672020180001e1348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/30/2018] [Indexed: 01/14/2023]
Abstract
Background: ERCP can lead to complications, which can be prevented by the recognition of risk factors. Aim: To identify these risk factors, with quality evaluation. Methods: Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy. Results: 211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending’s procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041). Conclusion: Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.
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Affiliation(s)
- Alana Costa Borges
- Zilda Arns Hospital and Maternity, Gastrointestinal Endoscopy, Fortaleza, CE, Brasil
| | | | | | - Marcelo de Sousa Cury
- SCOPE Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy, Campo Grande, MS, Brasil
| | - Douglas K Pleskow
- Beth Israel Deaconess Medical Center, Center for Advanced Endoscopy, Boston, Massachusetts,USA
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21
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Li YL, Wong KH, Chiu KWH, Cheng AKC, Cheung RKO, Yam MKH, Chan ALC, Chan VSH, Law MWM, Lee PSF. Percutaneous cholecystostomy for high-risk patients with acute cholangitis. Medicine (Baltimore) 2018; 97:e0735. [PMID: 29742738 PMCID: PMC5959387 DOI: 10.1097/md.0000000000010735] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/22/2018] [Indexed: 01/05/2023] Open
Abstract
Percutaneous cholecystostomy (PC) is a well-established treatment for acute cholecystitis. We investigate the performance and role of PC in managing acute cholangitis.Retrospective review on all patients who underwent PC for acute cholangitis between January 2012 and June 2017 at a major regional hospital in Hong Kong.Thirty-two patients were included. The median age was 84 years and median American Society of Anaesthesiologists (ASA) physical status was Class III (severe systemic disease). All fulfilled Tokyo Guidelines 2013 (TG13) diagnostic criteria for moderate or severe cholangitis. Eighty-four percent of the patients were shown to have lower common bile duct stones on imaging. The majority had previously failed intervention by endoscopic retrograde cholangiopancreatography (38%), percutaneous transhepatic biliary drainage (38%), or both (13%)The technical success rate for PC was 100% with no procedure-related mortality. The overall 30-day mortality was 9%. Rest of the patients (91%) had significant improvement in clinical symptoms and could be discharged with median length of stay of 14 days. Significant postprocedural biochemical improvement was observed in terms of white cell count (P < .001), serum bilirubin (P < .001), alkaline phosphatase (P = .001), and alanine transaminase levels (P < .001). Time from admission to PC was associated with excess mortality (P = .002).PC is an effective treatment for acute cholangitis in high-risk elderly patients. Early intervention is associated with lower mortality. PC is particularly valuable as a temporising measure before definitive treatment in critical patients or as salvage therapy where other methods endoscopic retrograde cholangiopancreatography/percutaneous transhepatic biliary drainage (ERCP/PTBD) have failed.
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Affiliation(s)
- Yan-Lin Li
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam
- Department of Radiology, North District Hospital, Sheung Shui
| | - Kin-Hoi Wong
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam
- Department of Radiology, North District Hospital, Sheung Shui
| | - Keith Wan-Hang Chiu
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam
- Department of Diagnostic Radiology, University of Hong Kong, Pokfulam, Hong Kong
| | - Andrew Kai-Chun Cheng
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam
- Department of Radiology, North District Hospital, Sheung Shui
| | | | - Max Kai-Ho Yam
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam
- Department of Radiology, North District Hospital, Sheung Shui
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Al-Mansour MR, Fung EC, Jones EL, Zayan NE, Wetzel TD, Martin Del Campo SE, Jalilvand AD, Suzo AJ, Dettorre RR, Fullerton JK, Meara MP, Mellinger JD, Narula VK, Hazey JW. Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers. Surg Endosc 2017; 32:2871-2876. [PMID: 29273876 DOI: 10.1007/s00464-017-5995-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Eleanor C Fung
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Edward L Jones
- Department of Surgery, Denver Veterans Affairs Medical Center, University of Colorado, Denver, CO, USA
| | - Nichole E Zayan
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Timothy D Wetzel
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Sara E Martin Del Campo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Andrew J Suzo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Rebecca R Dettorre
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - James K Fullerton
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael P Meara
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - John D Mellinger
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Vimal K Narula
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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Frost JW, Kurup A, Shetty S, Fisher N. Does the presence of a trainee compromise success of biliary cannulation at ERCP? Endosc Int Open 2017; 5:E559-E562. [PMID: 28670611 PMCID: PMC5482741 DOI: 10.1055/s-0043-105579] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 02/01/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Findings in the literature are conflicting on whether trainee involvement in endoscopic retrograde cholangiopancreatography (ERCP) procedures is detrimental to cannulation success rates. We addressed this in a prospective study, where cannulation success with or without trainee presence was the primary outcome measure. PATIENTS AND METHODS We prospectively recorded data on 2 senior endoscopists and their trainees over an 18-month period for ERCPs in patients with a virgin ampulla. Presence or absence of a trainee at ERCP procedures was pragmatic, reflecting their other service or training commitments or annual leave. For trainee presence, the training protocol allowed them 6 minutes of supervised time in which to achieve biliary cannulation after reaching the ampulla. Study outcome measures included cannulation success, time to cannulation, technique, whether this was achieved independently by the trainee, and complications. RESULTS There were 219 procedures recorded and analyzed (134 with a trainee, 85 without). Three trainees were involved. Selective biliary cannulation was achieved in 201 (92 %) of cases. When a trainee was present, cannulation was successful in 122/134 procedures (91 %), compared to 79/85 (93 %) with a senior endoscopist alone ( P = 0.8, Fisher's exact test). Mean time to biliary cannulation with a trainee present was 7 minutes, compared with 5 minutes with no trainee. Mean time for successful independent cannulation by the trainee was 4 minutes, and 9 minutes for a consultant following a trainee's attempt. There were no serious adverse events. CONCLUSION Our study shows that with this training protocol, involvement of a trainee on a routine secondary care ERCP list does not impair biliary cannulation success, and does not prolong a subsequent attempt by the senior endoscopist if initially unsuccessful. These findings support the involvement of trainees in routine ERCP lists with this training protocol.
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Affiliation(s)
- John Warwick Frost
- Dudley Group of Hospitals NHS Foundation Trust, Gastroenterology, Dudley, UK nad Northern Ireland,Corresponding author John Warwick Frost Dudley Group of Hospitals NHS Foundation Trust – GastroenterologyRussell’s Hall HospitalPensnett RoadDudley DY1 2HQUnited Kingdom of Great Britain and Northern Ireland+07903290821
| | - Arun Kurup
- Dudley Group of Hospitals NHS Foundation Trust, Gastroenterology, Dudley, UK nad Northern Ireland
| | - Sharan Shetty
- Dudley Group of Hospitals NHS Foundation Trust, Gastroenterology, Dudley, UK nad Northern Ireland
| | - Neil Fisher
- Dudley Group of Hospitals NHS Foundation Trust, Gastroenterology, Dudley, UK nad Northern Ireland
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Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, Ponnudurai R, Lakhtakia S, Lee DK, Ratanachu-Ek T, Yasuda I, Dy FT, Ho SH, Makmun D, Liang HL, Draganov PV, Rerknimitr R, Wang HP. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85:295-304. [PMID: 27720741 DOI: 10.1016/j.gie.2016.09.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/28/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Phonthep Angsuwatcharakon
- Department of Anatomy and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Global Hopsitals, Parel, Mumbai, India
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher J L Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Ryan Ponnudurai
- Division of Gastroenterology, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Dong-Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Thawee Ratanachu-Ek
- Department of Surgery, Rajavithi Hospital, Rangsit Medical College, Bangkok, Thailand
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | | | - Shiaw-Hooi Ho
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dadang Makmun
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Huei-Lung Liang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Peter V Draganov
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Wang AY, Strand DS, Shami VM. Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques. Clin Gastroenterol Hepatol 2016; 14:1521-1532.e3. [PMID: 27237430 DOI: 10.1016/j.cgh.2016.05.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
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Endoscopic Ultrasound Guided Rendezvous Drainage of Biliary Obstruction Using a New Flexible 19-Gauge Fine Needle Aspiration Needle. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:3125962. [PMID: 27822005 PMCID: PMC5086367 DOI: 10.1155/2016/3125962] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/12/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022]
Abstract
Background and Aim. A successful endoscopic ultrasound guided rendezvous (EUS-RV) biliary drainage is dependent on accurate puncture of the bile duct and precise guide wire manipulation across the ampulla of Vater. We aim to study the feasibility of using a flexible 19-gauge fine aspiration needle in the performance of EUS-RV biliary drainage. Method. This is a retrospective case series of EUS-RV biliary drainage procedures at a single center. Patients who failed ERCP during the same session for benign or malignant biliary obstruction underwent EUS-RV using a flexible, nitinol covered, 19-gauge needle for biliary access and guide wire manipulation. Result. 24 patients underwent EUS-RV biliary drainage via extrahepatic access while 1 attempt was via intrahepatic access. The technical success rate was 80%, including 83.3% of cases via extrahepatic access. There was no significant difference in success rate of inpatient and outpatient procedures, benign or malignant indications, or type of guide wire used. Adverse events included mild pancreatitis (3 patients) and cholangitis (1 patient). Conclusion. A flexible 19-gauge needle for biliary access can be safe and effective when used to perform EUS-RV biliary drainage. Direct comparison between the nitinol needle and conventional metal needles in the performance of EUS guided biliary drainage is needed.
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Abstract
BACKGROUND The verbalisation of quality standards and parameters by medical societies are relevant for qualitative improvement but may also be an instrument to demand more resources for health care or be a unique characteristic. Within the health care system 3 different quality levels can be defined: structure, process and result quality. METHODS The current S2k guideline of the German Society for Gastroenterology (quality requirements for gastrointestinal endoscopy) AWMF registry no. 021-022 provides recommendations based on the available evidence for the structure quality (requirements for equipment, human resources) as well as for the process quality (patient preparation, conduct, documentation) and result quality (follow-up of specific endoscopic procedures). RESULTS Based on these recommendations, measurable quality indicators/parameters for the endoscopy have been selected and formulated. General quality parameters for endoscopic examinations are given as well as quality parameters for specific procedures for the preparation, conduct, and follow-up of specific endoscopic interventions. CONCLUSION Only the regular review of processes and courses by means of defined measurement parameters builds up the basis for corrections based on facts. In addition, the implementation of recommended standards may be an instrument in demanding more resources from the health care system and, therefore, should be embedded as routine.
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Affiliation(s)
- Ulrike W. Denzer
- Clinic for Interdisciplinary Endoscopy, University Clinic Hamburg Eppendorf, Hamburg, Germany
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Cheriyan D, Obando JV. Therapeutic Endoscopic Ultrasound. Gastroenterol Hepatol (N Y) 2015; 11:467-473. [PMID: 27118942 PMCID: PMC4843025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Endoscopic ultrasound (EUS) technology has evolved dramatically over the past 20 years, from being a supplementary diagnostic aid available only in large medical centers to being a core diagnostic and therapeutic tool that is widely available. Although formal recommendations and practice guidelines have not been developed, there are considerable data supporting the use of EUS for its technical accuracy in diagnosing pancreaticobiliary and gastrointestinal pathology. Endosonography is now routine practice not only for pathologic diagnosis and tumor staging but also for drainage of cystic lesions and celiac plexus neurolysis. In this article, we cover the use of EUS in biliary and pancreatic intervention, ablative therapy, enterostomy, and vascular intervention.
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Affiliation(s)
- Danny Cheriyan
- Dr Cheriyan is an advanced endoscopy fellow and an instructor in medicine and Dr Obando is an assistant professor of medicine in the Division of Gastroenterology at Duke University Medical Center in Durham, North Carolina
| | - Jorge V Obando
- Dr Cheriyan is an advanced endoscopy fellow and an instructor in medicine and Dr Obando is an assistant professor of medicine in the Division of Gastroenterology at Duke University Medical Center in Durham, North Carolina
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