Advances in pancreatobiliary endoscopy

The Majority of Patients Who Undergo ERCP When Large Duct Obstruction Is Evident on Liver Biopsy Have Biliary Findings Amenable to Endoscopic Intervention

(1) Background: Abnormal liver function tests are commonly encountered in clinical practice, often leading to additional workup to determine the underlying etiology of these abnormal laboratory studies. As part of this evaluation, if less invasive imaging studies are performed and are without evidence of biliary obstruction, liver biopsy may be performed, and the finding of large duct obstruction on liver biopsy is commonly encountered. The utility of endoscopic retrograde cholangiopancreatography (ERCP) for evaluation and management of possible biliary obstruction in patients with large duct obstruction on liver biopsy has not been studied to date. (2) Methods: To assess the utility of ERCP in patients with large bile duct obstruction on liver biopsy, we retrospectively evaluated patients with large duct obstruction on liver biopsy from 2010-2019 at our tertiary care and transplant center. Demographic and clinical characteristics were evaluated for all patients, with sub-group analysis for patients who underwent ERCP and those who had intervenable findings at the time of ERCP. Descriptive statistics with proportions, means, and standard deviations were performed for demographics and clinical variables using absolute standardized difference. (3) Results: During the study period, 189 liver biopsies with evidence of large duct obstruction were performed. After exclusion criteria were applied, 166 unique patients were eligible for the study. Ninety-one patients with evidence of large duct obstruction on liver biopsy underwent ERCP and 75 did not. Of the 91 patients who underwent ERCP, 76 patients (84%) had an intervenable finding at ERCP. Patients who underwent ERCP were overall more likely to have had a liver transplant (65% ASD 0.63), have previously undergone cholecystectomy (80%, ASD 0.56), and be immunocompromised (80%, ASD 0.56). (4) Conclusions: ERCP is high yield when large duct obstruction is apparent on liver biopsy, with the majority of patients (84%) who undergo ERCP in this clinical context having a biliary finding necessitating therapeutic endoscopic intervention.

The Value of Contrast-Enhanced Ultrasound-Guided Contrast Injection via the Endoscopic Nasobiliary Drainage Duct in Diagnosing Residual Common Bile Duct Stones

Objectives

To investigate the diagnostic value of contrast-enhanced ultrasound- (CEUS-) guided contrast injection via an endoscopic nasobiliary drainage (ENBD) tube on the evaluation for residual stones in common bile duct (CBD).

Methods

116 patients with CBD stones were treated by endoscopic retrograde cholangiopancreatography and duodenoscopic sphincterotomy incision surgery and ENBD. The US group consisted of 54 patients who underwent US-guided saline injection via the ENBD tube to evaluate for residual CBD stones. The CEUS group consisted of 62 patients who underwent CEUS-guided contrast injection via the ENBD tube to evaluate for residual CBD stones. The length and width of CBD and the detection rate of residual stones before and after NS injection were compared.

Results

In both the US group and the CEUS group, the rate of complete demonstration and the average length and width of CBD before and after injection of NS were all increased significantly. In the US group, 6 patients had verified residual stones, 1 of which was detected by conventional US (detection rate, 1/6), 5 of which were detected by saline injection ultrasound (detection rate, 5/6), and 4 of which were detected by ENBD cholangiography (detection rate, 4/6). There was 1 false positive result on saline injection US and 2 false positives on ENBD cholangiography. In the CEUS group, 6 patients had verified residual stones, none of which were detected by conventional US (detection rate, 0/6), all of which were detected by saline injection CEUS (detection rate, 6/6), and 4 of which were detected by ENBD cholangiography (detection rate, 4/6). There was 1 false positive result on ENBD cholangiography.

Conclusions

CEUS-guided contrast injection via an ENBD tube helps to provide clear observation of residual stones in the CBD after ERCP with EST and provides comprehensive information for follow-up.

The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma

BACKGROUND/AIMS

Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma.

PATIENTS AND METHODS

A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated.

RESULTS

The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared.

CONCLUSIONS

The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.

Effect of submucosal injection in endoscopic papillectomy of ampullary tumor: Propensity-score matching analysis

Background

The role of submucosal injection (SI) in endoscopic papillectomy (EP) is controversial.

Objective

This study investigated the effects of SI before EP of ampullary tumors.

Methods

All patients who underwent initial curative EP at our institution between March 2006 and March 2014 were retrospectively recruited. The presence of residual tumor after three months, recurrence-free survival and post-procedural adverse events were compared between the SI group and non-injection (NI) group. Propensity-score matching was performed between the two groups to reduce potential selection bias and confounding.

Results

A total of 122 patients were included (SI: 26, NI: 96). Following propensity-score matching, 25 paired patients were selected. Residual tumor was not shown in the NI group, whereas seven (28.0%) patients in the SI group had residual tumor (p = 0.010). The recurrence-free survival of the NI group was significantly longer than that of the SI group (p = 0.036). Upon multivariate analysis, pathologic grade (p = 0.026) and SI (p = 0.033) were significantly related to recurrence-free survival. Post-procedural adverse events were not significantly different between the two groups.

Conclusion

SI before EP of ampullary tumor was related to more frequent residual tumor and shorter recurrence-free survival and did not reduce post-procedural adverse events.

Low ERCP Volume Is Associated with More Industry Representative Interactions but Similar Training of Nurses

BACKGROUND

Data on ERCP nurses and associate (ERCP-NA) training and comfort are lacking. Healthcare industry representative (HCIR) influence may be greater in low-volume units (LVUs) due to decreased procedure and device familiarity.

AIM

The aim of this study was to compare ERCP-NA training, safety, and HCIR relationships between LVU and high-volume unit (HVU) ERCP facilities.

METHODS

We conducted an electronic survey of all Society of Gastroenterology Nurses and Associates (SGNA) members assessing: (1) demographics and procedure volume, (2) ERCP training and radiation safety, and (3) HCIR interactions. Responses were stratified by ERCP volume.

RESULTS

Among 832 SGNA member respondents (median age 55), 615 (74%) worked as an ERCP-NA; 41% derived from LVUs. The majority of ERCP-NAs, irrespective of unit volume, had observed <50 ERCPs before starting. Except for lead glasses, the majority (>80%) adhered to basic radiation safety, irrespective of unit volume. LVUs were more likely than HVU ERCP-NAs to agree that HCIRs were requested for intra-procedure assistance (24 vs. 19%, p = 0.008), asked for input on the next choice of device (22 vs. 15%, p = 0.01), and assist in device usage (27 vs. 22%, p = 0.04). Irrespective of volume, 30% agreed that they were more likely to utilize a company's devices if that HCIR was present.

CONCLUSIONS

ERCP-NA training before independent participation in ERCP is suboptimal. HCIRs are frequently requested for assistance during ERCPs, especially in LVUs. HCIR impact on ERCP outcomes and device utilization and whether enhanced ERCP-NA training will impact the role of HCIR, require further study.

Mutational analysis of cytocentrifugation supernatant fluid from pancreatic solid mass lesions

Diagnosis of fine-needle aspirations of pancreatic solid masses is complicated by many factors that keep its false-negative rate high. Our novel approach analyzes cell-free cytocentrifugation supernatant, currently a discarded portion of the specimen. Supernatant and cytology slides were collected from 25 patients: 11 cases with confirmed outcome [five positive (adenocarcinoma) and six negative (inflammatory states)], plus 14 without confirmed outcomes. Slides were microdissected, DNA was extracted from microdissections and corresponding supernatants, and all were analyzed for KRAS point mutation and loss of heterozygosity. Notably, higher levels of free DNA were found in supernatants than in corresponding microdissected cells. Supernatants contained sufficient DNA for mutational profiling even when samples contained few to no cells. Mutations were present in 5/5 malignancies and no mutations were present in inflammatory states. In conclusion, these findings support using supernatant for mutational genotyping when diagnostic confirmation is required for pancreatic solid masses. Diagn. Cytopathol. 2014;42:719–725. © 2013 Wiley Periodicals, Inc.

Preventing pancreatitis after endoscopic retrograde cholangiopancreatography

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.

Efficacy of endoscopic nasobiliary drainage for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis after repeated clearance of common bile duct stones: experience from a Chinese center

BACKGROUND

The aim of the present study was to investigate whether it is reasonable to insert an endoscopic nasobiliary drainage (ENBD) tube in patients with endoscopic sphincterotomy (EST) and repeated clearance of common bile duct (CBD) stones.

PATIENTS AND METHODS

Patients with choledocholithiasis who underwent EST and CBD stone clearance at our center from January 2010 to May 2012 were reviewed. The following parameters were evaluated: (i) serum amylase 2 and 24 h after ERCP; (ii) incidence of endoscopic retrograde cholangiopancreatography (ERCP)-related pancreatitis and cholangitis; (iii) time elapsed to normalization of total serum bilirubin levels for those with jaundice before ERCP; and (iv) length of hospital stay.

RESULTS

Compared with the no-ENBD group, the ENBD group presented a significantly lower postoperative serum amylase of 2 and 24 h (81.3 ± 31.8 U/L vs 90.8 ± 31.2 U/L, 107.0 ± 51.1 U/Lvs 132.3 ± 100.8 U/L, respectively). The incidence of post-ERCP pancreatitis and cholangitis was also lower in the ENBD group, although the differences were not significant (1% vs 4.4%, 0 vs 4.5%, respectively). Time elapsed to normalization of total serum bilirubin levels and length of hospital stay was shorter in the ENBD group (4.3 days ± 0.6 days vs 4.5 days ± 0.7 days, P > 0.05; 4.8 days ± 2.1 days vs 6.3 days ± 2.8 days, respectively, P < 0.01).

CONCLUSIONS

ENBD significantly reduces the incidence of hyperamylasemia and decreases the length of hospital stay in patients with EST and repeated stone extraction. ENBD should be considered for patients with large or multiple CBD stones.

Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients with suspected biliary complications

Diagnostic endoscopic retrograde cholangiopancreatography (D-ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D-ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T-ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D-ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high-yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D-ERCP procedures were classified as high-yield, whereas 90.1% of the T-ERCP procedures were (P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high-yield D-ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T-ERCP is more likely to reveal a pathological process requiring an intervention, D-ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high-yield study and the low rate of serious complications.

Endoscopic biliary stenting for irretrievable common bile duct stones: Indications, advantages, disadvantages, and follow-up results

BACKGROUND

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery have made it the predominant method of treating patients with choledocholithiasis. After sphincterotomy, however, 10%-15% of common bile duct (CBD) stones cannot be removed with a basket or balloon. Methods for managing "irretrievable stones" include surgery; mechanical, intraductal shock wave, and extracorporeal shock wave lithotripsy; chemical dissolution; and biliary stenting. Endoscopic biliary stent insertion, which is frequently used in specific situations, has both advantages and disadvantages. To maximize the advantages and minimize the complications of biliary endoprosthesis, it is important to recognize its proper indications and to apply the technique in proper situations.

DATA SOURCES

We reviewed all publications cited in Pubmed and published through July 2011 on biliary endoprosthesis in patients with irretrievable CBD stones. We analyzed the indications, advantages, disadvantages, and long-term follow-up results of this technique.

RESULTS

Despite the occurrence of related complications, such as cholangitis, endoscopic placement of an endoprosthesis may reduce stone size, allowing later clearance of unextractable stones. Permanent biliary stenting may be a definitive treatment in selected elderly patients who are poor candidates for surgery.

CONCLUSION

Endoscopic biliary stenting remains a simple and safe method for patients with stones difficult to manage by conventional endoscopic methods and those patients unfit for surgery or at high surgical risks.