1
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Dai C, Xu C, Zheng L, Wang M, Fan Z, Ye J, Su D. Characteristics and metabolic potential of biliary microbiota in patients with giant common bile duct stones. Front Cell Infect Microbiol 2023; 13:1259761. [PMID: 38029241 PMCID: PMC10661410 DOI: 10.3389/fcimb.2023.1259761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is an effective minimally invasive operation for the management of choledocholithiasis, while successful extraction is hampered by large diameter of stones. Emerging studies have revealed the close correlation between biliary microbiota and common bile duct stones (CBDS). In this study, we aimed to investigate the community characteristics and metabolic functions of biliary microbiota in patients with giant CBDS. Methods Eligible patients were prospectively enrolled in this study in First Affiliated Hospital of Soochow University from February 2022 to October 2022. Bile samples were collected through ERCP. The microbiota was analyzed using 16S rRNA sequencing. Metabolic functions were predicted by PICRUSTs 2.0 calculation based on MetaCyc database. Bile acids were tested and identified using ultra performance liquid chromatography-tandem mass spectrometry. Results A total of 26 patients were successfully included into final analysis, 8 in giant stone (GS) group and 18 in control group. Distinct biliary microbial composition was identified in patients with giant CBDS, with a significantly higher abundance of Firmicutes at phylum level. The unique composition at genus level mainly consisted of Enterococcus, Citrobacter, Lactobacillus, Pyramidobacter, Bifidobacterium and Shewanella. Pyramidobacter was exclusively found in GS group, along with the absence of Robinsoniella and Coprococcus. The contents of free bile acids were significantly higher in GS group, including cholic acid (98.39μmol/mL vs. 26.15μmol/mL, p=0.035), chenodesoxycholic acid (54.69μmol/mL vs. 5.86μmol/mL, p=0.022) and ursodeoxycholic acid (2.70μmol/mL vs. 0.17μmol/mL, p=0.047). Decreasing tendency of conjugated bile acids were also observed. Metabolic pathways concerning cholelithiasis were abundant in GS group, including geranylgeranyl diphosphate biosynthesis, gluconeogenesis, glycolysis and L-methionine biosynthesis. Conclusions This study demonstrated the community structure and metabolic potential of biliary microbiota in patients with giant CBDS. The unique biliary microbial composition holds valuable predictive potential for clinical conditions. These findings provide new insights into the etiology of giant CBDS from the perspective of biliary microbiota.
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Affiliation(s)
- Chenguang Dai
- Department of Pathology, Nanjing Medical University, Nanjing, China
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunfang Xu
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lu Zheng
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Min Wang
- Digestive Endoscopy Department, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhining Fan
- Digestive Endoscopy Department, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jianxin Ye
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Dongming Su
- Department of Pathology, Nanjing Medical University, Nanjing, China
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2
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Mao YQ, Ni JB, Yu YN, Peng K, Qu Y, Xia YC, Luo SZ, Fu SW, Xie N, Lu LG, Wan XJ, Li BW. Favorable impact of a novel endoscopic auxiliary system (NEAS) on fluoroscopy-guided lithotripsy for difficult bile duct stones: A pilot study. J Dig Dis 2023; 24:630-637. [PMID: 37823361 DOI: 10.1111/1751-2980.13234] [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: 05/22/2023] [Revised: 09/17/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES Laser lithotripsy under fluoroscopic guidance is difficult to perform and risky due to its invisibility. In this study we aimed to investigate the efficacy and safety of a novel endoscopic auxiliary system (NEAS)-assisted lithotripsy under fluoroscopy for treating difficult common bile duct (CBD) stones. METHODS Patients with difficult CBD stones who were treated with NEAS-assisted laser lithotripsy (NEAS group) or conventional mechanical lithotripsy (ML) under fluoroscopy (ML group) were retrospectively evaluated. The primary outcome was the complete stone clearance rate and the secondary outcomes included operation time, complications, and medical cost. RESULTS Seventeen patients were treated with NEAS-assisted laser lithotripsy and 144 patients underwent ML. Using the propensity score matching analysis, 17 pairs of cases treated with NEAS-assisted lithotripsy and ML were included. Patients in the NEAS group showed a higher stone clearance rate than the ML group (94.1% vs 58.8%, P = 0.039), as well as shorter operation time (41.9 min vs 49.4 min, P < 0.001) and lower medical cost (USD 4607 vs USD 5014, P < 0.001). There was no significant difference in the complication rate between the two groups (5.9% vs 17.6%, P = 0.601). CONCLUSION NEAS-assisted fluoroscopy-guided laser lithotripsy is feasible and safe, which may be a promising technique in fluoroscopy-guided laser lithotripsy for difficult CBD stones.
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Affiliation(s)
- Yu Qing Mao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Bo Ni
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Neng Yu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kui Peng
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Qu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - You Chen Xia
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Zheng Luo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Seng Wang Fu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ni Xie
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lun Gen Lu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Jian Wan
- Department of Gastroenterology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bai Wen Li
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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3
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Kim J. Current Trends and Practice Patterns for Difficult Bile Ducts Stones in Korea. Gut Liver 2023; 17:349-350. [PMID: 37183723 PMCID: PMC10191783 DOI: 10.5009/gnl230155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Affiliation(s)
- Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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4
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Sljivic I, Trasolini R, Donnellan F. Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones. Endosc Int Open 2022; 10:E1193-E1200. [PMID: 36118645 PMCID: PMC9473834 DOI: 10.1055/a-1873-0884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background and study aims Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.
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Affiliation(s)
- Igor Sljivic
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Roberto Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard University, Cambridge, Massachusetts, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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5
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Paspatis GA, Papastergiou V, Mpitouli A, Velegraki M, Nikolaou P, Fragkaki M, Voudoukis E, Theodoropoulou A, Chlouverakis G, Vardas E, Paraskeva KD. Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents. Dig Dis Sci 2022; 67:4557-4564. [PMID: 35305168 DOI: 10.1007/s10620-022-07461-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known complication, although data beyond the recommended interval of temporary stenting (3-6 months) are lacking. We compared the long-term incidence of DSM between straight and double-pigtail stents in patients with IBDS. METHODS Consecutive patients with IBDS undergoing plastic biliary stenting (1/2009-12/2019) were retrospectively reviewed. DSM was confirmed on follow-up examination when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Kaplan-Meier and Cox regression analyses were used to determine estimates and predictors of DSM. RESULTS Overall, 618 biliary stenting procedures (410 patients) were included: 289 with a straight stent (group A) and 329 with a double-pigtail (group B). By Kaplan-Meier analysis, the DSM rates were 8.4 and 14.6% at 6 months, 21.4 and 27.7% at 12 months, 27 and 43.5% at 18 months, and 37.2 and 60.4% at 24 months, for groups A and B, respectively (p = 0.004). Double-pigtail stents were at higher risk for DSM (HR = 7.38, p = 0.04), whereas an inverse correlation was noted with age (HR = 0.97, p = 0.0001). Considering only temporary stenting procedures (≤ 6 months; n = 297), the probability of DSM was not significantly different between the two groups (p = 0.07). CONCLUSIONS In a setting of prolonged stenting for IBDS, the probability of DSM appears to be higher when a double-pigtail stent is used and in younger patients. A relative anti-migratory advantage of double-pigtail over straight stents appears negligible in this study.
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Affiliation(s)
- Gregorios A Paspatis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece.
| | - Vasilios Papastergiou
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, Athens, Greece
| | - Afroditi Mpitouli
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Pinelopi Nikolaou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Maria Fragkaki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Angeliki Theodoropoulou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | | | - Emmanouil Vardas
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
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Takenaka M, Kudo M. What is the most appropriate diagnostic strategy for evaluating a small common bile duct stone? Dig Endosc 2022; 34:1060-1062. [PMID: 35591778 DOI: 10.1111/den.14319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
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7
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Surapaneni S, Kiwan W, Chiu MK, Zingas A, Hussein S, Ehrinpreis M. The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula. Avicenna J Med 2021; 12:34-37. [PMID: 35586392 PMCID: PMC9110104 DOI: 10.1055/s-0041-1739541] [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] [Indexed: 11/22/2022] Open
Abstract
Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.
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Affiliation(s)
- Sarvani Surapaneni
- Internal Medicine Department, Wayne State University, Detroit, Michigan, United States
| | - Wissam Kiwan
- Gastroenterology Division, University of Southern California, Los Angeles, California, United States
| | - Michael K. Chiu
- Department of Radiology, Wayne State University, Detroit, Michigan, United States
| | - Alkis Zingas
- Department of Radiology, Wayne State University, Detroit, Michigan, United States
| | - Shakir Hussein
- Department of Surgery, Wayne State University, Detroit, Michigan, United States
| | - Murray Ehrinpreis
- Gastroenterology Division, Wayne State University, Detroit, Michigan, United States
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8
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Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol 2021; 27:7597-7611. [PMID: 34908801 PMCID: PMC8641054 DOI: 10.3748/wjg.v27.i44.7597] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/23/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.
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Affiliation(s)
- Alberto Tringali
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Deborah Costa
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
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9
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Kim JH, Yang MJ. Recent advances of endoscopic retrograde cholangiopancreatography in surgically altered anatomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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10
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Katanuma A, Kin T, Hayashi T. Comprehensive evaluation of endoscope performance involves balanced assessment, accurate feedback, and suggested improvements by endoscopists. Dig Endosc 2021; 33:749-750. [PMID: 33721380 DOI: 10.1111/den.13951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
| | - Tsuyoshi Hayashi
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
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11
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Dollhopf M, Schmetkamp H. Endoscopic management of difficult common bile duct stones. Minerva Gastroenterol (Torino) 2021; 68:144-153. [PMID: 34142521 DOI: 10.23736/s2724-5985.21.02876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. EVIDENCE ACQUISITION A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS). EVIDENCE SYNTHESIS This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones. CONLCLUSIONS For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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Affiliation(s)
- Markus Dollhopf
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany
| | - Henning Schmetkamp
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -
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12
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Nakai Y, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, Takahara N, Hamada T, Mizuno S, Kogure H, Tada M, Isayama H, Koike K. Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography. Gut Liver 2021; 14:297-305. [PMID: 31581389 PMCID: PMC7234877 DOI: 10.5009/gnl19157] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/19/2019] [Accepted: 07/28/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.
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Affiliation(s)
- Yousuke Nakai
- Departments of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Japan.,Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tatsuya Sato
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Ryunosuke Hakuta
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kazunaga Ishigaki
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kei Saito
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tomotaka Saito
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Naminatsu Takahara
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tsuyoshi Hamada
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Suguru Mizuno
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hirofumi Kogure
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Minoru Tada
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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13
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Lesmana CRA, Herjuningtyas C, Inggriani S, Pratiwi YE, Lesmana LA. Bedside Percutaneous Approach in a Critically Ill ICU Patient with Complex Pancreatobiliary Disorder Followed by Endoscopic Approach: Lessons Learnt from a Tertiary Referral Center. Case Rep Gastroenterol 2021; 15:210-217. [PMID: 33790707 PMCID: PMC7989824 DOI: 10.1159/000513282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/13/2020] [Indexed: 11/19/2022] Open
Abstract
Pancreatobiliary disorder is a challenging clinical condition, especially when this condition is causing severe infection or biliary sepsis, and sometimes it requires intensive care unit (ICU) treatment. Biliary drainage is the mainstay of therapy; however, the choice of the drainage method is dependent on the patient's clinical condition and the disease itself. A 79-year-old female was transferred on a ventilator to our ICU from another hospital due to biliary sepsis, a large common bile duct stone, and an infected pancreatic pseudocyst. The patient also has other comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. Bedside percutaneous transhepatic biliary drainage without fluoroscopy and percutaneous cyst aspiration was successfully performed, which improved the patient's condition; this was followed by an endoscopic approach, i.e., endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided pancreatic pseudocyst drainage. The clinical improvement showed itself in the change of the patient's respiratory status and ventilator mode. In conclusion, the percutaneous approach has a big role in managing critically ill patients in the ICU setting. However, expertise, training experience, and a multidisciplinary team approach are very important for successful management and patient outcome.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty University of Indonesia, Jakarta, Indonesia.,Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | | | - Sri Inggriani
- Department of Radiology, Medistra Hospital, Jakarta, Indonesia
| | - Yulia Estu Pratiwi
- Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
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Ali N, Nadeem M, Nauyan F, Mir I, Farooq T. Laparoscopic Management of Common Bile Duct Stones: Stratifying Risks, a District Hospital Experience. J Laparoendosc Adv Surg Tech A 2021; 32:165-170. [PMID: 33691073 DOI: 10.1089/lap.2021.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Management of bile duct stones is variable. Selection of the appropriate treatment modality based on identifiable risk factors can increase the chances of a successful outcome. The aim of this study is to identify factors affecting outcomes of a laparoscopic bile duct exploration. Methods: Retrospective data analysis of consecutive laparoscopic bile duct explorations over a period of 13 years at a district general hospital. Results: The total number of patients in the study was 85. Elective explorations were 56 while 29 were emergency procedures. The mean operative time was 154 minutes. The conversion rate was 14% with failure to extract stones being the most common reason. Forty-two percent of conversions were in nonelective procedures and 17% in previous endoscopic retrograde cholangiopancreatography (ERCP) failures. Eleven percent patients had a transcystic clearance of bile duct and the largest stone removed transcystic was 5 mm. The largest stone removed by a laparoscopic choledochotomy was 15 mm and stones >20 mm were removed on conversion. Seven patients (8%) had a postoperative bile leak, 4 of these required a postoperative ERCP stent and radiological drainage while 3 required a reoperation. Three patients had retained stones treated by postoperative ERCP. Conclusion: Emergency procedures, increasing number and size of stones, previous failed ERCP are factors that contribute to the outcomes of a laparoscopic bile duct exploration. The chances of a successful exploration can be improved by appropriate patient and procedure selection and preparation based on identification of these factors.
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Affiliation(s)
- Nauyan Ali
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Muhammad Nadeem
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Farah Nauyan
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Irfan Mir
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Tahir Farooq
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
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15
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Oh CH, Dong SH. Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy. Korean J Intern Med 2021; 36:235-246. [PMID: 32972127 PMCID: PMC7969058 DOI: 10.3904/kjim.2020.425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/16/2022] Open
Abstract
The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
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16
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Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones. Heliyon 2020; 6:e05515. [PMID: 33294669 PMCID: PMC7683307 DOI: 10.1016/j.heliyon.2020.e05515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/13/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Endoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. Methods A retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). Results One hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3–40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272–0.979], an intra-diverticular papilla OR 0.179 [0.035–0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068–0.385] and a stenosis of the common bile duct OR 0.068 [0.008–0.605]. The success rate of the second line treatment was 73%. Conclusion Endoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.
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17
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Heo J, Jung MK. Removal of a Large, Intractable Common Bile Duct Stone by Direct Peroral Cholangioscopy Using Upper Gastrointestinal Endoscopy and Polypectomy Snare. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:215-219. [PMID: 33100318 DOI: 10.4166/kjg.2020.76.4.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/03/2022]
Abstract
ERCP is the standard treatment for common bile duct stones. On the other hand, 10-15% of cases involve intractable common bile duct stones, which cannot be treated by conventional biliary sphincterotomy with a stone retrieval method. Large bile duct stones are typically managed by mechanical lithotripsy and endoscopic papillary large balloon dilatation. Peroral cholangioscopy techniques can be applied if this technique fails. In the present case, a 67-year-old woman had a large common bile duct stone that could not be retracted using the conventional ERCP stone extraction method. The common bile duct stone was eventually removed by direct peroral upper gastrointestinal endoscopy and a polypectomy snare.
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Affiliation(s)
- Jun Heo
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea.,Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Min Kyu Jung
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea.,Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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18
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Ultra-mini Percutaneous Hepatolithotomy in Patients With Large and Multiple Hepatolithiasis. Surg Laparosc Endosc Percutan Tech 2020; 31:76-84. [PMID: 32910108 DOI: 10.1097/sle.0000000000000853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND In this study, we applied the ultra-mini percutaneous hepatolithotomy (UM-PHL) technique on hepatolithiasis patients with multiple and large stones on which other minimally invasive methods failed, and our aim was to report its results, sharing in series for the first time. MATERIALS AND METHODS Preoperative and postoperative data, laboratory parameters, radiologic findings, and preoperative and postoperative details were recorded for a total of 14 patients for whom the UM-PHL technique was applied between April 2017 and December 2019. As all patients had multiple stones and extreme stone load and had bile duct surgery, they did not have a normal anatomy. All patients were radiologically confirmed to have had preprocedural magnetic retrograde cholangiopancreatography. RESULTS Operation duration of the patients was 137.6±44.9 minutes, while intraoperative blood loss was 69.2±24.9 mL, drainage catheter removal time was 2.85±0.86 days, and the hospitalization time was 4.28±2.55 days. Intraoperative balloon dilation was applied to enlarge the stricture area in 5 patients (35.7%). On the basis of the Clavien-Dindo classification, grade 2 complication was observed in 2 patients (14.2%) due to postoperative cholangitis. Patients were followed up for an average of 15 months, and nonsymptomatic radiologic stone recurrence was detected in the 12th month control of 1 patient (7.1%). CONCLUSION The UM-PHL technique is a successful method that facilitates stone clearance by providing minimal dilatation through percutaneous intervention and by using instruments with small diameter, and it can safely be applied with its low complication level, low recurrence ratio, and short hospitalization time.
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Kogure H, Kawahata S, Mukai T, Doi S, Iwashita T, Ban T, Ito Y, Kawakami H, Hayashi T, Sasahira N, Kubota K, Togawa O, Kato H, Okabe Y, Matsubara S, Yagioka H, Saito T, Nakai Y, Isayama H. Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: MARVELOUS trial. Endoscopy 2020; 52:736-744. [PMID: 32299114 DOI: 10.1055/a-1145-3377] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND : Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. METHODS : This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. RESULTS: 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). CONCLUSION : EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinpei Doi
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.,Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tesshin Ban
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Tokyo Takanawa Hospital of Japan Community Health-care Organization, Tokyo, Japan
| | - Kensuke Kubota
- Division of Gastroenterology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University of Medicine, Kurume, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, JR Tokyo General Hospital, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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20
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Mukai S, Tsuchiya T, Itoi T. Endoscopic ultrasonography-guided hepaticogastrostomy with novel two-step puncture technique following peroral cholangioscopy-assisted stone removal. Dig Endosc 2020; 32:e32-e33. [PMID: 31732992 DOI: 10.1111/den.13556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/04/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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21
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Ayoub F, Brar TS, Banerjee D, Abbas AM, Wang Y, Yang D, Draganov PV. Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis. Endosc Int Open 2020; 8:E423-E436. [PMID: 32118116 PMCID: PMC7035133 DOI: 10.1055/a-1070-9132] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, 'short' double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7-98.7 %) with little heterogeneity (I 2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5-82.6 %) with significant heterogeneity (I 2 : 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6-26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9-9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.
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Affiliation(s)
- Fares Ayoub
- Section of Gastroenterology, Hepatology & Nutrition, University of Chicago, Illinois, United States
| | - Tony S. Brar
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Debdeep Banerjee
- Department of Medicine, University of Florida, Gainesville, Florida, United States
| | - Ali M. Abbas
- Brigham and Women's Hospital, Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts, United States
| | - Yu Wang
- Department of Biostatistics, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States,Corresponding author Peter V. Draganov, MD Professor of MedicineDivision of Gastroenterology, Hepatology & NutritionUniversity of Florida1329 SW 16th StreetGainesville, FL 32608+1-352-627-9002
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22
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Mahalingam S, Langdon J, Muniraj T, Do A, Guo Y, Spektor M, Mathur M. Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White. Curr Probl Diagn Radiol 2020; 50:74-84. [PMID: 32063296 DOI: 10.1067/j.cpradiol.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/01/2020] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.
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Affiliation(s)
- Sowmya Mahalingam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
| | - Jonathan Langdon
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | | | - Albert Do
- Yale University School of Medicine, Section of Digestive Diseases, New Haven, CT
| | - Yang Guo
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT; Brigham and Women's Hospital, Brookline, MA
| | - Michael Spektor
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
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23
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Lamanna A, Maingard J, Tai J, Ranatunga D, Goodwin M. Percutaneous transhepatic Laser lithotripsy for intrahepatic cholelithiasis. Diagn Interv Imaging 2019; 100:793-800. [DOI: 10.1016/j.diii.2019.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/18/2019] [Accepted: 05/22/2019] [Indexed: 02/07/2023]
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24
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Wen XD, Ren LN, Liu WH. Efficient clearance of intractable biliary calculi by combination of mechanical clamping and electrohydraulic lithotripsy. Dig Endosc 2019; 31:e94-e96. [PMID: 31231914 DOI: 10.1111/den.13452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Xu-Dong Wen
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Li-Na Ren
- Chengdu Military General Hospital, Chengdu, China
| | - Wei-Hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
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25
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Li JS, Zou DW, Jin ZD, Shi XG, Chen J, Li ZS, Liu F. Predictive factors for extraction of common bile duct stones during endoscopic retrograde cholangiopancreatography in Billroth II anatomy patients. Surg Endosc 2019; 34:2454-2459. [PMID: 31376008 DOI: 10.1007/s00464-019-07039-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/24/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in Billroth II anatomy patients is still a technical challenge and factors affecting stone extraction have not yet been clarified. This study aimed to analyze our experience and evaluate potential factors affecting CBD stone extraction. METHODS A retrospective analysis of CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from August 1999 to December 2017, was conducted. The outcomes of ERCP and potential factors affecting stone extraction were examined. RESULTS A total of 227 patients were enrolled, and 176 patients (77.5%) achieved technical success. The success rate of duodenal ampullary access and selective biliary cannulation was 84.1% (191/227) and 92.1% (176/191), respectively. The mean CBD diameter was 15 mm (range 6-35 mm), and the largest stone size was 13 mm (range 4-36 mm). CBD stones were ultimately removed in 137 patients (77.8%), and 105 patients (59.7%) for the first session. Mechanical lithotripsy was used in 17 patients (9.7%). The overall ERCP-related complication rate was 6.3% (11/176), including bleeding in 3 patients (1.7%) and mild pancreatitis in 6 patients (3.4%). The multivariate analysis indicated that CBD stone number ≥ 2 (OR 2.171; 95% CI 1.095-4.306; p = 0.027), and the largest CBD stone size ≥ 12 mm (OR 3.646; 95% CI 1.833-7.251; p < 0.001) were patient-related risk factors for failed stone removal; while the use of endoscopic papillary (large) balloon dilation (EPBD/EPLBD) (OR 0.291; 95% CI 0.147-0.576; p < 0.001) was a procedure-related protective factor for successful stone extraction. CONCLUSIONS ERCP is safe and effective for extraction of CBD stones in Billroth II anatomy patients. The number and the largest size of CBD stones, and the use of EPBD/EPLBD are predictive factors for CBD stone extraction.
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Affiliation(s)
- Jia-Su Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xin-Gang Shi
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jie Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Middle Yanchang Road No. 301, Shanghai, 200072, China.
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26
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Jin Z, Wei Y, Tang X, Shen S, Yang J, Jin H, Zhang X. Single-operator peroral cholangioscope in treating difficult biliary stones: A systematic review and meta-analysis. Dig Endosc 2019; 31:256-269. [PMID: 30468534 DOI: 10.1111/den.13307] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/19/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Current evidence supporting the utility of single-operator peroral cholangioscope (SOPOC) in the management of difficult bile duct stones is limited. We conducted the present systematic review and meta-analysis to evaluate the efficacy and safety of SOPOC in treating difficult bile duct stones. METHODS We searched studies up to April 2018, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. Quality assessment of the studies was completed with the Newcastle-Ottawa Scale. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverse events. We calculated the pooled estimates with random-effects models. Potential publication bias was assessed. RESULTS Twenty-four studies involving 2786 patients met the inclusion criteria. Pooled proportion of patients with complete stone clearance was 94.3% (95% confidence interval [95% CI]: 90.2-97.5%). Single-session stone clearance was achieved in 71.1% (95% CI: 62.1-79.5%) of the pooled patients. Pooled number of sessions needed for stone clearance was 1.26 (95% CI: 1.17-1.34%). Pooled adverse event rate was 6.1% (95% CI: 3.8-8.7%). Potential publication bias was detected but had no significant influence on the results. CONCLUSIONS Single-operator peroral cholangioscope is an effective and safe treatment for difficult bile duct stones when conventional methods have failed. More randomized controlled trials are warranted to confirm the results.
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Affiliation(s)
- Zheng Jin
- Hangzhou Geriatric Hospital, Hangzhou First People's Hospital Group, Hangzhou, China.,Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Wei
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaowei Tang
- Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Sisi Shen
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Yang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hangbin Jin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Zhang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Hakuta R, Kogure H, Nakai Y, Hamada T, Noguchi K, Saito K, Saito T, Takahara N, Mizuno S, Yagioka H, Ito Y, Tada M, Isayama H, Koike K. Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study. Dig Endosc 2019; 31:316-322. [PMID: 30586206 DOI: 10.1111/den.13326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. METHODS In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants). RESULTS We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively). CONCLUSIONS Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kedia P, Tarnasky PR. Endoscopic Management of Complex Biliary Stone Disease. Gastrointest Endosc Clin N Am 2019; 29:257-275. [PMID: 30846152 DOI: 10.1016/j.giec.2018.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Choledocholithiasis is a common disorder that is managed universally by endoscopic retrograde cholangiopancreatography (ERCP). For difficult or complex stones, ERCP with conventional techniques may fail to achieve biliary clearance in 10% to 15% of cases. This review summarizes the literature regarding the current available endoscopic techniques for complex stone disease, including mechanical lithotripsy, endoscopic papillary large balloon dilation, cholangioscopy-guided lithotripsy, and endoscopic ultrasound-guided biliary access.
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA.
| | - Paul R Tarnasky
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA
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29
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Lee Y, Park SM, Han JH. Use of a lithotripter to salvage a bile duct stone and kinking retrieval basket in the distal common bile duct. Dig Endosc 2019; 31:e32-e33. [PMID: 30427549 DOI: 10.1111/den.13295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/08/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Yunhyeong Lee
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, South Korea
| | - Seon Mee Park
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea.,Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea.,Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
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30
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Liu P, Lin H, Chen Y, Wu YS, Tang M, Lai L. Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis. Ther Clin Risk Manag 2019; 15:91-101. [PMID: 30666119 PMCID: PMC6331186 DOI: 10.2147/tcrm.s182615] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim To compare endoscopic papillary large balloon dilation (EPLBD) alone with EPLBD following endoscopic sphincterotomy (EST) in patients with large and/or multiple common bile duct stones. Methods We conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles until July 19, 2018. Complete common bile duct stone (CBDS) removal rate, frequency of mechanical lithotripsy (ML) usage, total procedure time and intra- and postoperative adverse events were analyzed. We used RevMan 5.3 to perform the pooled analyses. Results Seven RCTs matched the selection criteria. A total of 369 patients underwent EPLBD alone, and 367 patients underwent EPLBD following EST. Our meta-analysis revealed that there were no significant differences in terms of initial success rate (OR =0.69, 95% CI=0.44–1.09, P=0.11), frequency of ML usage (OR =1.18, 95% CI=0.68–2.05, P=0.55), rate of post-endoscopy pancreatitis (PEP) (OR =0.88, 95% CI=0.43–1.78, P=0.72), total procedure time (MD =1.52, 95% CI=-0.13–3.17, P=0.07), or other intra- and postoperative adverse events between the groups for patients with large and/or multiple CBDSs. Conclusions EPLBD alone was comparable to EPLBD with prior EST in patients with large and/or multiple CBDSs. Further studies are required to confirm the mechanisms of PEP in patients who accept EPLBD during endoscopic retrograde cholangiopancreatography (ERCP).
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Affiliation(s)
- Pan Liu
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Sichuan, People's Republic of China,
| | - Huapeng Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, People's Republic of China
| | - Yuanyuan Chen
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yu-Shen Wu
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Maocai Tang
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, People's Republic of China
| | - Liang Lai
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Sichuan, People's Republic of China,
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31
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Franzini TAP, Visconti TADC, de Moura EGH. Large biliary stone: Lessons from a difficult case. Dig Endosc 2018; 30:812-813. [PMID: 30085363 DOI: 10.1111/den.13254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/03/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Tomazo Antônio Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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