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Kusumo Rahardjo A, Lesmana T, Wibowo HS, Prabowo R, Rosita E. One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System. Int J Surg Case Rep 2023; 109:108550. [PMID: 37499351 PMCID: PMC10413057 DOI: 10.1016/j.ijscr.2023.108550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/08/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities. CASE PRESENTATION This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance. CLINICAL DISCUSSION Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study. CONCLUSION One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.
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Affiliation(s)
- Arif Kusumo Rahardjo
- Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Airlangga University, Surabaya, Indonesia
| | - Tomy Lesmana
- Division of Digestive Surgery, Department of Surgery, Dr. Soetomo General Hospital, Airlangga University, Surabaya, Indonesia.
| | - Heru Seno Wibowo
- Division of Digestive Surgery, Dr. Ramelan Naval Center Hospital, Surabaya, Indonesia
| | - Rianto Prabowo
- Division of Digestive Surgery, Dr. Ramelan Naval Center Hospital, Surabaya, Indonesia
| | - Emilia Rosita
- Division of Digestive Surgery, Dr. Ramelan Naval Center Hospital, Surabaya, Indonesia
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2
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Ben Abdallah K, Hamzaoui L, Mahmoudi M, Cherif I, Ben Mohamed A, Yakoubi M, Khsiba A, Medhioub M, Azouz M. Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center. Heliyon 2022; 8:e12526. [PMID: 36619425 PMCID: PMC9812703 DOI: 10.1016/j.heliyon.2022.e12526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Selective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques. Methods We conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05). Results We included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24-2.65], SOD OR 4.71 [1.11-19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63-3.92], small papilla OR 4.09 [1.82-9.17] and difficult orientation of the papilla OR 14.90 [3.28-67.62]. Conclusion DBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.
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Affiliation(s)
- K. Ben Abdallah
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia,Corresponding author.
| | - L. Hamzaoui
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Mahmoudi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - I. Cherif
- Laboratory of Medical Epidemiology, Institut Pasteur de Tunis, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Ben Mohamed
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Yakoubi
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A. Khsiba
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M. Medhioub
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - M.M. Azouz
- Gastroenterology Department, Mohamed Taher Maamouri University Hospital, Nabeul, Tunisia,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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3
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Demir T, Ustaoglu M. Evaluation of the success and complication rates of endoscopic retrograde cholangiography according to the difficulty of the procedure. PRECISION MEDICAL SCIENCES 2022. [DOI: 10.1002/prm2.12088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Teyfik Demir
- Department of Internal Medicine Ondokuz Mayis University, Faculty of Medicine Samsun Turkey
| | - Muge Ustaoglu
- Department of Gastroenterology Ondokuz Mayis University, Faculty of Medicine Samsun Turkey
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4
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van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, Hucl T, Kunda R, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Perez-Miranda M, van Hooft JE. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:185-205. [PMID: 34937098 DOI: 10.1055/a-1717-1391] [Citation(s) in RCA: 167] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.
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Affiliation(s)
- Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, The Netherlands
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology Hospitals, Gachibowli, Hyderabad, India
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, and Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Abdenor Badaoui
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo G Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training (CERTT), Catholic University, Rome, Italy
| | - Marc Giovannini
- Paoli-Calmettes Institute, Department of Gastrointestinal Disease, Marseille, France
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Marc Barthet
- Department of Gastroenterology, Aix-Marseille Université, APHM, Hôpital Nord, Marseille, France
| | - Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Dalal A, Gandhi C, Patil G, Kamat N, Vora S, Maydeo A. Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography. Hosp Pract (1995) 2022; 50:61-67. [PMID: 35025705 DOI: 10.1080/21548331.2022.2029451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes. METHODS Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied. RESULTS As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage. CONCLUSION Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.
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Affiliation(s)
- Ankit Dalal
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Chaiti Gandhi
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Gaurav Patil
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Nagesh Kamat
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Sehajad Vora
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
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6
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Syrén EL, Sandblom G, Enochsson L, Eklund A, Isaksson B, Österberg J, Eriksson S. Outcome of ERCP related to case-volume. Surg Endosc 2022; 36:5339-5347. [PMID: 34981237 PMCID: PMC9160106 DOI: 10.1007/s00464-021-08915-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Abstract
Background and aims In some studies, high endoscopic retrograde cholangiopancreatography (ERCP) case-volume has been shown to correlate to high success rate in terms of successful cannulation and fewer adverse events. The aim of this study was to analyze the association between ERCP success and complications, and endoscopist and centre case-volumes. Methods Data were obtained from the Swedish National Register for Gallstone Surgery and ERCP (GallRiks) on all ERCPs performed for Common Bile Duct Stone (CBDS) (n = 17,873) and suspected or confirmed malignancy (n = 6152) between 2009 and 2018. Successful cannulation rate, procedure time, intra- and postoperative complication rates and post-ERCP pancreatitis (PEP) rate, were compared with endoscopist and centre ERCP case-volumes during the year preceding the procedure as predictor. Results In multivariable analyses of the CBDS group adjusting for age, gender and year, a high endoscopist case-volume was associated with higher successful cannulation rate, lower complication and PEP rates, and shorter procedure time (p < 0.05). Centres with a high annual case-volume were associated with high successful cannulation rate and shorter procedure time (p < 0.05), but not lower complication and PEP rates. When indication for ERCP was malignancy, a high endoscopist case-volume was associated with high successful cannulation rate and low PEP rates (p < 0.05), but not shorter procedure time or low complication rate. Centres with high case-volume were associated with high successful cannulation rate and low complication and PEP rates (p < 0.05), but not shorter procedure time. Conclusions The results suggest that higher endoscopist and centre case-volumes are associated with safer ERCP and successful outcome.
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Affiliation(s)
- Eva-Lena Syrén
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden. .,Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden. .,Department of Surgery, Akademiska Hospital, Uppsala, Sweden.
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Arne Eklund
- Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden.,Department of Surgery, Hospital of Västmanland, Västerås, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, 751 35, Uppsala, Sweden.,Department of Surgery, Akademiska Hospital, Uppsala, Sweden
| | - Johanna Österberg
- Department of Surgery, Mora Hospital, Mora, Sweden.,Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Staffan Eriksson
- Centre for Clinical Research, Uppsala University, Region Västmanland, Uppsala, Sweden.,Department of Surgery, Hospital of Västmanland, Västerås, Sweden
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7
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Flumignan VK, Seike MG, Souza VSD, Cirqueira MI, Silva AB, Artifon ELDA. DIFFICULT BILIARY CANNULATION: SHOULD WE ALWAYS TRY A SECOND ERCP AFTER A FAILED NEEDLE-KNIFE FISTULOTOMY? ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:509-513. [PMID: 34909858 DOI: 10.1590/s0004-2803.202100000-91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/14/2021] [Indexed: 05/06/2023]
Abstract
BACKGROUND A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.
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8
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Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique? GASTROENTEROLOGY INSIGHTS 2021. [DOI: 10.3390/gastroent12040039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.
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9
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Bill JG, Ryou M, Hathorn KE, Cortes P, Maple JT, Al-Shahrani A, Lang G, Mullady DK, Das K, Cosgrove N, Salameh H, Kumta NA, DiMaio CJ, Zia H, Orr J, Yachimski P, Kushnir VM. Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study. Surg Endosc 2021; 36:1362-1368. [PMID: 33712939 DOI: 10.1007/s00464-021-08418-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. METHODS We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. RESULTS 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. CONCLUSIONS EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA.
- University of Illinois College of Medicine - Peoria, 5105 North Glen Park Place, Peoria, IL, 61614, USA.
| | - Marvin Ryou
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Kelly E Hathorn
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Pedro Cortes
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Abdullah Al-Shahrani
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Gabriel Lang
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Koushik Das
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Natalie Cosgrove
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | | | | | | | | | | | | | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
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10
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Al manasra ARA, Jadallah K, Aleshawi A, Al-Omari M, Elheis M, Reyad A, Fataftah J, Al-Domaidat H. Intractable Biliary Candidiasis in Patients with Obstructive Jaundice and Regional Malignancy: A Retrospective Case Series. Clin Exp Gastroenterol 2021; 14:83-89. [PMID: 33707962 PMCID: PMC7941053 DOI: 10.2147/ceg.s301340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series. METHODS We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures - obtained by PTC - for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed. RESULTS A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy. CONCLUSION We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).
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Affiliation(s)
- Abdel rahman A Al manasra
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Jadallah
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Abdelwahab Aleshawi
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mamoon Al-Omari
- Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mwaffaq Elheis
- Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmad Reyad
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Jehad Fataftah
- Department of Radiology, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Hamzeh Al-Domaidat
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Lee SH, Lee JM, Han NY, Kim MJ, Park BJ, Sung DJ, Sim KC. Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis. Acta Radiol 2020; 61:1484-1493. [PMID: 32208743 DOI: 10.1177/0284185120909334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important. PURPOSE To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation. MATERIAL AND METHODS A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation. RESULTS Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy. CONCLUSION The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.
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Affiliation(s)
- Sun Hwa Lee
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Min Lee
- Department of Internal Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Na Yeon Han
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ju Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Beom Jin Park
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Deuk Jae Sung
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ki Choon Sim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, Hult M, Lindström O, Laine S, Karjula H, Hauge T, Sadik R, Arnelo U. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019; 90:957-963. [PMID: 31326385 DOI: 10.1016/j.gie.2019.07.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Leena Kylänpää
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Grönroos
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Arto Saarela
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Mari Hult
- Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Outi Lindström
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Karjula
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Riadh Sadik
- Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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Kim J, Lee JS, Kim EJ, Kim YS, Cho JH. The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:168-172. [PMID: 29566478 DOI: 10.4166/kjg.2018.71.3.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.
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Affiliation(s)
- Joonhwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jun Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Eui Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeon Suk Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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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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A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review. Am J Gastroenterol 2017; 112:537-554. [PMID: 28139655 PMCID: PMC5659272 DOI: 10.1038/ajg.2016.610] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/01/2016] [Indexed: 12/11/2022]
Abstract
In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.
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Laparoscopic management after failed endoscopic stone removal in nondilated common bile duct. Int J Surg 2016; 29:49-52. [DOI: 10.1016/j.ijsu.2016.03.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 03/13/2016] [Accepted: 03/17/2016] [Indexed: 01/17/2023]
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Nalankilli K, Kannuthurai S, Moss A. A modern approach to ERCP: maintaining efficacy while optimising safety. Dig Endosc 2016; 28 Suppl 1:70-6. [PMID: 26684277 DOI: 10.1111/den.12592] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and complications such as post-ERCP pancreatitis (PEP) remain a concern. Modern ERCP techniques aim to maintain efficacy and improve safety. There are limited data regarding efficacy and safety of ERCP carried out by a newly qualified practitioner using modern techniques. The aim of the present study was to conduct an ERCP practice audit and compare it with an Australian national survey in order to review the evidence base underlying modern ERCP practice. METHODS All ERCP carried out by a newly qualified practitioner, using prospectively collected data, from September 2011 to May 2015, were audited. Outcomes were compared to an Australia-wide survey of ERCP practice. A literature review was carried out regarding recent developments in ERCP practice. RESULTS Audit results correlated well with national data. All 478 ERCP were therapeutic and had pre-procedure imaging. Wire-guided biliary cannulation was used. Success rate was 97%. Overall adverse-event rate was 0.8%. Choledocholithiasis was the predominant indication (72%). Biliary cannulation was successful in 338 of 348 naiive papillae. Of these, there were 53 (16%) difficult cannulations but the needle-knife sphincterotomy (NKS) rate was low compared to national data (13% vs 33%). Rate of dual-wire cannulation technique was higher (87% vs 30%). Pancreatic duct stenting (done in 32 cases [70% of dual-wire cannulation cases]) and rectal indomethacin (25%) were used to reduce PEP risk. CONCLUSIONS A newly qualified ERCP proceduralist achieved high success rates with minimal adverse events using modern techniques. Practice was consistent with national data, although dual-wire cannulation technique was preferred to NKS. Evidence base for modern ERCP techniques was reviewed. ERCP efficacy and safety should be monitored by practice audit.
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Affiliation(s)
- Kumanan Nalankilli
- Department of Endoscopic Services, Western Health, Melbourne,, Australia
| | | | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne,, Australia.,Western Clinical School, University of Melbourne, Melbourne, Australia
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Abstract
GOALS The aim of this study was to assess the cumulative radiation exposure incurred by patients when using single-frame fluoroscopy. BACKGROUND Single-frame fluoroscopy is a technique that can be used instead of pulsed fluoroscopy or continuous live fluoroscopy to minimize radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP). STUDY We retrospectively reviewed ERCPs performed at our academic medical center. We recorded fluoroscopy time (FT, minutes), total radiation dose (mGy), dose area product (DAP, Gy cm²), and effective dose (ED, mSv). ERCP degree of difficulty was graded based on procedure complexity level. RESULTS There were 400 ERCP procedures performed on 210 patients, 32 ERCPs were unsuccessful. The mean FT for all procedures was 1.57 minutes (median, 1.2 min); the mean FT for complexity score 1 procedures (0.78 min) was significantly shorter than for all other procedures (P<0.0001). The mean total radiation dose delivered for all procedures was 23.02 mGy (median, 14.95 mGy). The total radiation dose for complexity score 1 procedures (13.15 mGy) was significantly lower than for all other complexity scores (P<0.0001). The mean total DAP was 3.62 Gy cm² and the mean ED was 0.94 mSv. Procedure complexity score 1 DAP (2.1 Gy cm²) and ED (0.55 mSv) were significantly lower than for all other procedures (P<0.0001 for both). There was no statistically significant difference in these parameters when comparing successful and unsuccessful procedures. CONCLUSIONS Successful ERCP can be performed using single-frame fluoroscopy only. Our results demonstrate lower radiation exposure using this technique than what is reported in the literature.
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Reply: To PMID 23313840. Clin Gastroenterol Hepatol 2013; 11:1524. [PMID: 23954645 DOI: 10.1016/j.cgh.2013.08.004] [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: 02/07/2023]
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Swan MP, Alexander S, Moss A, Williams SJ, Ruppin D, Hope R, Bourke MJ. Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation. Clin Gastroenterol Hepatol 2013; 11:430-436.e1. [PMID: 23313840 DOI: 10.1016/j.cgh.2012.12.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. METHODS We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. RESULTS Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. CONCLUSIONS Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.
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Affiliation(s)
- Michael P Swan
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
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Paik KY, Kim EK. Laparoscopic Common Bile Duct Exploration After Unsuccessful Endoscopic Stone Removal. J Laparoendosc Adv Surg Tech A 2013; 23:137-40. [DOI: 10.1089/lap.2012.0331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Eung Kook Kim
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Löhr JM, Aabakken L, Arnelo U, Grönroos J, Halttunen J, Hauge T, Jonas E, Kleveland PM, Nordblad Schmidt P, Swahn F, Saarela A, Toth E, Meisner S, Meisner S. How to cannulate? A survey of the Scandinavian Association for Digestive Endoscopy (SADE) in 141 endoscopists. Scand J Gastroenterol 2012; 47:861-9. [PMID: 22512404 DOI: 10.3109/00365521.2012.672588] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cannulation of the papilla vateri represents an enigmatic first step in endoscopic retrograde cholangiopancreaticography (ERCP). In light of falling numbers of (diagnostic) ERCP and novel techniques, e.g. short-wire system, we were interested in the approach novice and experienced endoscopist are taking; especially, what makes a papilla difficult to cannulate and how to approach this. We devised a structured online questionnaire, sent to all endoscopists registered with SADE, the Scandinavian Association for Digestive Endoscopy. A total of 141 responded. Of those, 49 were experienced ERCP-endoscopists (>900 ERCPs). The first choice of cannulation is with a sphincterotome and a preinserted wire. Both less experienced and more experienced endoscopists agreed on the criteria to describe a papilla difficult to cannulate and both would choose the needle-knife sphincterotomy (NKS) to get access to the bile duct. The less experienced used more "upward" NKS, whereas the more experienced also used the "downward" NKS technique. This survey provides us with a database allowing now for a more differentiated view on cannulation techniques, success, and outcome in terms of pancreatitis.
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Affiliation(s)
- J-Matthias Löhr
- Gastrocentrum Kirurgi, Karolinska Universitetssjukhuset, Stockholm, Sweden.
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