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Bényei E, Molinaro A, Hedenström P, Sadik R. The additional value of the combined use of EUS and ERCP for the evaluation of unclear biliary strictures. Scand J Gastroenterol 2024; 59:980-988. [PMID: 38821116 DOI: 10.1080/00365521.2024.2354403] [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: 11/15/2023] [Revised: 04/26/2024] [Accepted: 05/07/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Assessing unclear biliary strictures is challenging. We analyzed the diagnostic performance of radiology, EUS, and ERCP. METHODS All patients referred for EUS and ERCP to assess an unclear biliary stricture were prospectively included. The data from radiology, EUS, ERCP, and tissue sampling were recorded. The diagnostic modalities were analyzed separately and in combination, with a focus on PSC. RESULTS Between 2013 and 2020, 78 patients were included; 31% had PSC. A cholangioscopy was not performed in this study. The final diagnosis indicated that the biliary stricture was benign in 62% of the patients and malignant in 38%. The differences among the modalities were numerical, not significant. The modalities showed an accuracy between 78 and 83% in all the patients and between 75 and 83% in the patients with PSC. The combination of radiology and EUS showed the highest sensitivity of 94% in all the patients and a sensitivity of 100% in PSC. Tissue sampling showed the highest specificity of 93% in all patients and 89% in PSC. In 22 cases with combined EUS, ERCP, and tissue sampling, the accuracy, sensitivity, and specificity were 82%, 70%, and 92%, respectively. Minor differences were observed between the intention-to-diagnose analysis and the per-protocol analysis. Adverse events were recorded in 4% of cases. CONCLUSION The combination of EUS and ERCP with tissue sampling seems to be useful and safe for excluding malignancy in unclear biliary strictures. In cases with a reduced suspicion of malignancy, radiology with an EUS may be sufficient.
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Affiliation(s)
- Eszter Bényei
- Department of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
| | - Antonio Molinaro
- Department of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
| | - Per Hedenström
- Department of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
| | - Riadh Sadik
- Department of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
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Vila JJ, Jusué Irurita V, Rullán Iriarte M. Is ERCP still the elective primary biliary drainage technique in patients with malignant distal biliary obstruction? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:182-185. [PMID: 38095214 DOI: 10.17235/reed.2023.10029/2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been established as the first line therapy for the resolution of biliary and pancreatic diseases. The main disadvantage of the procedure is the rate of adverse events, around 10%1. So, despite being a minimally invasive procedure, ERCP has a non-negligible rate of adverse effects (AEs) and secondary mortality.
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Affiliation(s)
- Juan J Vila
- Endoscopy Unit. Gastroenterology Department, Hospital Universitario de Navarra, España
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3
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Mauro A, Binda C, Fugazza A, Vanella G, Mirante VG, Mazza S, Scalvini D, Tarantino I, Fabbri C, Anderloni A. Italian Survey on Endoscopic Biliary Drainage Approach in Patients with Surgically Altered Anatomy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:472. [PMID: 38541198 PMCID: PMC10972116 DOI: 10.3390/medicina60030472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/04/2024] [Accepted: 03/09/2024] [Indexed: 07/01/2024]
Abstract
Background and Objectives: Biliary drainage (BD) in patients with surgically altered anatomy (SAA) could be obtained endoscopically with different techniques or with a percutaneous approach. Every endoscopic technique could be challenging and not clearly superior over another. The aim of this survey is to explore which is the standard BD approach in patients with SAA. Materials and Methods: A 34-question online survey was sent to different Italian tertiary and non-tertiary endoscopic centers performing interventional biliopancreatic endoscopy. The core of the survey was focused on the first-line and alternative BD approaches to SAA patients with benign or malignant obstruction. Results: Out of 70 centers, 39 answered the survey (response rate: 56%). Only 48.7% of them declared themselves to be reference centers for endoscopic BD in SAA. The total number of procedures performed per year is usually low, especially in non-tertiary centers; however, they have a low tendency to refer to more experienced centers. In the case of Billroth-II reconstruction, the majority of centers declared that they use a duodenoscope or forward-viewing scope in both benign and malignant diseases as a first approach. However, in the case of failure, the BD approach becomes extremely heterogeneous among centers without any technique prevailing over the others. Interestingly, in the case of Roux-en-Y, a significant proportion of centers declared that they choose the percutaneous approach in both benign (35.1%) and malignant obstruction (32.4%) as a first option. In the case of a previous failed attempt at BD in Roux-en-Y, the subsequent most used approach is the EUS-guided intervention in both benign and malignant indications. Conclusions: This survey shows that the endoscopic BD approach is extremely heterogeneous, especially in patients with Roux-en-Y reconstruction or after ERCP failure in Billroth-II reconstruction. Percutaneous BD is still taken into account by a significant proportion of centers in the case of Roux-en-Y anatomy. The total number of endoscopic BD procedures performed in non-tertiary centers is usually low, but this result does not correspond to an adequate rate of referral to more experienced centers.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy; (S.M.); (D.S.); (A.A.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy; (C.B.); (C.F.)
| | - Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
- IRCCS San Raffaele Scientific Institute, Pancreatobiliary Endoscopy and Endosonography Division, 20132 Milan, Italy
| | - Vincenzo Giorgio Mirante
- Gastroenterology and Digestive Endoscopy Unit, Azienda USL—IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy; (S.M.); (D.S.); (A.A.)
| | - Davide Scalvini
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy; (S.M.); (D.S.); (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, 90127 Palermo, Italy;
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy; (S.M.); (D.S.); (A.A.)
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4
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Spadaccini M, Giacchetto CM, Fiacca M, Colombo M, Andreozzi M, Carrara S, Maselli R, Saccà F, De Marco A, Franchellucci G, Khalaf K, Koleth G, Hassan C, Anderloni A, Repici A, Fugazza A. Endoscopic Biliary Drainage in Surgically Altered Anatomy. Diagnostics (Basel) 2023; 13:3623. [PMID: 38132207 PMCID: PMC10742737 DOI: 10.3390/diagnostics13243623] [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: 10/17/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures.
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Affiliation(s)
- Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Carmelo Marco Giacchetto
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Matteo Fiacca
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Marta Andreozzi
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Fabio Saccà
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
| | - Alessandro De Marco
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Gianluca Franchellucci
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Kareem Khalaf
- Department of Gastroenterology, Saint Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada;
| | - Glenn Koleth
- Hospital Sultan Ismail, Malaysian Ministry of Health, Johor Bahru 81100, Malaysia;
| | - Cesare Hassan
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.S.); (C.M.G.); (M.F.); (M.C.); (M.A.); (S.C.); (R.M.); (F.S.); (A.D.M.); (G.F.); (C.H.)
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5
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De Angelis CG, Dall’Amico E, Staiano MT, Gesualdo M, Bruno M, Gaia S, Sacco M, Fimiano F, Mauriello A, Dibitetto S, Canalis C, Stasio RC, Caneglias A, Mediati F, Rocca R. The Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound Connection: Unity Is Strength, or the Endoscopic Ultrasonography Retrograde Cholangiopancreatography Concept. Diagnostics (Basel) 2023; 13:3265. [PMID: 37892086 PMCID: PMC10606726 DOI: 10.3390/diagnostics13203265] [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: 07/29/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the "Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept", has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain.
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Affiliation(s)
- Claudio Giovanni De Angelis
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Eleonora Dall’Amico
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Maria Teresa Staiano
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Marcantonio Gesualdo
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Mauro Bruno
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Silvia Gaia
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Marco Sacco
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Federica Fimiano
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Anna Mauriello
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Simone Dibitetto
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Chiara Canalis
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Rosa Claudia Stasio
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Alessandro Caneglias
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Federica Mediati
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (M.G.)
| | - Rodolfo Rocca
- Gastroenterology Department, Mauriziano Hospital, 10128 Turin, Italy
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Giri S, Mohan BP, Jearth V, Kale A, Angadi S, Afzalpurkar S, Harindranath S, Sundaram S. Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis. Gastrointest Endosc 2023; 98:515-523.e18. [PMID: 37392952 DOI: 10.1016/j.gie.2023.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND AND AIMS Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD. METHODS A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model. RESULTS One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%). CONCLUSIONS Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Vaneet Jearth
- Department of Gastroenterology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davanagere, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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7
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Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy. Life (Basel) 2023; 13:life13020473. [PMID: 36836830 PMCID: PMC9962362 DOI: 10.3390/life13020473] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
The number and complexity of endoscopic gastrointestinal diagnostic and therapeutic procedures is globally increasing. Procedural analgosedation during gastrointestinal endoscopic procedures has become the gold standard of gastrointestinal endoscopies. Patient satisfaction and safety are important for the quality of the technique. Currently there are no uniform sedation guidelines and protocols for specific gastrointestinal endoscopic procedures, and there are several challenges surrounding the choice of an appropriate analgosedation technique. These include categories of patients, choice of drug, appropriate monitoring, and medical staff providing the service. The ideal analgosedation technique should enable the satisfaction of the patient, their maximum safety and, at the same time, cost-effectiveness. Although propofol is the gold standard and the most used general anesthetic for endoscopies, its use is not without risks such as pain at the injection site, respiratory depression, and hypotension. New studies are looking for alternatives to propofol, and drugs like remimazolam and ciprofol are in the focus of researchers' interest. New monitoring techniques are also associated with them. The optimal technique of analgosedation should provide good analgesia and sedation, fast recovery, comfort for the endoscopist, patients' safety, and will have financial benefits. The future will show whether these new drugs have succeeded in these goals.
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Role of endoscopic ultrasound in the evaluation of unexplained extrahepatic bile duct dilatation. Eur J Gastroenterol Hepatol 2023; 35:73-79. [PMID: 36468572 DOI: 10.1097/meg.0000000000002485] [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: 12/10/2022]
Abstract
OBJECTIVE This study was performed to assess the diagnostic performance of endoscopic ultrasonography (EUS) in patients with extrahepatic bile duct (EBD) dilatation and develop a novel model incorporating EUS-based signature with clinical parameters for distinguishing the malignant dilation of EBD. METHODS The EUS data and clinical parameters of the patients were collected and analyzed retrospectively. First, we evaluated the diagnostic performance of EUS in detecting the cause of EBD dilatation. Then, we performed univariate and multivariate binary logistic regression analyses based on clinical and EUS features. Finally, a nomogram was established to aid in distinguishing between malignant dilation and noncalculous benign dilatation of EBD in patients. RESULTS A total of 184 patients were enrolled. For the diagnosis of malignant dilation, EUS achieved an accuracy of 90.76%, sensitivity of 85.96%, and specificity of 92.91%. For the diagnosis of calculous dilation, EUS achieved an accuracy of 100%, sensitivity of 100%, and specificity of 100%. For the diagnosis of noncalculous benign dilatation, EUS achieved an accuracy of 90.76%, sensitivity of 90.90%, and specificity of 90.58%. Multivariable logistic regression analyses indicated that abnormal liver function test, elevated tumor markers, and EUS findings were the well-diagnostic factors of malignant EBD dilation. The nomogram established by these factors showed good calibration and discrimination. CONCLUSION EUS is a useful examinational modality in the work-up of EBD dilatation. In combination with abnormal liver function test and elevated tumor markers, EUS may provide additional information for the detection of malignant dilation of EBD and should be further investigated.
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Maaty MEGAE, Ibrahim AM, Soliman AH, Mohamed AH. Role of interventional radiology in management of post-liver transplant anastomotic complications. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [PMCID: PMC9344456 DOI: 10.1186/s43055-022-00853-6] [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: 01/10/2023] Open
Abstract
Background Liver transplantation is considered to be the treatment of choice in cases of end-stage liver disease; however, as a major procedure, the operation is fraught with complications. The etiology, symptoms, and diagnostic methods for arterial, portal, and biliary issues are thoroughly discussed. Interventional procedures such as balloon angioplasty and stent placement in the arterial and portal systems, as well as biliary interventional procedures, are described.
Results In our study, we reviewed 25 cases of post-living donor transplanted liver, with anastomotic complications including biliary stenosis 40%, hepatic vein stenosis 20%, portal vein stenosis 16%, biliary leakage 16%, and hepatic artery stenosis or pseudo-aneurysm 16%. We had 10 cases of biliary stenosis, 7 of which were successfully treated with the insertion of an internal/external drain, and one case failed. Two patients died. We had four cases of hepatic venous obstruction with successfully implanted stents and a perfect outcome, efficacy, and patency rate of 100%. We also had two cases of hepatic artery stenosis that were perfectly managed by stent placement, with a patency rate of 100%. We came across two cases of hepatic artery pseudo-aneurysm. One case failed due to large sac size, while the other was successful. Finally, in our study, we had a 100% success rate in 5 cases of portal vein stenosis in the early postoperative period.
Conclusions Percutaneous IR was effective treatment for hepatic vein occlusion, portal vein stenosis, hepatic artery stenosis, and anastomotic biliary stricture after living donor liver transplantation. The interventional radiology team is now an integral part of the multi-disciplinary care of transplant patients. As new interventional instruments are developed and experience is gained, the outcomes of interventional treatments will continue to improve.
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Vicini S, Bellini D. Indwelling biliary stent during Endoscopic Ultrasound-Guided Tissue Acquisition of pancreatic masses: Not necessarily a problem. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:850-851. [PMID: 35834664 DOI: 10.1002/jcu.23254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Simone Vicini
- Department of Radiological Sciences, Oncology and Pathology, "Sapienza" University of Rome - I.C.O.T. Hospital, Latina, Italy
| | - Davide Bellini
- Department of Radiological Sciences, Oncology and Pathology, "Sapienza" University of Rome - I.C.O.T. Hospital, Latina, Italy
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Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm. Medicina (B Aires) 2022; 58:medicina58030331. [PMID: 35334507 PMCID: PMC8951173 DOI: 10.3390/medicina58030331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Marco Spadaccini
- Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Rozzano, Digestive Endoscopy Unit, Milano, Italy,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milano), Italy
| | - Luigi Cugia
- Gastroenterology and Digestive Endoscopy Department, Azienda Ospedaliero Universitaria Sassari, Sassari, Italy
| | - Andrea Anderloni
- Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Rozzano, Digestive Endoscopy Unit, Milano, Italy,Address for correspondence Dr. Andrea Anderloni, Humanitas Clinical and Research Center – IRCCS, Digestive Endoscopy Unit, Via Manzoni 56, 20089 Rozzano Milano, Italy. E-mail:
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EUS and ERCP in the Same Session for Biliary Stones: From Risk Stratification to Treatment Strategy in Different Clinical Conditions. MEDICINA-LITHUANIA 2021; 57:medicina57101019. [PMID: 34684056 PMCID: PMC8539296 DOI: 10.3390/medicina57101019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89-94% and 94-95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients' outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis.
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