Endoscopic removal of a bile-duct stone using sphincterotomy and a large-balloon dilator in a patient with situs inversus totalis

Endoscopic retrograde cholangiopancreatography in a patient with complete situs inversus viscerum: A case report and literature review

Complete situs inversus viscerum (SIV) is a rare congenital condition, defined by a left‐right transposition of all viscera with dextroposition of the heart. In patients with SIV that requires endoscopic intervention, namely endoscopic retrograde cholangiopancreatography (ERCP), the left‐right coordination can be technically demanding even with skilled endoscopist. We report a case of a patient with underlying SIV who presented with septic shock secondary to ascending cholangitis compounded with a malaria infection. Despite the ascertainment of a relatively large Common Bile Duct (CBD) stone, ERCP and stenting were pursued as an initial treatment modality in view of the clinical presentation of cholangitis and COVID‐19‐related delays in surgical intervention at our center. This case is unique as the patient was maintained in a supine position throughout the procedure. The patient underwent a successful ERCP procedure followed by a CBD Exploration and cholecystectomy 2 weeks later. A key factor that contributed to the success of this procedure was the combined utilization of a rotatable sphincterotome and extractor balloon which assisted with cannulation and shortening manoeuvre of the duodenoscope to facilitate biliary stenting.

Laparoendoscopic rendezvous procedure in a patient with situs inversus totalis: A case report and review of the literature

Situs inversus totalis patients may be associated with difficulties in the diagnosis and treatment of surgical diseases. This case suggests that laparoendoscopic rendezvous procedure could be associated with a lower morbidity and length of hospital stay.

Successful removal of multiple bile duct stones using a papillary large balloon dilation in a very elderly woman with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly in which all viscera are transposed to the opposite side of the body. This uncommon anatomy causes technical difficulties in endoscopic treatment. A 98-year-old woman with SIT was admitted to our hospital complaining of upper abdominal pain and fever. Blood examinations and findings of abdominal computed tomography imaging confirmed the diagnosis of acute pancreatitis and cholangitis associated with biliary stones. After recovering from pancreatitis and cholangitis with conservative treatment, she underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to remove the common bile duct (CBD) stones. The patient and the endoscopist were positioned in the usual ERCP position, and the scope was inserted into the duodenum with an approach in the direction opposite to the routine practice. Biliary cannulation was performed in the direction of 1 o'clock, and the cholangiography showed remarkably dilated CBD filled with numerous stones. Endoscopic papillary large balloon dilation was performed, and the CBD stones were successfully removed. There were no complications, such as bleeding, pancreatitis, or perforation. Over 3 years of follow-up, she had no recurrence of cholangitis or pancreatitis.

Successful ERCP for management of traumatic pancreatic disruption in a patient with situs inversus

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for treatment of pancreaticobiliary diseases. However, ERCP may be difficult in patients who have altered gastrointestinal anatomy due to congenital or surgical reasons. A 40-year-old male with HIV infection presented with abdominal pain following abdominal trauma. The patient was diagnosed to have traumatic pancreatic injury and underlying situs inversus. The pancreatic fluid collection was drained using radiology guided pigtail placement done for the symptoms of abdominal pain and vomiting. The resulting external pancreatic fistula was successfully managed with ERCP and stenting. The patient improved with disappearance of ascites and resolution of pigtail output which was then removed. We report the technique used for ERCP in this patient. We also review the literature on pancreatic endotherapy in patients with situs inversus. The published literature suggests that with modifications in the standard ERCP technique like mirror image technique, 180 degree turn technique, left lateral technique etc. these patients can be managed successfully.

[Removal of Choledocholith by Endoscopic Retrograde Cholangiopancreatography in a Situs Invsersus Patient]

Situs inversus is an extremely rare autosomal recessive disease with left-right inversion of internal organs. It carries technical difficulties in diagnostic or therapeutic procedures. There have been a few case reports on stone extraction by ERCP in situs inversus patients. ERCP techniques in situs inversus can be classified into conventional method and mirror image method. In mirror image method, the procedure is performed with the patient in the right lateral decubitus position and the endoscopist on the patient's left side. Until now, there is no consensus about which method is better. Herein, we report an unusual case of choledocholithiasis in a patient with situs inversus who underwent ERCP for stone extraction by both conventional method and mirror image method.

Therapeutic endoscopic retrograde cholangiopancreatography in a patient with situs inversus viscerum

Situs inversus viscerum (SIV) is a rare congenital condition characterized by complete transposition of all viscera. This anatomical pathology makes endoscopic retrograde cholangiopancreatography (ERCP) technically difficult. We report a new case of a 70-year-old Chinese male with total SIV who had obstructive jaundice. Magnetic resonance cholangiopancreatography demonstrated a number of stones in the gallbladder and common bile duct (CBD). Therapeutic ERCP was performed to relieve biliary obstruction and remove the CBD stones. This procedure started with the patient in a supine position and the endoscopist at the left side of the table. When the papilla was maintained, the patient was repositioned to a prone position and standard endoscopic sphincterotomy and endoscopic papillary balloon dilatation procedures were conducted. ERCP was performed successfully and relevant complications did not occur in this patient. We also present a review of the literature published between 1985 and 2014 in the PubMed and EMBASE databases. There were eight published cases during this period, with one each from America, Finland, India, Italy, South Korea and Pakistan, and two from Spain. Our case is the first reported in China.

Endoscopic duodenal papillary balloon dilatation via fistula for treatment of patients with common bile duct stones and papillary choledochoduodenal fistula

AIM: To evaluate the efficacy and safety of endoscopic duodenal papillary balloon dilatation via fistula in the treatment of patients with common bile duct stones and papillary choledochoduodenal fistula.

METHODS: Twenty-eight patients with bile duct stones and papillary choledochoduodenal fistula who received endoscopic retrograde cholangiopancreatography (ERCP) examination from June 2009 to October 2014 at our hospital were divided into either an endoscopic sphincterotomy (EST) group or a balloon dilatation group to receive the two procedures, respectively. Clinical effects were compared for the two groups.

RESULTS: Stones were successfully removed in all patients. Bleeding occurred in four patients in the EST group and one in the balloon dilatation group. Perforation did not occur in either group. The operation time was longer in the EST group than in the balloon dilation group (P < 0.01). With regard to intraoperative complications, the balloon dilation group was better than the EST group (P < 0.05). Mild abdominal pain occurred in four patients in the EST group and one in the balloon dilation group. Fever occurred in one patient in the EST group and did not occur in the balloon dilation group. Delayed perforation, hemorrhage, severe acute pancreatitis, and suppurative cholangitis did not occur in either group. Postoperative complications in the two groups were different significantly (P < 0.05).

CONCLUSION: Endoscopic duodenal papillary balloon dilatation via fistula for treatment of patients with common bile duct stones and papillary choledochoduodenal fistula is safe and effective.

Clinical effectiveness of whole course staged health education for patients treated by endoscopic retrograde cholangiopancreatography

AIM: To explore the clinical effectiveness of whole course staged health education for patients treated by endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Forty-eight patients who underwent ERCP treatment from January 2013 to February 2014 at our hospital were selected as an observation group and given whole course staged health education, and 48 patients who underwent ERCP treatment from October 2011 to December 2012 at our hospital were selected as a control group and given conventional health education. Mood state before and after education, satisfaction to health education, length of hospital stay, and complications were compared for the two groups.

RESULTS: Before the education, the seven mood state dimensions did not differ significantly between the two groups (P > 0.05). After the education, fatigue and energy still had no significant difference between the two groups (P > 0.05), and the other five dimensions differed significantly (P < 0.05). In the observation group, energy and fatigue showed no significant difference before and after intervention (P > 0.05), while the other five dimensions differed significantly (P < 0.05). In the control group, tension had a significant difference between before and after the education (P < 0.05), while other six dimensions had no significant difference (P > 0.05). The percentages of patients who were satisfied with health education mode, health education content, nursing service attitude, and communication were also significantly higher in the observation group than in the control group (P < 0.05). The rate of complications was significantly lower in the observation group than in the control group (P < 0.05). Length of hospital stay was significantly shorter in the observation group (11.2 d ± 3.6 d) than in the control group (15.3 d ± 4.1 d) (P < 0.01).

CONCLUSION: Application of whole course staged health education can significantly reduce the length of hospital stay and the incidence of complications and improve patient's satisfaction to health education and patient's mental state in patients treated by endoscopic retrograde cholangiopancreatography.

Clinical effects of endoscopic sphincterotomy and papillary balloon dilation for treatment of obstructive jaundice

AIM: To assess the clinical effects of endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), alone or in combination, in the management of obstructive jaundice.

METHODS: A retrospective analysis was performed of the clinical data of 97 patients with obstructive jaundice treated at the First Affiliated Hospital of Shihezi University from January 2013 to August 2014.

RESULTS: The 97 patients were divided into three groups: an EST group (n = 55), an EPBD group (n = 8) and a small EST plus balloon dilatation (sEST + EPBD) group (n = 34). The clinical symptoms such as abdominal pain and jaundice were relieved obviously after these treatments. The success rate of first stone removal was significantly higher in the sEST + EPBD group than in the other two groups (P < 0.05). For choledocholithiasis with duodenal diverticula, the sEST + EPBD group also had a significantly higher success rate of stone removal than the EST group (P < 0.05). The EST group had a significantly lower rate of hyperamylasemia compared with the EPBD group (P < 0.05).

CONCLUSION: EST, EPBD, and sEST + EPBD are all effective for palliative treatment of biliary obstruction. sEST + EPBD is associated with a higher rate of stone removal and a lower incidence rate of postoperative complications, especially for patients with biliary anatomical changes such as duodenal diverticulum.

Clinical effectiveness of clinical nursing pathway for patients treated by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy

AIM: To analyze the clinical effectiveness of clinical nursing pathway (CNP) for patients treated by endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).

METHODS: Seventy-eight patients with extrahepatic gallstones treated at our hospital from September 2010 to August 2011 comprised a control group, and 98 patients with extrahepatic gallstones treated at our hospital from September 2011 to August 2011 comprised a treatment group. All patients received routine care, and the treatment group received CNP on the basis of routine care. Clinical effectiveness was observed and compared between the two groups.

RESULTS: The hospitalization duration, hospital costs and incidence of postoperative complications in the treatment group were significantly lower than those in the control group (P < 0.05). The rates of health knowledge awareness and satisfaction to care quality in the treatment group were significantly higher than those in the control group (95.9% vs 87.2%, 96.9% vs 87.2%, P < 0.05).

CONCLUSION: CNP is effective for patients treated by ERCP and EST.

Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

Endoscopic sphincterotomy plus balloon dilation for large bile duct stones: An analysis of 80 cases

AIM: To evaluate the therapeutic efficacy and safety of endoscopic sphincterotomy (EST) plus balloon dilation for large bile duct stones.

METHODS: Eighty patients with bile duct stones larger than 1.2 cm, who received endoscopic retrograde eholangiopancreatography (ERCP) from January 2010 to October 2011 at our hospital, were randomly and equally divided into two groups to receive EST and EST plus balloon dilation (ESBD), respectively. Balloon dilation was conducted after small EST in the ESBD group, while conventional EST was used in the EST group.

RESULTS: All stones were removed successfully from 36 patients (90%) of the EST group and 38 (95%) patients of the ESBD group. Mechanical lithotripsy was used to fragment stones in 15 (37.5%) EST procedures and 4 (10%) ESBD procedures. The operation time was longer in the EST group than in the ESBD group (41.78 ± 10.41 vs 36.28 ± 8.64, P < 0.05). Bleeding occurred in two patients of the EST group but not in patients of the ESBD group. Fever, abdominal pain, and acute pancreatitis developed in 1, 1 and 2 patients in the EST group, while abdominal pain and acute pancreatitis in 2 and 1 patients in the ESBD group, respectively. There is no significant difference in the incidence of early complications between the two groups (10% vs 7.5%, P > 0.05). No patient died.

CONCLUSION: ESBD is superior to EST in terms of operating time and the use of mechanical lithotripsy in managing large bile duct stones.