Novel 8-wire basket catheter is useful for endoscopic removal of common bile duct stones up to 10 mm: A multicenter prospective study

BACKGROUND/PURPOSE

Endoscopic treatment of common bile duct (CBD) stones involves the use of basket or balloon catheters; however, what is the appropriate device remains controversial. In this study we aimed to prospectively evaluate the usefulness of a novel 8-wire helical basket (8WB) catheter made of Nitinol for the removal of CBD stones ≤10 mm.

METHODS

We conducted a multicenter prospective trial. Patients with CBD stones ≤10 mm were enrolled. The primary endpoint was the rate of complete stone removal within 10 min using the 8WB. The number of cases was determined using a previous study of stone removal by a conventional basket catheter as a historical control.

RESULTS

A total of 155 patients were enrolled and 139 were ultimately included in the analysis. Patients with a single stone were the most common (84 cases, 60.4%), with a median maximum stone diameter of 5 mm. The median stone removal time using the 8WB was 6 min. The complete stone removal rate was 95.0% (132/139). Adverse events were observed in 14 patients (10.1%).

CONCLUSIONS

The novel 8WB catheter is useful in the treatment of CBD stones ≤10 mm, presenting a high complete stone removal rate in this study.

TRIAL REGISTRATION NUMBER

jRCT1032200324.

Outcomes of endoscopic papillectomy of ampullary carcinoma and factors affecting additional surgery

BACKGROUND/PURPOSE

Data on the prognosis of endoscopic papillectomy (EP) for ampullary carcinoma (AC) is limited; therefore, we aimed to identify the factors associated with endoscopically controlled AC.

METHODS

Between January 2003 and October 2022, 75 patients underwent EP for ampullary tumors and were diagnosed with AC based on the pathological features of the resected tissue. The factors associated with additional surgery after EP were also evaluated.

RESULTS

A total of 67 patients had ACs ranging from carcinoma in situ to tumors limited to the mucosa (M group), and eight patients had ACs ranging from those limited to the sphincter of Oddi to those invading the duodenal muscularis propria (OD group). The 3-year endoscopic tumor control (condition not requiring additional surgery) rates in the M and OD groups were 90.8% and 84.6% (p = .033), respectively. In the M group, the presence of tumor components in the resection margins was the only significant factor associated with additional surgeries (p = .010) in the univariate analysis. The 3-year endoscopic tumor control rates were 100% for negative and uncertain resection margins and 76.6% for positive margins (p = .009).

CONCLUSIONS

If the AC is confined to the mucosa and the resection margins are negative or uncertain, the tumor can be well-controlled endoscopically.

Cholecystectomy and ERCP in pregnancy: a nationwide register-based study

OBJECTIVE

The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age.

SUMMARY BACKGROUND DATA

Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients.

METHODS

Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed.

RESULTS

A total of 21 328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up.

CONCLUSION

Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.

Sphincter of Oddi dysfunction that could not be diagnosed with Rome IV: a case report

A 30-year-old female patient presented with monthly episodes of severe intermittent upper abdominal pain, especially after consuming fatty meals. Over a period of 5 years, she visited the emergency department 21 times due to the intensity of the pain. Although the pain appeared consistent with biliary pain, both blood and imaging tests showed no abnormalities. Despite not meeting the Rome IV criteria, we suspected sphincter of Oddi dysfunction (SOD). To further investigate, we conducted hepatobiliary scintigraphy (HBS), which revealed a clear delay in bile excretion. With the patient's informed consent, we performed endoscopic sphincterotomy (EST) and as of 10 months later, there have been no recurrences. This case demonstrates an instance of SOD that could not be diagnosed using the Rome IV criteria alone but was successfully identified through HBS. It underscores the possibility of hidden cases of SOD among patients who regularly experience severe epigastric pain, where routine blood or imaging tests may not provide a diagnosis. HBS may be a useful non-invasive test in confirming the presence of previously undiagnosed SOD. As SOD can be easily treated with EST, updating the current diagnostic criteria to include such types of SOD should be considered in the future.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Comparison of Outcomes between a Basket Catheter and a Balloon Catheter for Endoscopic Common Bile Duct Stone Removal

INTRODUCTION

Evidence for the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) between a basket catheter and a balloon catheter for endoscopic common bile duct stone (CBDS) removal is lacking. This study aimed to compare ERCP outcomes using a basket catheter and a balloon catheter for endoscopic CBDS removal.

METHODS

This multicenter retrospective study included 904 consecutive patients with native papilla who underwent endoscopic stone removal for CBDS ≤10 mm using a basket catheter and/or a balloon catheter at three institutions in Japan. ERCP outcomes between the basket and balloon groups were compared using inverse probability of treatment weighting (IPTW) method.

RESULTS

ERCP-related adverse events occurred in 6.5% (29/449) and 7.7% (35/455) of patients in the basket and balloon groups, respectively (IPTW-adjusted p = 0.52). The incidences of post-ERCP pancreatitis, cholangitis, and perforation were similar in the basket and balloon groups (3.8% vs. 2.9%, 1.3% vs. 0.9%, and 0.7% vs. 0.7%, respectively). However, bleeding incidences were significantly higher in the balloon group than in the basket group (3.3% vs. 0.7%, IPTW-adjusted p = 0.012). Successful complete stone removal at one ERCP session using a single catheter was achieved in 17.8% (80/449) in the basket group and in 81.3% (370/455) in the balloon group (IPTW-adjusted p < 0.001).

DISCUSSION

A balloon catheter is more likely to complete stone extraction for CBDS ≤10 mm with a single catheter at one endoscopic stone removal session. However, the risk for post-ERCP bleeding is higher in the balloon group than in the basket group.

Comparison of the Efficacy of Endoscopic Radial Incision and Cutting Procedure and Endoscopic Balloon Dilation for Benign Anastomotic Stricture After Low Anterior Resection Combined With Preventive Loop Ileostomy in Rectal Cancer

BACKGROUND

Endoscopic radial incision and cutting procedure is a notable technique in the treatment of benign anastomotic strictures after low anterior resection in rectal cancer. However, the efficacy and safety of the endoscopic radial incision and cutting procedure and traditional endoscopic balloon dilation remain unknown.

OBJECTIVE

To compare the efficacy and safety of the endoscopic radial incision and cutting procedure and endoscopic balloon dilation in patients with anastomotic stricture after low anterior resection.

DESIGN

Rectal cancer patients with anastomotic stricture after low anterior resection combined with synchronous preventive loop ileostomy between January 2014 and June 2021 were retrospectively collected. These patients underwent the endoscopic radial incision and cutting procedure or endoscopic balloon dilation as an initial treatment. The clinicopathological baseline data of the patients, endoscopic surgery success rate, complications, and restricture rate were analyzed.

SETTINGS

This study was conducted at Nanfang Hospital in China.

PATIENTS

A total of 30 patients were eligible after reviewing the medical records. Twenty patients underwent endoscopic balloon dilation, and 10 patients underwent endoscopic radial incision and cutting procedure.

MAIN OUTCOME MEASURES

The adverse event rate and stricture recurrence rate.

RESULTS

There were no significant differences in patient demographics or clinical features. No adverse events occurred in either of the 2 groups. The mean operation time was 18.9 ± 3.6 minutes in the endoscopic balloon dilation group and 10.2 ± 3.3 minutes in the endoscopic radial incision and cutting procedure group ( p < 0.001). The stricture recurrence rates between the endoscopic balloon dilation group and the endoscopic radial incision and cutting procedure group were significantly different (44.4% vs 0%; p = 0.025).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

The endoscopic radial incision and cutting procedure is safe and more efficacious than endoscopic balloon dilation for anastomotic stricture after low anterior resection combined with synchronous preventive loop ileostomy in rectal cancer.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis

INTRODUCTION

Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.

METHODS

Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.

RESULTS

A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.

CONCLUSION

Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy for patients with gallbladder and common bile duct stones a meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to compare the efficacy and safety of laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) to determine which one provides a better outcome for patients with gallbladder and common bile duct stones.

MATERIALS AND METHODS

An electronic literature search was undertaken using Embase, Medline, PubMed, and Cochrane Library databases up to April 2022. For quality assessment of included studies, randomized controlled trials (RCTs) were assessed by utilizing the Jadad scale. The primary outcome includes surgical success rate, retained stone rate, stone clearance rate, major morbidity, and mortality. The second outcome includes conversion to open surgery rate, postoperative pancreatitis, bile leakage, cholangitis, hemorrhage, pneumonia, and surgical-site infection.

RESULTS

14 randomized controlled trials with 2,181 patients were included. No significant difference was seen between the two groups in terms of surgical success, stone clearance, retained stones, operation time, and total morbidity. LC-LCBDE had higher rate of bile leakage [relative risk (RR): 4.52; 95% confidence interval (CI): 2.19-9.31] and lower rate of postoperative pancreatitis (RR: 0.25; 95% CI: 0.13-0.46), cholangitis (RR: 0.17; 95% CI: 0.05-0.67), and hemorrhage (RR: 0.18; 95% CI: 0.07-0.42).

CONCLUSIONS

Both LC+LCBDE and LC+ERCP are safe, effective, and minimal-invasive treatments for concomitant gallbladder and CBD stones. LC-LCBDE was associated with comparable effects compared with LC+ERCP in terms of surgical success rate, stone clearance rate, retained stones rate, operation time, and total morbidity. At the same time, LC-LCBDE had a higher rate of bile leakage and a lower rate of postoperative pancreatitis, cholangitis, and hemorrhage.

[Recurrent acute pancreatitis secondary to sphincter of oddi dysfunction: Case report]

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Design and execution of sham-controlled endoscopic trials in acute pancreatitis: Lessons learned from the SHARP trial

Using the ongoing NIDDK-funded multicenter randomized clinical trial, Sphincterotomy for Acute Recurrent Pancreatitis (SHARP) as an example, this article discusses the rationale and key aspects of study design that need to be considered when conducting a clinical trial of endoscopic therapy in acute pancreatitis. SHARP, the first trial using a sham ERCP in the placebo group, is designed to address a decades long controversy in clinical pancreatology, i.e. whether minor papilla sphincterotomy benefits patients with idiopathic acute recurrent pancreatitis who also have pancreas divisum. Although the trial has already enrolled and randomized over 5 times the number of subjects enrolled in the only randomized trial in this area published in 1992 (107 vs. 19), recruitment has been challenging and we are at ∼46% of target recruitment. The review discusses the challenges in the execution of the trial and strategies the SHARP team has used to address these, which investigators planning or considering treatment trials in pancreatitis may find helpful. It will also inform the general gastroenterologists the importance of discussing and referring potentially eligible subjects to centers participating in clinical trials. Developing evidence-based treatment will provide a solid scientific basis for physicians to recommend evidence-based treatments for pancreatitis.

Ectopic Opening of Common Bile Duct into Duodenal Bulb and Gastric Antrum and Its Importance

BACKGROUND

Ectopic opening of the common bile duct (CBD) is extremely rare, and its importance has not been adequately defined. The aim of our study is to present the characteristics of patients with this abnormality.

METHODS

This retrospective study was conducted in a tertiary center in Dicle University Hospital, Diyarbakır, Turkey, between October 2008 and December 2020. We present clinical, laboratory, endoscopic and cholangiographic features as well as the success rate of therapeutic interventions of consecutive patients with this abnormality undergoing endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Ectopic opening of the CBD was identified in 29 (21 men; mean age 62) out of 3872 (0.74%) patients. There was a history of cholecystectomy in 14 (48%) and recurrent acute cholangitis in 20 (69%) patients. We found peptic ulcer in 13 (45%) and duodenal deformity associated with apical stenosis in 21 (72%) patients. Opening site was seen as abnormal in all patients, and it opened into the antrum in 2 (6.8%) and into the first part of the duodenum in 27 (93%) patients. Copious amount of bile and/ or bile sediment in the stomach were seen in all patients. We observed dilatation in both intrahepatic and extrahepatic bile ducts together with tapered narrowing and a hook-shaped distal end of CBD in all patients. There was bile stone in 26 (89%) and sludge in 3 (10%) patients. Sphincterotomy was not performed in any patients because there was not enough incision distance. Balloon dilatation was performed for extraction of stone and sludge in all patients. Complete stone extraction was achieved in only 7 out of 26 (27%) patients.

CONCLUSION

Ectopic opening of CBD is usually associated with gastroduodenal and bile ducts disease. Endoscopic treatment is unsatisfactory in most patients with this abnormality.

Two Cases of Hemorrhagic Ampullary Lesions Successfully Treated by Endoscopic Papillectomy

We herein report two cases of hemorrhagic ampullary lesions in which endoscopic papillotomy was performed to control bleeding and resulted in successful treatment. Both patients were pathologically diagnosed with an underlying pathology characterized by inflammatory cell infiltration and capillary proliferation. They also had disposing factors for bleeding, such as antithrombotic therapy and idiopathic thrombocytopenic purpura. Endoscopic treatment was selected because the risk of surgical resection was high due to the patients' hemorrhagic condition. Both patients were successfully treated without any serious adverse events and had an uneventful postoperative course with no relapse of bleeding.

[Pay attention to endoscopic diagnosis and treatment for confluence disease of pancreaticobiliary ducts]

The confluence of pancreaticobiliary ducts refers to the area between the end of common bile duct, the opening of main pancreatic duct and duodenal papilla. Those confluence diseases of pancreaticobiliary ducts will cause obstruction of biliary and pancreatic outflow tract, cholestasis, pancreatic juice deposition or pancreaticobiliary reflux, and thus induce gallstones, cholangitis, pancreatitis and other diseases. Endoscopic ampullary sphincterotomy is an important way to treat biliary and pancreatic diseases, but the length of incision is determined by the anatomy of Oddi sphincter. The endoscopic approach aims to relieve biliary and pancreatic outflow tract obstruction and pancreatic biliary reflux, and avoid enterobiliary reflux.

Management of Choledocholithiasis: Should We Remove the Bile Duct?

Retrieval of stone by endoscopic papillotomy, laparoscopic choledochotomy or open choledochotomy is the treatment of choice for choledocholithiasis. Published literature shows that the recurrence rate is 4% to 24% with existing method of treatment. We have treated 8 patients who admitted with recurrent choledocholithiasis in the department of Hepato-Biliary-Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh in the period of January 2016 to December 2019. None had intrahepatic duct abnormality or stones. All patients underwent either ERCP stenting, open choledocholithotomy or both 16 to 84 months back. Management policy is designed and outcome is observed on these patients. There were 3 males and 5 females; age ranges 18 to 60 years. The common bile duct (CBD) diameter of all patient ranges from 15 to 24mm. The shape of CBD is different from normal variant; S shaped, saculated, grossly dilated with terminal narrowing. Considering the anatomical abnormality and recurrence of disease we have removed the abnormal part of common bile duct along with stones and the operation was completed by Roux-en-Y hepaticojejunostomy. All patients were completely symptom free for 6 to 48 months after surgery. Removal of abnormal part of common bile duct with reconstruction in the form of Roux-en-Y hepatico-jejunostomy may be considered for treating choledocholithiasis with abnormal CBD (abnormally dilated, abnormally shaped, angulated or sacculated) however, long-term follow up is required for final comment.

What makes acute cholecystitis recur after removing the percutaneous cholecystostomy tube?

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment option for acute cholecystitis. However, the disease may recur after PTGBD catheter removal. This study aimed to evaluate the role of endoscopic sphincterotomy and other risk factors in reducing the recurrence of cholecystitis.We retrospectively analyzed data from 1088 patients who underwent PTGBD for cholecystitis at Kyungpook National University Hospital, Republic of Korea, between January 2011 and April 2018.A total of 115 patients were enrolled in the study. The recurrence rate of cholecystitis was 17.4% (n = 20) during a median follow-up period of 1159 (range, 369-2774) days. Endoscopic biliary sphincterotomy did not significantly affect the recurrence rate of cholecystitis (P = .561). In multivariable analysis, cystic duct stones (P = .013) and PTGBD catheter migration before the prescheduled removal time (P = .002) were identified as independent risk factors for cholecystitis recurrence after PTGBD.To reduce post-PTGBD recurrence in cholecystitis, caution must be exercised to avoid inadvertent dislodging of the PTGBD catheter. In cases of cholecystitis with cystic duct stones, cholecystectomy should be considered only after careful assessment of postoperative risks. Instead, transluminal endoscopic gallbladder drainage could represent a promising option for the prevention of recurrent cholecystitis.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938-3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons.

METHODS

A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality.

RESULTS

The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis.

CONCLUSION

A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.

Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

BACKGROUND AND AIMS

Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons.

METHODS

We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence.

RESULTS

Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively).

CONCLUSIONS

Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation.

[A Slight Change of Cholangiography Revealed Papillary Carcinoma of the Duodenum after Endoscopic Sphincterotomy(EST)]

A 79-year-old woman with chillness and nausea was admitted to our hospital. CT findings displayed a common extended bile duct with stacked stones and duodenal diverticulosis. The diagnosis was cholangitis with choledocholithiasis. She underwent endoscopic retrograde cholangiopancreatography(ERCP)to remove the common bile duct stones. Thereafter, she developed cholangitis several times without any obvious cause of biliary obstruction. A careful follow-up was continued using ERCP, and finally, a slightly irregular edge of the distal common bile duct was observed. Subsequently, bile duct brush cytology revealed adenocarcinoma. The final diagnosis was distal cholangiocarcinoma. An operation was performed and the pathological diagnosis of papillary carcinoma of the duodenum invading the common bile duct was made. We reviewed the first ERCP image findings retrospectively and noticed an abnormal papillary of the duodenum. We could not evaluate the papilla after endoscopic sphincterotomy(EST). We learned 2 important things. The first is to carefully observe naïve papilla, and the second is to pay attention to a slight change of cholangiography.

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is an inflammatory process characterized by irreversible morphological changes in the pancreas. Pain is the predominant symptom observed during the course of CP. The etiopathogenesis of pain in CP is multifactorial and includes ductal hypertension due to obstruction of the pancreatic duct (PD), neuropathic causes, and extrapancreatic complications of CP like pseudocyst and distal biliary obstruction. A sizeable proportion of patients with CP are amenable to endoscopic treatment. The mainstay of endotherapy includes decompression of PD with one or more plastic stents in those with stricture, and fragmentation of PD calculi using extracorporeal shock wave lithotripsy. Nearly two-thirds of the patients achieve pain relief in the long term with endotherapy. Upfront assessment for the suitability of endotherapy is paramount to achieve the best outcomes. The predictors of poor response to endotherapy include multifocal disease, like those with multifocal strictures or multiple calculi throughout the pancreas, or a combination of both PD strictures and stones. With the emerging use of covered metal stents, the outcomes are likely to improve in cases with refractory PD strictures as well as CP-related distal biliary obstruction. The optimum stent design and indwell time of metal stents in cases with refractory PD strictures need further evaluation. Endoscopic ultrasonography has emerged as a complementary endoscopic modality in the management of CP as well as associated complications like pseudocysts, refractory pain, and vascular complications.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Long-term Outcomes of Therapeutic Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients ≥90 Years Old: A Multicenter Retrospective Study

Objective The safety and prognosis of complete stone removal for the treatment of choledocholithiasis in older patients are unknown. This multicenter retrospective study assessed the outcomes of complete stone removal in elderly patients (≥90 years) with respect to the prognosis. Methods We divided patients who underwent endoscopic cholangiopancreatography for choledocholithiasis into two groups: complete stone removal or incomplete stone removal with plastic stent insertion. The patient characteristics, adverse events, number of endoscopic cholangiopancreatographies, overall survival rates, and disease-specific cumulative death were compared between the groups. Patients Two hundred and twenty-three participants ≥90 years old were included in the study, including 48 (22%) men and 175 (78%) women. The median age was 92 (range, 90-104) years old. There were 160 (72%) and 63 (28%) patients in the complete and incomplete groups, respectively. Results The age, performance status, comorbidities, severe complication rates, and stone diameter were comparable between the groups. The proportion of patients with at least 5 stones was significantly higher in the incomplete group than in the complete group [complete group: 8.1% (13/160) and incomplete group: 21% (13/63), p<0.01]. The overall survival rate was significantly higher in the complete group (p<0.01), while the disease-specific cumulative death rate was higher in the incomplete group (p<0.01). Conclusion Complete stone removal for choledocholithiasis may contribute to a better prognosis in elderly patients ≥90 years old.

[Association between the type of major duodenal papilla and difficult biliary cannulation in a private tertiary center]

INTRODUCTION

Difficult cannulation in cases of endoscopic retrograde cholangiopancreatography (ERCP) could be associated with several factors, including: type of major papilla, however, there are limited data regarding this possible association.

OBJECTIVES

To determine the association between the type of papilla and difficult biliary cannulation.

MATERIALS AND METHODS

A retrospective cross-sectional analytical study was conducted in patients over 18 years old who underwent ERCP on papilla naive, from July 2019 to April 2021, in a private institution. Unsuccessful cannulations were excluded. The papilla was classified based on Haraldsson classification. The crude association and adjusted for possible confounders between the type of papilla and difficult cannulation was evaluated. Relative risks (RR) and 95% confidence intervals were calculated.

RESULTS

188 patients were included. The mean age was 55 years, 66% female. The most frequent indication was choledocholithiasis with 88.5%. The most frequent type of major duodenal papilla was type 1 (32%), followed by type 3 (27%), type 2 (25%) and type 4 (16%). Type 2, 3, 4 papillae showed a significant relationship with difficult cannulation compared to type 1 (p<0.001, p<0.001 and p=0.008 respectively). The indication other than choledocholithiasis also showed a significant relationship with difficult cannulation (p<0.001). In the adjusted analysis, the RR for difficult cannulation compared to type 1 papilla was: 2.51 (95% CI 1.23-5.94) for type 2 papilla, 3.72 (95% CI 1.79-7.71) for papilla type 3 and 3.41 (95% CI 1.54-7.71) for type 4. Theindication other than choledocholithiasis was also associated with a higher risk of difficult cannulation with a RR of 2.36 (95% CI 1.57-3.56). The fistulotomy type precut was used more frequently in the type 3 papilla (46%), while the use of cannula was more frequent in the type 4 papilla (29.6%).

CONCLUSIONS

Papilla types 2, 3 and 4 are associated with a higher risk of difficult cannulation. This should be considered when performing ERCP in order to reduce the risk of complications.

[Effectiveness of simulation in endoscopic retrograde cholangiopancreatography (ERCP) for successful bile duct cannulation: systematic review and meta-analysis]

INTRODUCTION

The evidence for simulation in endoscopic retrograde cholangiopancreatography is limited.

OBJECTIVE

The objective of this study is to review the effectiveness of simulation in endoscopist training in endoscopic retrograde cholangiopancreatography with emphasis on the successful cannulation of the bile duct, as well as on the cannulation time and performance evaluation.

MATERIALS AND METHODS

A systematic review was conducted in MEDLINE, EMBASE, and Web of Science, from 1970 to June 2021. Randomized clinical studies comparing endoscopic retrograde cholangiopancreatography simulated training versus traditional training were included.

RESULTS

4 studies were included, with a total of 80 participants and 1,475 procedures. The odds ratio (OR) for successful bile duct cannulation with the use of simulation was 2.12 (95% CI, 1.60-2.81) and the mean time to cannulation was shorter compared to traditional training (p<0.001). Two studies found a better score in the global performance of endoscopists with simulated training (OR: 1.86 (95% CI 1.29-2.7)) and (OR2.98 (95% CI, 1.38-6.43).

CONCLUSIONS

Endoscopic retrograde cholangiopancreatography simulation can improve the performance of endoscopists in terms of time and successful bile duct cannulation.

[Difficult or Complex Bile duct stones in ERCP: Large Balloon Dilation and other stone management methods. Accumulated experience in a referral Endoscopic Center 2009- 2018.]

INTRODUCTION

Bile duct stones constitutes 20% of symptomatic gallbladder disease and difficult stones are one third of this. Endoscopic papillary large balloon dilation (EPLBD) with or without prior endoscopic sphincterotomy (EST) produces excellent outcomes for the treatment of complex or difficult common bile duct (CBD) stones, alone or combined with previous therapeutic options as mechanical lithotripsy (ML) and temporary or definitive stenting.

OBJECTIVES

Show success rate, complications and adverse events. Show that higher success rates are obtained combining ERCP techniques with no increase in complications.

MATERIALS AND METHODS

We evaluated the safety and therapeutic outcomes of EPLBD with vs. without EST and other combinations for the removal of difficult bile duct stones. We described our procedures for a decade and compare them with the previous decade without balloon dilation. Of 865 patients and procedures, 223 (25.78%) had difficult stones. Treatments where EPLBD with EST (n=183), EPLBD alone group (n=40). Additional modalities where required in 15.25% (n=34). These two groups were compared with respect to overall procedure-related adverse events, overall stone removal success rate, number of sessions required for complete stone removal, need for mechanical lithotripsy, temporal or definite stenting and total procedure time. Results Safety removal of stones was achieved in one session on 84.75% of cases with EPLBD. The incidence of adverse events was not significantly different between the groups (EPLBD alone vs. EPLBD with EST: overall adverse events 12.5% vs. 10.38% (including pain); pancreatitis 2.7% vs. 2.5%, p=0.62). Overall success similar, initial success similar, and the need for additional techniques were also similar between groups. Median total procedure time tended to be greater in the EPLBD alone group (20.5 minutes) than in the EPLBD with EST group. Conclusion DPBGD in ERCP allows bile duct stone extraction rates close to 99.65% (90% in previous decade) according to other reports of literature. Adverse events of EPLBD alone or with EST are similar between them and with classic ERCP without statistical difference and similar to other world series.

Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study

OBJECTIVE

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists.

MATERIALS AND METHODS

Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests.

RESULTS

The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications.

CONCLUSIONS

Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

BACKGROUND

At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period. 

AIM

To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.

METHODS

Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as “standard” or “advanced” and duodenoscope position was labeled as “standard” (short position) or “non-standard” (e.g., long, semi-long).

RESULTS

Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 (P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) (P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) (P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques (P < 0.03 for each).

CONCLUSION

Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

Morphology of the major papilla predicts ERCP procedural outcomes and adverse events

BACKGROUND

The morphology of the major papilla affects the difficulty of endoscopic retrograde cholangiopancreatography (ERCP), but no associations with adverse events have previously been established. We aimed to assess whether papillary morphology predicts ERCP adverse events.

METHODS

A retrospective analysis was performed of a prospective registry of patients undergoing ERCP for biliary indications. The primary outcome was post-ERCP pancreatitis (PEP), with secondary outcomes including other adverse events and procedural outcomes such as inadvertent pancreatic duct cannulation, cannulation time, and attempts. Papillae were classified as normal (Type I), small or flat (Type II), bulging (Type IIIa), pendulous (Type IIIb), creased (Type IV), or peri-diverticular (Type D). Outcomes were ascertained prospectively at 30 days from index procedures.

RESULTS

A total of 637 patients with native papillae were included. Compared to Type I papillae, Type II and Type IIIb papillae were associated with PEP, with adjusted odds ratios (AOR) of 7.28 (95% confidence intervals, CI, 1.84-28.74) and 4.25 (95% CI 1.26-14.32), respectively. Type II and IIIb papillae were associated with significantly longer cannulation times by 5.37 (95% CI 2.39-8.35) and 4.01 (95% CI 1.72-6.30) minutes, respectively. Type IIIb papillae were associated with lower deep cannulation success (AOR 0.17, 95% CI 0.06-0.48).

CONCLUSION

Papillary morphology is an important factor influencing both ERCP success and outcomes. Understanding this is key for managing intraprocedural approaches and minimizing adverse events.

PROSPECTIVE REGISTRY REGISTRATION

Clinicaltrials.gov identifier NCT04259580.