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Mohamed I, Naeem A, Hassan N, Jung D, Bader A, Gaur R, Yousaf A, Abosheaishaa H, Salem AE, Mohamed WT, Telbany A, Dahiya DS, Yusuke H. Comparative efficacy and safety of SpyGlass percutaneous transhepatic cholangioscopy versus conventional cholangioscopy in challenging biliary access: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2025; 37:523-533. [PMID: 39976014 DOI: 10.1097/meg.0000000000002909] [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] [Indexed: 02/21/2025]
Abstract
Percutaneous transhepatic cholangioscopy (PTCS) is essential for managing patients with altered biliary anatomy when endoscopic retrograde cholangiopancreatography fails. This study aimed to compare the safety and efficacy of conventional PTCS (C-PTCS) with the SpyGlass PTCS (S-PTCS) system in cases of challenging biliary access. A systematic review and meta-analysis included 12 studies with 998 patients. Results indicated that S-PTCS had a significantly higher clinical success rate of 99% [confidence interval (CI): 96-100%] compared to 84% (CI: 73-95%) for C-PTCS ( P < 0.01). Both techniques showed high technical success rates of 99% (CI: 96-100%) for S-PTCS and 98% (CI: 97-100%) for C-PTCS, with no significant difference ( P = 0.61). Safety outcomes, such as pain, liver ischemia, hemobilia, cholangitis, and bleeding, were low and similar across both techniques. These findings highlight the superior clinical success of S-PTCS in challenging biliary access cases while maintaining comparable safety profiles with C-PTCS.
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Affiliation(s)
- Islam Mohamed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Ahmed Naeem
- Department of Medicine, School of Medicine, Al-Azhar University, Asyut, Egypt
| | - Noor Hassan
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Daniel Jung
- Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Abbas Bader
- Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Rishabh Gaur
- Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Abdulrehman Yousaf
- Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Hazem Abosheaishaa
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Ahmed E Salem
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Wael T Mohamed
- Department of Transplant Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Telbany
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
| | - Dushyant Singh Dahiya
- Department of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Hashimoto Yusuke
- Department of Gastroenterology & Hepatology, The University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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Gupta P, Singla V, Singh P, Madan K, Kaalia S, Shawl MR, Goel A, Garg P, Bhargava R. Early cholangioscopy-guided lithotripsy for clearance of biliary stones associated with narrow lower bile duct. Endosc Int Open 2025; 13:a25524629. [PMID: 40230566 PMCID: PMC11996019 DOI: 10.1055/a-2552-4629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Accepted: 01/26/2025] [Indexed: 04/16/2025] Open
Abstract
Background and study aims Stones larger than the distal common bile duct (CBD) are difficult to remove with conventional techniques. Large papillary balloon dilatation (> 12 mm) of the biliary sphincter is an effective technique for stone removal but is associated with risk of leak in patients with narrower lower CBD. Mechanical or cholangioscopy-guided lithotripsy has been used in this situation for clearance of the bile duct. In the present study, we report outcomes of early cholangioscopy-guided lithotripsy in patients with narrow lower CBD compared with stone size. Patients and methods The present study is a retrospective analysis of prospectively collected data from all patients with large proximal stones with a narrow lower bile duct who underwent digital cholangioscopy and electrohydraulic lithotripsy (EHL). Outcomes were proportion of patients with complete bile duct clearance after the first session of electrohydraulic lithotripsy, mean number of EHL sessions for complete clearance, and complications. Results Eighty-one patients with mean age 54 ± 17 years underwent digital cholangioscopy and EHL. Mean stone size was 14.02 ± 3.5 mm and 71 patients (87.7%) had a stone only in the bile duct. Three (3.7%) and seven patients (8.6%) had stones also in the cystic duct and intrahepatic ducts, respectively. Balloon sphincteroplasty never exceeding distal CBD size was performed in 12 patients (14.8%). Complete stone clearance was achieved in 78 patients (96.3%) after a single session. Mean number of EHL sessions were 1.04 ± 0.19. Three patients developed mild adverse events, which were managed conservatively. Conclusions Early upfront digital cholangioscopy with EHL has high efficacy and safety for stone clearance after a single session in patients with narrow distal CBD.
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Affiliation(s)
- Pankaj Gupta
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Vikas Singla
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Singh
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Kaushal Madan
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Shivam Kaalia
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Muzaffer Rashid Shawl
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Akash Goel
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pallavi Garg
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Richa Bhargava
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
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Facciorusso A, Crinò SF, Gkolfakis P, Spadaccini M, Arvanitakis M, Beyna T, Bronswijk M, Dhar J, Ellrichmann M, Gincul R, Hritz I, Kylänpää L, Martinez-Moreno B, Pezzullo M, Rimbaş M, Samanta J, van Wanrooij RLJ, Webster G, Triantafyllou K. Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2025; 57:166-185. [PMID: 39689874 DOI: 10.1055/a-2481-7048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2024]
Abstract
1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.
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Affiliation(s)
- Antonio Facciorusso
- Experimental Medicine, Università del Salento, Lecce, Italy
- Clinical Effectiveness Research Group, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Paraskevas Gkolfakis
- Gastroenterology, "Konstantopoulio-Patision" General Hospital of Nea Ionia, Athens, Greece
| | | | - Marianna Arvanitakis
- Gastroenterology, Digestive Oncology and Hepatopancreatology, HUB Hôpital Erasme, Brussels, Belgium
| | - Torsten Beyna
- Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Michiel Bronswijk
- Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
- Gastroenterology and Hepatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | | | - Mark Ellrichmann
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rodica Gincul
- Gastroenterology, Jean Mermoz Private Hospital, Lyon, France
| | - Istvan Hritz
- Centre for Therapeutic Endoscopy, Semmelweis University, Budapest, Hungary
| | - Leena Kylänpää
- Surgery, Helsinki Univeristy Central Hospital, Helsinki, Finland
| | | | | | - Mihai Rimbaş
- Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Roy L J van Wanrooij
- Gastroenterology and Hepatology, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
| | - George Webster
- Pancreatobiliary Medicine Unit, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, 2nd Department of Internal Medicine, Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Raza D, Singh S, Crinò SF, Boskoski I, Spada C, Fuccio L, Samanta J, Dhar J, Spadaccini M, Gkolfakis P, Maida MF, Machicado J, Spampinato M, Facciorusso A. Diagnostic Approach to Biliary Strictures. Diagnostics (Basel) 2025; 15:325. [PMID: 39941254 PMCID: PMC11816488 DOI: 10.3390/diagnostics15030325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Accepted: 01/23/2025] [Indexed: 02/16/2025] Open
Abstract
Biliary strictures represent a narrowing of the bile ducts, leading to obstruction that may result from benign or malignant etiologies. Accurate diagnosis is crucial but challenging due to overlapping features between benign and malignant strictures. This review presents a comprehensive diagnostic approach that integrates biochemical markers, imaging modalities, and advanced endoscopic techniques to distinguish between these causes. Imaging tools such as ultrasound, MRI/MRCP, and CECT are commonly used, each with distinct advantages and limitations. Furthermore, endoscopic procedures such as ERCP and EUS are key in tissue acquisition, enhancing diagnostic accuracy, especially for indeterminate or complex strictures. Recent innovations, including artificial intelligence and new endoscopic techniques, hold promise in enhancing precision and reducing diagnostic challenges. This review emphasizes a multidisciplinary strategy to improve diagnostic pathways, ensuring timely management for patients with biliary strictures.
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Affiliation(s)
- Daniyal Raza
- Department of Internal Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA;
| | - Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, USA;
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, University Hospital of Verona, 37134 Verona, Italy;
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Roma, Italy; (I.B.); (C.S.)
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Roma, Italy; (I.B.); (C.S.)
| | - Lorenzo Fuccio
- Department of Medical Sciences and Surgery, University of Bologna, 40126 Bologna, Italy;
| | - Jayanta Samanta
- Gastroenterology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.S.); (J.D.)
| | - Jahnvi Dhar
- Gastroenterology Unit, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.S.); (J.D.)
| | - Marco Spadaccini
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milano, Italy;
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital of Nea Ionia, 142 33 Athens, Greece
| | | | - Jorge Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA;
| | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Experimental Medicine, University of Salento, 73100 Lecce, Italy
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Rehman MMU, Tawab MA. A closer look at the novel ultrafine POCS for gallbladder lesion detection: Potential and pitfalls. Dig Liver Dis 2024; 56:1957. [PMID: 38997846 DOI: 10.1016/j.dld.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024]
Affiliation(s)
| | - Muhammad Abdul Tawab
- Shifa college of medicine, NCBMS Tower, Sector H-8/4 Service road, Islamabad, Pakistan
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Agudo Castillo B, Mascarenhas M, Martins M, Mendes F, de la Iglesia D, Costa AMMPD, Esteban Fernández-Zarza C, González-Haba Ruiz M. Advancements in biliopancreatic endoscopy - A comprehensive review of artificial intelligence in EUS and ERCP. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:613-622. [PMID: 38832589 DOI: 10.17235/reed.2024.10456/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
The development and implementation of artificial intelligence (AI), particularly deep learning (DL) models, has generated significant interest across various fields of gastroenterology. While research in luminal endoscopy has seen rapid translation to clinical practice with approved AI devices, its potential extends far beyond, offering promising benefits for biliopancreatic endoscopy like optical characterization of strictures during cholangioscopy or detection and classification of pancreatic lesions during diagnostic endoscopic ultrasound (EUS). This narrative review provides an up-to-date of the latest literature and available studies in this field. Serving as a comprehensive guide to the current landscape of AI in biliopancreatic endoscopy, emphasizing technological advancements, main applications, ethical considerations, and future directions for research and clinical implementation.
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Affiliation(s)
| | | | - Miguel Martins
- Gastroenterology, Centro Hospitalar Universitário de São João
| | - Francisco Mendes
- Gastroenterology, Centro Hospitalar Universitário de São João, Portugal
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7
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Ang TL. Climate Sustainability as a Catalyst for Quality and Excellence in Gastrointestinal Endoscopy: A Narrative Review. J Dig Dis 2024; 25:638-644. [PMID: 39909063 DOI: 10.1111/1751-2980.13330] [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: 12/29/2024] [Accepted: 12/31/2024] [Indexed: 02/07/2025]
Abstract
The significant contribution of greenhouse gas (GHG) emissions to global warming and the resultant negative impact on health is well established. Within the hospital setting, the endoscopy center has been ranked third-after the operating theater complex and intensive care unit-in terms of the volume of hazardous medical waste generated. Such regulated medical waste cannot be recycled, and the disposal process results in higher costs and a larger carbon footprint. There have been clarion calls to reduce the number of endoscopic procedures as a means of reducing GHG emissions. Previous studies have demonstrated the carbon footprint of inappropriate endoscopic procedures. However, endoscopy is an important diagnostic and therapeutic tool that has been shown to be cost-effective. A focus simply on reduction in procedural case volume alone raises the unintended consequences of inequitable access to endoscopy for those in need. A more nuanced approach that is aligned with the innate sense of healthcare professional aspirations and pride, in terms of seeking quality and clinical excellence, should be considered. An evidence-based approach, with a focus on quality and efficiency, as well as appropriate and timely use of new technology, will serve as a catalyst for positive behavioral change toward quality procedures and excellence. This will improve patient satisfaction, increase professional expertise and pride, and reduce carbon footprint through minimization of inappropriate and avoidable repeat procedures.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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8
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [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: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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9
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Manti M, Shah J, Papaefthymiou A, Facciorusso A, Ramai D, Tziatzios G, Papadopoulos V, Paraskeva K, Papanikolaou IS, Triantafyllou K, Arvanitakis M, Archibugi L, Vanella G, Hollenbach M, Gkolfakis P. Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:340. [PMID: 38399627 PMCID: PMC10890215 DOI: 10.3390/medicina60020340] [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: 12/23/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.
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Affiliation(s)
- Magdalini Manti
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital of Nea Ionia, 14233 Athens, Greece; (M.M.); (G.T.); (K.P.)
| | - Jimil Shah
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Apostolis Papaefthymiou
- Endoscopy Unit, Cleveland Clinic London, London SW1X 7HY, UK;
- Department of Gastroenterology, General University Hospital of Larissa, 41110 Larissa, Greece;
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy;
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Georgios Tziatzios
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital of Nea Ionia, 14233 Athens, Greece; (M.M.); (G.T.); (K.P.)
| | - Vasilios Papadopoulos
- Department of Gastroenterology, General University Hospital of Larissa, 41110 Larissa, Greece;
| | - Konstantina Paraskeva
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital of Nea Ionia, 14233 Athens, Greece; (M.M.); (G.T.); (K.P.)
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine—Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece; (I.S.P.); (K.T.)
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine—Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece; (I.S.P.); (K.T.)
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, University Hospital of Brussels (HUB), 1070 Brussels, Belgium;
| | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.A.); (G.V.)
| | - Giuseppe Vanella
- Pancreato-Biliary Endoscopy and Endosonography Division, Vita-Salute San Raffaele University, 20132 Milan, Italy; (L.A.); (G.V.)
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, D-04103 Leipzig, Germany;
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital of Nea Ionia, 14233 Athens, Greece; (M.M.); (G.T.); (K.P.)
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, University Hospital of Brussels (HUB), 1070 Brussels, Belgium;
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Rey Rubiano AM, González-Teshima LY, Arango L, Blanco-Avellaneda C, Carvajal Gutiérrez JJ, Castaño-Llano R, Gómez Zuleta MA, González C, Peñaloza-Ramírez A, Pinilla Morales R, Pinto Carta R, Polanía Liscano HA, Rincón Sánchez RA, Sepúlveda Copete M, Vargas-Rubio R, Avendaño Capriles CA, García-Sierra AM, Yepes-Nuñez JJ. Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones. Surg Endosc 2024; 38:499-510. [PMID: 38148404 PMCID: PMC10830582 DOI: 10.1007/s00464-023-10569-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/23/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.
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Affiliation(s)
- Adriana Margarita Rey Rubiano
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia
| | | | - Lázaro Arango
- Department of Clinical Surgical Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Department of Endoscopy and Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Union of surgeons, Zentria Group, Manizales, Caldas, Colombia.
| | - Camilo Blanco-Avellaneda
- Department of Gastrointestinal Surgery and Digestive Endoscopy, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia
- Education and Research Group, Faculty of Education, Universidad El Bosque, Bogotá, D.C., Colombia
- Videoendoscopy Unit of Restrepo Ltda, Bogotá, D.C, Colombia
| | - Jhon Jaime Carvajal Gutiérrez
- Department of Gastroenterology, Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Rodrigo Castaño-Llano
- Department of Gastroenterology, Universidad de Antioquia, Medellín, Antioquia, Colombia
- Institute of Cancerology, Clínica las Américas Auna, Medellín, Antioquia, Colombia
| | - Martin Alonso Gómez Zuleta
- Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
- Department of Internal Medicine, Gastroenterology Section, Hospital Universitario Nacional de Colombia, Bogotá, D.C., Colombia
| | - Carlos González
- Department of Gastroenterology and Digestive Endoscopy, Clínica Reina Sofia, Bogotá, D.C., Colombia
- Department of Gastroenterology and Digestive Endoscopy, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
- Department of Gastroenterology, Clínica Colombia, Bogotá, D.C., Colombia
| | - Arecio Peñaloza-Ramírez
- Department of Gastroenterology, Fundación Universitaria de Ciencias de la Salud, Bogotá, D.C., Colombia
- Department of Gastroenterology, Hospital de San José, Bogotá, D.C., Colombia
| | - Raúl Pinilla Morales
- Department of Gastroenterology and Oncological Digestive Endoscopy, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
| | - Renzo Pinto Carta
- Colombian Association of Digestive Endoscopy, Bogotá, D.C., Colombia
- American Society for Gastrointestinal Endoscopy, Rochester, USA
| | - Héctor Adolfo Polanía Liscano
- Department of Gastroenterology, Universidad Surcolombiana, Neiva, Huila, Colombia
- Endotek Ltda, Hospital Universitario Neiva, Neiva, Huila, Colombia
| | - Reinaldo Andrés Rincón Sánchez
- Department of Internal Medicine and Gastroenterology, Pontificia Universidad Javeriana - Hospital Universitario San Ignacio, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Clínica Shaio, Bogotá, D.C., Colombia
| | | | - Rómulo Vargas-Rubio
- Department of Gastroenterology, Hospital Universitario de San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Camilo Andrés Avendaño Capriles
- School of Medicine, Universidad del Norte, Barranquilla, Colombia
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrés Mauricio García-Sierra
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- School of Global Health Management and Informatics, University of Central Florida, Orlando, USA
| | - Juan José Yepes-Nuñez
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia.
- Pulmonology Service, Internal Medicine Section, Fundación Santa Fe de Bogotá University Hospital, Bogotá, D.C., Colombia.
- Colombia GRADE Network, Bogotá, D.C., Colombia.
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11
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Laleman W, Vanderschueren E, Mehdi ZS, Wiest R, Cardenas A, Trebicka J. Endoscopic procedures in hepatology: Current trends and new developments. J Hepatol 2024; 80:124-139. [PMID: 37730125 DOI: 10.1016/j.jhep.2023.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium; Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany.
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Zain Seyad Mehdi
- Department of Mechanical Engineering, KU LEUVEN, Leuven, Belgium
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain; Institute of Digestive Disease and Metabolism, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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12
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Fujii-Lau LL, Thosani NC, Al-Haddad M, Acoba J, Wray CJ, Zvavanjanja R, Amateau SK, Buxbaum JL, Wani S, Calderwood AH, Chalhoub JM, Coelho-Prabhu N, Desai M, Elhanafi SE, Fishman DS, Forbes N, Jamil LH, Jue TL, Kohli DR, Kwon RS, Law JK, Lee JK, Machicado JD, Marya NB, Pawa S, Ruan W, Sawhney MS, Sheth SG, Storm A, Thiruvengadam NR, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: methodology and review of evidence. Gastrointest Endosc 2023; 98:694-712.e8. [PMID: 37307901 DOI: 10.1016/j.gie.2023.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023]
Abstract
Biliary strictures of undetermined etiology pose a diagnostic challenge for endoscopists. Despite advances in technology, diagnosing malignancy in biliary strictures often requires multiple procedures. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the available literature on strategies used to diagnose undetermined biliary strictures. Using a systematic review and meta-analysis of each diagnostic modality, including fluoroscopic-guided biopsy sampling, brush cytology, cholangioscopy, and EUS-guided FNA or fine-needle biopsy sampling, the American Society for Gastrointestinal Endoscopy Standards of Practice Committee provides this guideline on modalities used to diagnose biliary strictures of undetermined etiology. This document summarizes the methods used in the GRADE analysis to make recommendations, whereas the accompanying article subtitled "Summary and Recommendations" contains a concise summary of our findings and final recommendations.
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Affiliation(s)
| | | | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jared Acoba
- Department of Hematology and Medical Oncology, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | | | - Rodrick Zvavanjanja
- Department of Diagnostic and Interventional Imaging, UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Madhav Desai
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Terry L Jue
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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13
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Uribe Rivera AK, Seeliger B, Saldivar CA, Houghton E, Rodríguez F, Acquafresca P, Palermo M, Giménez ME. Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope. Surg Endosc 2023; 37:7774-7783. [PMID: 37580582 DOI: 10.1007/s00464-023-10337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/23/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The length of conventional single-use cholangioscopes poses a challenge for percutaneous or laparoscopic approaches for direct visualization of the biliary tract. The aim of this retrospective observational clinical study was to assess the use of a dedicated percutaneous short single-operator cholangioscope (PSSOC) for diagnosis and treatment of benign or malignant biliary diseases. METHODS Retrospective analysis of a prospectively maintained database including all consecutive patients undergoing percutaneous transhepatic cholangioscopy with the PSSOC between 06/2021 and 01/2023. RESULTS Forty patients were included (22F/18 M, age 58.7 ± 16.7 years). The diagnostic and therapeutic management plan was based on procedural findings. Indications were bile duct obstruction associated with complex anatomy (n = 13), choledocholithiasis (n = 11), suspected malignant stenosis of the biliary tract (n = 11), biliary stent placement (n = 2) and removal (n = 1), and failed endoscopic retrograde cholangiopancreatography (n = 2). The cholangioscopies were diagnostic (n = 5), therapeutic (n = 20) or both simultaneously (n = 15). The most frequent procedures were electrohydraulic lithotripsy (n = 25) and biopsy sampling (n = 12). Complications occurred in 7 cases (17.5%), including cholangitis (n = 4, B2), pleural perforation (n = 1, B2), portal bleeding (n = 1, B3), and Tako-Tsubo syndrome (n = 1, B3), classified according to the Society of Interventional Radiology classification. Intraprocedural visual diagnosis was confirmed by the histopathologic result in 11/12 patients in which biopsies were performed (91.7%). PSSOC was relevant to avoid surgery in 2 patients (5%) with indeterminate strictures, allowing to rule out malignancy and treat the lithiasis. CONCLUSIONS Direct visualization of the biliary tract enabled targeted biopsies for histopathological diagnosis. The visual and histopathological diagnoses were concordant in all but one case. Percutaneous cholangioscopy with a dedicated PSSOC allows to optimize identification and treatment of complex biliary disease including biliary lithiasis while assessing bile duct patency. The clinical use of the novel PSSOC system was safe and effective and could prevent surgical exploration in select patients.
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Affiliation(s)
- A K Uribe Rivera
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina.
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.
| | - B Seeliger
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- Department of Visceral and Digestive Surgery, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - C A Saldivar
- Dr. Eduardo Liceaga, General Hospital, Mexico City, Mexico
| | - E Houghton
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - F Rodríguez
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - P Acquafresca
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - M Palermo
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
| | - M E Giménez
- DAICIM Foundation (Training, Research and Clinical Activity in Minimally Invasive Surgery), Buenos Aires, Argentina
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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14
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El Menabawey T, Mulay A, Graham D, Phillpotts S, Sethi A, Webster GJ. Predictors of success of conventional ERCP for bile duct stones and need for single-operator cholangioscopy. Endosc Int Open 2023; 11:E943-E951. [PMID: 37818453 PMCID: PMC10562053 DOI: 10.1055/a-2164-8557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023] Open
Abstract
Background and study aims The characteristics of difficult stones requiring cholangioscopy-assisted lithotripsy are poorly defined. We sought to determine clinician perception of these characteristics and decision-making in biliary endoscopy. Methods One hundred twenty-four delegates attending an online course were invited to assess 20 clinical stone cases. Each image was graded on a 4-point Likert for: grading of stone difficulty, confidence of clearance with conventional endoscopic retrograde cholangiopancreatography (ERCP) methods, likelihood of needing cholangioscopy-assisted lithotripsy, and confidence of clearance with one session of lithotripsy. An independent reviewer rated each case on largest stone size, stone number, presence of stricture distal to stone, size of stone relative to distal duct size, and acute common bile duct (CBD) angulation < 135°. Multilevel (mixed) statistical methods with a two-level model were utilized with multilevel ordinal logistic regression. Results Stone size and location, stricture and stone diameter:duct ratio impacted perceived procedural difficulty P < 0.01). Stone:duct ratio (< 50% odds ratio [OR] 0.22, P < 0.001), stricture (OR 7.26, P < 0.001) and stone location impacted confidence of clearance with conventional ERCP. Intrahepatic and cystic duct stones were least likely to engender confidence ( P < 0.01). The same factors plus CBD angulation < 135° predicted cholangioscopy requirement ( P < 0.01). Stone number did not influence procedure difficulty or cholangioscopy requirement. Strictures (OR 0.29, P < 0.001) and location, especially intrahepatic (OR 0.42, P < 0.001) impaired confidence in clearance with one cholangioscopy session. Conclusions Ductal anatomy, the presence of a stricture distal to a stone, cystic and intrahepatic stones and stones larger than the distal duct are considered by endoscopists to be significant predictors of requiring cholangioscopy-assisted lithotripsy.
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Affiliation(s)
- Tareq El Menabawey
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Akhilesh Mulay
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - David Graham
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Amrita Sethi
- Gastroenterology and Hepatology, Columbia University Medical Center, New York, United States
| | - George J Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
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15
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Yadlapati S, Mulki R, Sánchez-Luna SA, Ahmed AM, Kyanam Kabir Baig KR, Peter S. Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup. World J Gastroenterol 2023; 29:5198-5210. [PMID: 37901449 PMCID: PMC10600956 DOI: 10.3748/wjg.v29.i36.5198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.
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Affiliation(s)
- Sujani Yadlapati
- Department of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, IN 46202, USA
| | - Ramzi Mulki
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Sergio A Sánchez-Luna
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Ali M Ahmed
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | | | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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16
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Mauro A, Mazza S, Scalvini D, Lusetti F, Bardone M, Quaretti P, Cobianchi L, Anderloni A. The Role of Cholangioscopy in Biliary Diseases. Diagnostics (Basel) 2023; 13:2933. [PMID: 37761300 PMCID: PMC10528268 DOI: 10.3390/diagnostics13182933] [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: 07/07/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Pietro Quaretti
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
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17
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Sánchez-Ocaña R, Foruny Olcina JR, Vila Costas J, Gallego Rojo F, Jiménez Pérez J, Domínguez-Muñoz E, González Huix F, Pons Beltrán V, Gornals Soler J, Sánchez Hernández E, Gómez Oliva C, Dolz Abadía C, Aparicio Tormo JR. SEED Consensus Document on SpyGlass-DS. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:69-79. [PMID: 36179947 DOI: 10.1016/j.gastrohep.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/07/2022] [Accepted: 08/26/2022] [Indexed: 01/18/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.
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Affiliation(s)
- Ramón Sánchez-Ocaña
- Servicio de Medicina Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José Ramón Foruny Olcina
- Unidad de Endoscopia, Servicio de Medicina Digestiva, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Vila Costas
- Unidad de Endoscopia, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | | | - Javier Jiménez Pérez
- Unidad de Endoscopia, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - Enrique Domínguez-Muñoz
- Servicio de Gastroenterología, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | | | - Vicente Pons Beltrán
- Endoscopia Digestiva, Hospital Universitari i Politecnic La Fe, Valencia, España
| | - Joan Gornals Soler
- Endoscopia Digestiva, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | | | | | - Carlos Dolz Abadía
- Aparato Digestivo, Hospital Universitario Son Llàtzer, Palma de Mallorca, España
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18
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Kawai H, Sato T, Natsui M, Watanabe K, Inoue R, Kimura M, Yoko K, Sasaki SY, Watanabe M, Ohashi T, Tsukahara A, Tanaka N, Tsukada Y. Mirizzi Syndrome Type IV Successfully Treated with Peroral Single-operator Cholangioscopy-guided Electrohydraulic Lithotripsy: A Case Report with Literature Review. Intern Med 2022; 61:3513-3519. [PMID: 35569988 PMCID: PMC9790796 DOI: 10.2169/internalmedicine.9526-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 76-year-old man presented with liver dysfunction and intrahepatic bile duct dilatation. Imaging studies showed two large stones that had become impacted in the common hepatic duct, which was fused with the gallbladder. The patient was diagnosed with Mirizzi syndrome type IV. Hepaticojejunostomy and stone removal failed due to dense gallbladder adhesions involving the right hepatic artery. The bile flow was temporarily restored; however, the patient experienced cholangitis 16 months later. The stones were extracted via peroral single-operator cholangioscopy (SOC)-guided electrohydraulic lithotripsy. This is the first case in which stones were completely removed by SOC-guided treatment in a patient with Mirizzi syndrome type IV.
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Affiliation(s)
- Hirokazu Kawai
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Toshifumi Sato
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Masaaki Natsui
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Kotaro Watanabe
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Ryosuke Inoue
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Mayuki Kimura
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Kazumi Yoko
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Syun-Ya Sasaki
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Masashi Watanabe
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
| | - Taku Ohashi
- Department of Surgery, Niigata Prefectural Shibata Hospital, Japan
| | | | - Norio Tanaka
- Department of Surgery, Niigata Prefectural Shibata Hospital, Japan
| | - Yoshihisa Tsukada
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Japan
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19
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Shin J, Oh CH, Dong SH. Single-operator Cholangioscopy Guided Lithotripsy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 80:163-168. [DOI: 10.4166/kjg.2022.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jungha Shin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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20
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Sljivic I, Trasolini R, Donnellan F. Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones. Endosc Int Open 2022; 10:E1193-E1200. [PMID: 36118645 PMCID: PMC9473834 DOI: 10.1055/a-1873-0884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background and study aims Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.
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Affiliation(s)
- Igor Sljivic
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Roberto Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard University, Cambridge, Massachusetts, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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21
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Barakat MT, Berquist WE, Gugig R. Cholangioscopy in Children and Adolescents: Utilization, Outcomes, and Safety. J Pediatr Gastroenterol Nutr 2022; 75:196-201. [PMID: 35653429 DOI: 10.1097/mpg.0000000000003499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly utilized for management of biliary disorders in children and adolescents. Practice patterns surrounding cholangioscopy in pediatric patients, however, are largely uncharacterized. METHODS We retrospectively analyzed all ERCPs in which cholangioscopy was performed on patients 18 and under at our tertiary care children's hospital from 2015 to 2020 using our institution's paper and electronic medical record system. Patient demographics, procedure indications, interventions, and associated adverse events were analyzed. RESULTS Over the study period, 307 ERCPs were performed on 282 patients at our children's hospital. Cholangioscopy was performed in 36 procedures (11.7%) using the SpyGlass cholangioscope (Boston Scientific). Antibiotics to cover biliary organisms were administered to all patients precholangioscopy. Mean patient age was 13.6 years (range 7-18 years). The 2 most common indications for cholangioscopy included electrohydraulic lithotripsy for biliary stone disease and evaluation of biliary stricture (with incidental finding of biliary web in 2 patients and retained suture material in 2 patients). Adverse events were less prevalent in patients who underwent cholangioscopy relative to those who underwent ERCP. 0/36 (0%) developed post-ERCP pancreatitis, one patient had self-limited melena (possible self-limited postsphincterotomy bleeding). Patient care was enhanced by cholangioscopy in 30/36 (83.3%) of these patients. CONCLUSIONS These data attest to the safety and clinical utility of cholangioscopy in children and adolescents. Cholangioscopy was performed in just over 11% of pediatric patients who underwent ERCP at our academic medical center-rates similar to those reported in adult patients. The radiation-sparing nature of cholangioscopy, coupled with these data supporting its safety, make it particularly appealing for use in children. Further multi-institution evaluation of the utility, safety, and range of indications for cholangioscopy in other practice settings would be of great interest and help guide endoscopic care.
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Affiliation(s)
- Monique T Barakat
- From the Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CAand the
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
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22
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Phillpotts S, Webster G, Arvanitakis M. Endoscopic Management of Complex Biliary Stones. Gastrointest Endosc Clin N Am 2022; 32:477-492. [PMID: 35691692 DOI: 10.1016/j.giec.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.
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Affiliation(s)
- Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England.
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, Brussels 1070, Belgium
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23
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Abstract
Bile duct stenosis continues to present a diagnostic dilemma for clinicians. It is important to establish the benign or malignant nature of the stricture early in order to avoid any unnecessary delay in medical treatment or surgery. Tissue acquisition for histological diagnosis is particularly crucial when the initial diagnostic work up is inconclusive. The diagnostic yield from the conventional endoscopic retrograde cholangiopancreatography (ERCP) with brushing and biopsy is suboptimal. Patients with indeterminate biliary strictures (IDBSs) often require a multi-disciplinary diagnostic approach and additional endoscopic evaluation, including cholangioscopy and endoscopic ultrasound, before a final diagnosis can be reached. In this article, we discuss the recent endoscopic advancements in the diagnosis of biliary stricture with a focus on the roles of cholangioscopy and endoscopic ultrasound (EUS).
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24
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Oleas R, Alcívar-Vasquez J, Robles-Medranda C. New technologies for indeterminate biliary strictures. Transl Gastroenterol Hepatol 2022; 7:22. [PMID: 35548472 PMCID: PMC9081913 DOI: 10.21037/tgh.2020.03.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/12/2020] [Indexed: 08/30/2023] Open
Abstract
An early and accurate diagnosis of biliary strictures yields optimal patient outcomes; however, endoscopic retrograde cholangiopancreatography (ERCP) with cytobrush/biopsy forceps has low sensitivity with a high number of false negatives. Various attempts to improve the accuracy of diagnosing indeterminate biliary strictures though ERCP-guided specimen acquisition have been proposed, such as with the use of fluorescence in situ hybridization, an endoscopic scraper, and the wire-grasping method, with modest to large improvements in sensitivity. Direct visualization of the biliary tree during peroral cholangioscopy has shown high sensitivity and specificity for the differentiation of neoplastic and non-neoplastic biliary lesions; however, there is no consensus on the visual characteristics of neoplastic lesions and moderate agreement between observers. Peroral cholangioscopy system (POCS)-guided specimen acquisition using forceps has shown inferior sensitivity compared to the visual characteristics; however, the specificity remains high. Optimal specimen processing with onsite evaluations and touch imprint cytology have been shown to improve the sensitivity and accurately diagnose nearly 90% of patients. In vivo evaluations of biliary strictures with probe-based confocal laser endomicroscopy have demonstrated high sensitivity with modest specificity for malignant biliary strictures. Optical computed tomography described reproductible criteria for malignancy detection in biliary strictures, increasing the sensitivity during ERCP evaluations. Differentiating benign causes from malignant causes of biliary strictures is a challenging task in clinical practice, with various concerns that still need to be addressed. Efforts should be made to define each diagnostic method's role in the evaluation of indeterminate biliary strictures.
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Affiliation(s)
- Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Juan Alcívar-Vasquez
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
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25
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Subhash A, Buxbaum JL, Tabibian JH. Peroral cholangioscopy: Update on the state-of-the-art. World J Gastrointest Endosc 2022; 14:63-76. [PMID: 35316979 PMCID: PMC8908329 DOI: 10.4253/wjge.v14.i2.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/25/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
Peroral cholangioscopy (POC) is an endoscopic procedure that allows direct intraductal visualization of the biliary tract. POC has emerged as a vital tool for indeterminate biliary stricture evaluation and treatment of difficult biliary stones. Over several generations of devices, POC has fulfilled additional clinical needs where other diagnostic or therapeutic modalities have been inadequate. With adverse event rates comparable to standard endoscopic retrograde cholangioscopy and unique technical attributes, the role of POC is likely to continue expand. In this frontiers article, we highlight the existing and growing clinical applications of POC as well as areas of ongoing research.
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Affiliation(s)
- Amith Subhash
- Department of Gastroenterology, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89102, United States
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, NV 90033, United States
| | - James H Tabibian
- David Geffen School of Medicine at UCLA, Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, NV 90095, United States
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26
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Abstract
Indeterminate biliary strictures are defined as a narrowing of the bile duct that cannot be differentiated as malignant or benign after performing cross-sectional imaging and an ERCP. Identifying the etiology of a bile duct stricture is the single most important step in determining whether a complex and potentially morbid surgical resection is warranted. Due to this diagnostic and therapeutic dilemma, new technologies, laboratory tests, and procedures are emerging to solve this problem.
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27
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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28
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Angsuwatcharakon P, Kulpatcharapong S, Moon JH, Ramchandani M, Lau J, Isayama H, Seo DW, Maydeo A, Wang HP, Nakai Y, Ratanachu-Ek T, Bapaye A, Hu B, Devereaux B, Ponnudurai R, Khor C, Kongkam P, Pausawasdi N, Ridtitid W, Piyachaturawat P, Khanh PC, Dy F, Rerknimitr R. Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture. HPB (Oxford) 2022; 24:17-29. [PMID: 34172378 DOI: 10.1016/j.hpb.2021.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures. METHODS The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement. RESULTS Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties. CONCLUSION Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Santi Kulpatcharapong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jong H Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Seoul, South Korea
| | | | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Dong W Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Global Gleneagles Hospital, Mumbai, India
| | - Hsiu-P Wang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yousuke Nakai
- Departments of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
| | | | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital & Research Center, India
| | - Bing Hu
- Department of Gastroenterology, Eastern Hepatobiliary Hospital, Naval Medical University, Shanghai, China
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore
| | - Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pham C Khanh
- Department of Endoscopy, University Medical Center, Ho Chi Minh City, Viet Nam
| | - Federick Dy
- Section of Gastroenterology, Department of Internal Medicine, Faculty of Medicine and Surgery, University of Santo Tomas Hospital, Manila, Philippines
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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29
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Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol 2021; 27:7597-7611. [PMID: 34908801 PMCID: PMC8641054 DOI: 10.3748/wjg.v27.i44.7597] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/23/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.
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Affiliation(s)
- Alberto Tringali
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Deborah Costa
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
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30
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Del Vecchio Blanco G, Mossa M, Troncone E, Argirò R, Anderloni A, Repici A, Paoluzi OA, Monteleone G. Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review. World J Gastrointest Endosc 2021; 13:473-490. [PMID: 34733408 PMCID: PMC8546565 DOI: 10.4253/wjge.v13.i10.473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/24/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023] Open
Abstract
Biliary stenosis may represent a diagnostic and therapeutic challenge resulting in a delay in diagnosis and initiation of therapy due to the frequent difficulty in distinguishing a benign from a malignant stricture. In such cases, the diagnostic flowchart includes the sequential execution of imaging techniques, such as magnetic resonance, magnetic resonance cholangiopancreatography, and endoscopic ultrasound, while endoscopic retrograde cholangiopancreatography is performed to collect tissue for histopathological/cytological diagnosis or to treat the stenosis by insertion of stent. The execution of percutaneous transhepatic drainage with subsequent biopsy has been shown to increase the possibility of tissue diagnosis after failure of the above techniques. Although the diagnostic yield of histopathology and imaging has increased with improvements in endoscopic ultrasound and peroral cholangioscopy, differential diagnosis between malignant and benign stenosis may not be easy in some patients, and strictures are classified as indeterminate. In these cases, a multidisciplinary workup including biochemical marker assays and advanced technologies available may speed up a diagnosis of malignancy or avoid unnecessary surgery in the event of a benign stricture. Here, we review recent advancements in the diagnosis and management of biliary strictures and describe tips and tricks to increase diagnostic yields in clinical routine.
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Affiliation(s)
| | - Michelangela Mossa
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Renato Argirò
- Department of Interventional Radiology, University of Rome Tor Vergata, Rome 00133, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Rozzano 20093, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital & Humanitas University, Rozzano 20093, Italy
| | - Omero Alessandro Paoluzi
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome Tor Vergata, Rome 00133, Italy
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31
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Alrajhi S, Barkun A, Adam V, Callichurn K, Martel M, Brewer O, Khashab MA, Forbes N, Almadi MA, Chen YI. Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective. Therap Adv Gastroenterol 2021; 14:17562848211031388. [PMID: 34804204 PMCID: PMC8600178 DOI: 10.1177/17562848211031388] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. METHODS A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. RESULTS The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. CONCLUSIONS Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.
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Affiliation(s)
- Saad Alrajhi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Viviane Adam
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Kashi Callichurn
- Department of Internal Medicine, University of Montreal, Montreal, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Majid A. Almadi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Canada
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Glen Site, 1001 Décarie Blvd., Montreal, QC H4A 3J1, Canada
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32
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Kulpatcharapong S, Pittayanon R, Kerr SJ, Rerknimitr R. Diagnostic performance of digital and video cholangioscopes in patients with suspected malignant biliary strictures: a systematic review and meta-analysis. Surg Endosc 2021; 36:2827-2841. [PMID: 34076761 DOI: 10.1007/s00464-021-08571-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/18/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Per-oral cholangioscopy (POC) has evolved over the past decade from fiberoptic to digital and video imaging systems. Nowadays, only direct per-oral cholangioscopy (DPOC) and digital single-operator cholangioscopy (DS) are performed in daily practice. With better image resolution, POC is increasingly used as diagnostic tools in patients with suspected malignant biliary stricture (MBS). We aimed to evaluate the diagnostic yield of digital/video cholangioscopes for the diagnosis of MBS. METHODS A systematic search was performed in MEDLINE, Embase, and ISI Web of Knowledge databases until April 2020, to identify randomized controlled trials and prospective studies using digital or video POC. The meta-analysis of diagnostic accuracy study was performed to calculate summary estimates of the primary outcomes, including pooled sensitivity, and specificity of POC to diagnose MBS using bivariate random-effects models. Tissue histopathology was used as the reference standard for MBS diagnosis. For benign stricture, negative tissue histopathology and at least 6 months clinical follow-up were required. RESULTS Thirteen original articles with 876 patients were identified. The overall pooled sensitivity and specificity were 88 (95% CI 83-91) and 95 (95% CI 89-98), respectively. The area under the curve (AUROC) was 0.94 (95% CI 0.92-0.96). Subgroup analysis showed that cholangioscopic image impression provided significantly higher sensitivity (93% (95% CI 88-96) vs 82% (95% CI 76-87); p = 0.007), but lower specificity 86% (95% CI 75-92) vs 98 (95% CI 95-99); p < 0.001) than the tissue diagnosis from cholangioscopic-guided biopsy. In addition, biopsy obtained from DPOC had significantly higher sensitivity than that of DS (92% (95% CI 81-97) vs 79% (95% CI 72-84); p = 0.004). Diagnostic performance under image-enhanced endoscopy was not significantly better from white light endoscopy. CONCLUSIONS Digital/video POC has very high diagnostic performance to diagnose MBS. While image diagnosis provides higher sensitivity than biopsy, its specificity drops as a trade-off.
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Affiliation(s)
- Santi Kulpatcharapong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Rama 4 Road, Patumwan, Bangkok, 10330, Thailand. .,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand.
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Rama 4 Road, Patumwan, Bangkok, 10330, Thailand. .,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand.
| | - Stephen J Kerr
- Department of Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Rama 4 Road, Patumwan, Bangkok, 10330, Thailand. .,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand.
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Scholte M, Rovers MM, Grutters JPC. The Use of Decision Analytic Modeling in the Evaluation of Surgical Innovations: A Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:884-900. [PMID: 34119087 DOI: 10.1016/j.jval.2020.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/05/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The main objective of this review was to map how decision analytic models are used in surgical innovation (in which research phase, with what aim) and to understand how challenges related to the assessment of surgical interventions are incorporated. METHODS We systematically searched PubMed, Embase, and the Cochrane Library for studies published in 2018. We included original articles using a decision analytic model to compare surgical strategies. We included modeling studies of surgical innovations. General, innovation, and modeling characteristics were extracted, as were outcomes, recommendations, and handling of challenges related to the assessment of surgical interventions (learning curve, incremental innovation, dynamic pricing, quality variation, organizational impact). RESULTS We included 46 studies. The number of studies increased with each research phase, from 4% (n = 2) in the preclinical phase to 40% (n = 20) in phase 3 studies. Eighty-one studies were excluded because they investigated established surgical procedures, indicating that modeling is predominantly applied after the innovation process. Regardless of the research stage, the aim to determine cost-effectiveness was most frequently identified (n = 40, 87%), whereas exploratory aims (eg, exploring when a strategy becomes cost-effective) were less common (n = 9, 20%). Most challenges related to the assessment of surgical interventions were rarely incorporated in models (eg, learning curve [n = 1, 2%], organizational impact [n = 2, 4%], and incremental innovation [n = 1, 2%]), except for dynamic pricing (n = 10, 22%) and quality variation (n = 6, 13%). CONCLUSIONS In surgical innovation, modeling is predominantly used in later research stages to assess cost-effectiveness. The exploratory use of modeling seems still largely overlooked in surgery; therefore, the opportunity to inform research and development may not be optimally used.
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Affiliation(s)
- Mirre Scholte
- Department of Operating Rooms, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Zhang H, Huo C, Guo Y, Zhu K, Li F, Huang J. Tissue sampling for biliary strictures using novel elbow biopsy forceps. Sci Rep 2021; 11:10895. [PMID: 34035351 PMCID: PMC8149446 DOI: 10.1038/s41598-021-90197-4] [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] [Received: 01/04/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
We aim to evaluate the safety and feasibility of novel elbow biopsy forceps with a prebent head for sampling biliary strictures in our institution. A total of 24 patients (15 males and 9 females) with biliary stricture who underwent biliary biopsy during endoscopic retrograde cholangiopancreatography (ERCP) using novel elbow biopsy forceps from June 2019 to August 2020 were retrospectively included. The novel biopsy forceps had a head angulation of 30 degrees and were able to cannulate the bile duct and approach the biliary strictures easily to obtain adequate samples. The technical success rate, incidence of adverse events, and consistency of pathological and surgical specimens were assessed. This device was used successfully in all patients. A total of 52 biopsy specimens were obtained from 24 patients, and all specimens could be used for histopathological examination. Seventeen patients were diagnosed with malignancy based on biopsies, and all of them underwent surgical treatment. The histopathological findings of the biopsy specimens were in accordance with the postoperative pathology diagnoses. One of the seven patients was diagnosed with a benign lesion that was proven to be malignant during surgical treatment in the follow-up period. Two patients experienced a single episode of acute pancreatitis and recovered shortly after appropriate treatment. No patients experienced biliary perforation or biliary bleeding. Biopsy using novel elbow forceps in patients with biliary stenosis is feasible and safe. The novel device and related biopsy technique may be widely applied for biliary disease differentiation.
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Affiliation(s)
- Huahui Zhang
- Graduate School of Dalian Medical University, Dalian, China
| | - Chunyan Huo
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China
| | - Yongxin Guo
- Graduate School of Dalian Medical University, Dalian, China
| | - Keyuan Zhu
- Graduate School of Dalian Medical University, Dalian, China
| | - Fengdong Li
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China
| | - Jin Huang
- Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, China.
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Nakai Y, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, Takahara N, Hamada T, Mizuno S, Kogure H, Tada M, Isayama H, Koike K. Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography. Gut Liver 2021; 14:297-305. [PMID: 31581389 PMCID: PMC7234877 DOI: 10.5009/gnl19157] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/19/2019] [Accepted: 07/28/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.
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Affiliation(s)
- Yousuke Nakai
- Departments of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Japan.,Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tatsuya Sato
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Ryunosuke Hakuta
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kazunaga Ishigaki
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kei Saito
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tomotaka Saito
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Naminatsu Takahara
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tsuyoshi Hamada
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Suguru Mizuno
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hirofumi Kogure
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Minoru Tada
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Departments of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
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Robles-Medranda C, Oleas R, Sánchez-Carriel M, Olmos JI, Alcívar-Vásquez J, Puga-Tejada M, Baquerizo-Burgos J, Icaza I, Pitanga-Lukashok H. Vascularity can distinguish neoplastic from non-neoplastic bile duct lesions during digital single-operator cholangioscopy. Gastrointest Endosc 2021; 93:935-941. [PMID: 32707155 DOI: 10.1016/j.gie.2020.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/05/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Various macroscopic features are proposed for the diagnosis of biliary lesions during digital single-operator cholangioscopy (DSOC); however, neovasculature may be one of the most reliable features of neoplasia. We aimed to evaluate the detection of neovasculature during DSOC to distinguish neoplastic from non-neoplastic bile duct lesions. METHODS A retrospective, single-center, cohort study was used. Neovasculature was defined as the presence of irregular or "spider" vascularity on bile duct lesions. The accuracy of detection of neovasculature for the identification of neoplastic lesions was estimated using the histologic results, surgical specimens, and/or 6-month follow-up as the criterion standard. Interobserver agreement analysis (kappa value) was performed between 2 expert endoscopists and 3 nonexpert physicians. RESULTS Ninety-five patients were included; the median age was 65.6 years (range, 20-93 years), and 51 (53.7%) patients were female. Signs of neovasculature were observed in 65 of 95 (68.4%) patients. Histology confirmed neoplasia in 48 of 95 (50.5%) patients, and 6-month follow-up survival confirmed neoplasia in 52 of 95 (54.7%) patients. The use of vascularity for identifying neoplastic lesions achieved an accuracy of 80%, sensitivity of 94%, specificity of 63%, positive predictive value of 75%, negative predictive value of 90%, positive likelihood ratio of 2.53 (95% confidence interval, 1.71-3.76), and negative likelihood ratio of 0.09 (95% confidence interval, 0.03-0.28). The interobserver and intraobserver agreement were excellent (κ > 80%; P < .001) between expert endoscopists and nonexpert physicians. CONCLUSION Detection of irregular or spider vascularity on bile duct lesions during DSOC evaluations accurately identifies biliary neoplastic lesions. Prospective multicenter trials are required to evaluate neovasculature as a single factor for predicting neoplasia.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - María Sánchez-Carriel
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Juan I Olmos
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Juan Alcívar-Vásquez
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Ivanna Icaza
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
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Abstract
Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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38
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Archibugi L, Mariani A, Ciambriello B, Petrone MC, Rossi G, Testoni SGG, Carlucci M, Aldrighetti L, Falconi M, Balzano G, Doglioni C, Capurso G, Arcidiacono PG. High sensitivity of ROSE-supported ERCP-guided brushing for biliary strictures. Endosc Int Open 2021; 9:E363-E370. [PMID: 33655035 PMCID: PMC7895655 DOI: 10.1055/a-1322-2638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in biliary strictures, with brushing being a cheap and fast method to acquire a cytological specimen, despite a sensitivity around 45 %. Rapid on-site evaluation (ROSE) is widely used for endoscopic ultrasound-acquired cytological specimen adequacy, improving its sensitivity and specificity. Nevertheless, no study has evaluated its role for ERCP-guided brushing. Our aim was to assess the diagnostic yield of ERCP-guided brushing of biliary strictures when supported by ROSE. Patients and methods This was a retrospective single-center study that included patients undergoing ERCP-guided brush cytology supported by ROSE for biliary strictures. Recorded data included patient clinical-radiological and ERCP features. Final diagnosis was determined after surgery, intraductal biopsy or adequate follow-up. The diagnostic yield was calculated and a subgroup analysis for factors associated with false-negative or true-positive results was performed. Results Two hundred six patients were included, 57.3 % males, median age 72 years, 77.2 % having extrahepatic biliary strictures. Of the patients, 99 % had an adequate sample at ROSE after a mean of 2.6 passages. The diagnostic yield was accuracy 83 %, sensitivity 74.6 %, and specificity 98 %, positive and negative predictive values 98 % and 71 % respectively, with an area under the curve of 0.86. A diagnosis of cholangiocarcinoma was significantly more frequent among true-positive cases (68 % vs 46.8 %; P = 0.04). Conclusions This is the first study evaluating the use of ROSE as support for ERCP-guided brushing of biliary strictures, with a sensitivity far higher than those reported for brushing alone and at least comparable to those of more expensive and invasive techniques.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Carlucci
- Department of General and Emergency Surgery, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Oh CH, Dong SH. Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy. Korean J Intern Med 2021; 36:235-246. [PMID: 32972127 PMCID: PMC7969058 DOI: 10.3904/kjim.2020.425] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/16/2022] Open
Abstract
The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
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40
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Ma Z, Zhou J, Yao L, Dai Y, Xie W, Song G, Meng H, Xu B, Zhang T, Zhou B, Yang T, Song Z. Safety and efficacy of laparoscopic common bile duct exploration for the patients with difficult biliary stones: 8 years of experiences at a single institution and literature review. Surg Endosc 2021; 36:718-727. [PMID: 33619595 DOI: 10.1007/s00464-021-08340-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity for the treatment of choledocholithiasis. However, it remains unclear whether LCBDE is a better alternative option for the patients with difficult biliary stones. Thus, the aim of the present study was to explore the safety and efficacy of LCBDE for these patients by retrospectively analyzing our data and combing with literature review. METHODS Between September 2011 and February 2019, 1064 consecutive patients who underwent LCBDE at Shanghai Tenth People's Hospital were reviewed. The clinical data of patients with difficult biliary stones were selected and retrospectively analyzed. RESULTS Of these patients, 334 cases were confirmed with difficult biliary stones, and the overall complete stone clearance rate was 98.8% (330/334). 34 cases (10.2%) were performed with laser lithotripsy. A total of 296 patients (88.6%) underwent primary closure of common bile duct, and T-tube drainage was indwelled in 38 patients (11.4%). No bile duct injury, bleeding, perforation and surgery-related deaths were observed. The overall morbidity rate was 6.6%. 16 cases (4.8%) occurred in bile leakage with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 9 months with stone recurrence occurring in 9 patients (2.7%). There was no evidence of bile duct stricture in all cases. CONCLUSIONS The current study suggests that LCBED is a considerable safe and effective option for the patients with difficult biliary stones. A randomized clinical trial is needed to further evaluate the benefit of LCBDE in this subgroup.
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Affiliation(s)
- Zhilong Ma
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Jia Zhou
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Le Yao
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Yuxiang Dai
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Wangcheng Xie
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Guodong Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Hongbo Meng
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bin Xu
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Ti Zhang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bo Zhou
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Tingsong Yang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
| | - Zhenshun Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Robles-Medranda C, Soria-Alcívar M, Oleas R, Baquerizo-Burgos J, Puga-Tejada M, Valero M, Pitanga-Lukashok H. Digital per-oral cholangioscopy to diagnose and manage biliary duct disorders: a single-center retrospective study. Endosc Int Open 2020; 8:E796-E804. [PMID: 32490166 PMCID: PMC7247902 DOI: 10.1055/a-1153-8950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Digital, per-oral cholangioscopy (POCS) allows diagnosis of biliary ducts disorders and treatment for complicated stones. We aimed to determine the diagnostic accuracy of digital POCS systems for stricture lesions and the factors precluding complete biliary stone clearance. Patients and methods We performed a retrospective analysis of a prospective database of 265 consecutive patients referred for POCS between December 2016 and July 2018. We first analyzed the diagnostic accuracy of digital POCS for malignant and benign stricture lesions in 147 patients. Then, we analyzed the factors associated with complete or partial biliary stone clearance achieved with electrohydraulic lithotripsy (EHL) delivered via POCS in 118 patients. Results In the diagnostic group, digital POCS achieved 91 % visual-impression sensitivity, 99 % specificity, 99 % positive and 91 % negative predictive values, and 63.64 positive and 0.09 negative likelihood ratios for malignancy diagnosis. In the therapeutic group, complete biliary stone clearance was achieved by EHL in 94.9 % patients; the mean stone size was 20 mm (10-40 mm). In multivariable analyses, a stone size > 20 mm (OR: 1.020, P < 0.001) and the number of stones ≥ 3 (OR: 1.276, P < 001) was associated with partial biliary stone clearance. Adverse events were reported in 3.3 % patients; no deaths were reported 30 days after the procedure. Conclusions Digital POCS has excellent diagnostic efficacy for biliary lesions. EHL via POCS is effective for complicated biliary stone clearance. Stone size (> 20 mm) and the number of stones (≥ 3) are associated with partial biliary stone clearance.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Miguel Soria-Alcívar
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Manuel Valero
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
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Arvanitakis M. Digital single-operator cholangioscopy-guided biopsy for indeterminate biliary strictures: Seeing is believing? Gastrointest Endosc 2020; 91:1114-1116. [PMID: 32327120 DOI: 10.1016/j.gie.2020.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/05/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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43
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Gerges C, Beyna T, Tang RSY, Bahin F, Lau JYW, van Geenen E, Neuhaus H, Reddy DN, Ramchandani M. Response. Gastrointest Endosc 2020; 91:1215-1217. [PMID: 32327122 DOI: 10.1016/j.gie.2020.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/31/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Christian Gerges
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Raymond S Y Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Farzan Bahin
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - James Y W Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Erwin van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Horst Neuhaus
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video). Gastrointest Endosc 2020; 91:1105-1113. [PMID: 31778656 DOI: 10.1016/j.gie.2019.11.025] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Accurately diagnosing indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy sampling under direct cholangioscopic vision might be superior to standard ERCP techniques such as brushing or biopsy sampling. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP workup improves the diagnostic yield in patients with indeterminate biliary strictures. METHODS Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (control arm [CA]) or DSOC visualization and DSOC-guided biopsy sampling (study arm [SA]). This was a prospective, international, multicenter trial with a procedure-blinded pathologist. RESULTS The first sample sensitivity of DSOC-guided biopsy samples was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P < .01). The sensitivity of visualization (SA 95.5% vs CA 66.7%, P = .02) and overall accuracy (SA 87.1% vs CA 65.5%, P = .05) were significantly higher in the SA compared with the CA, whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms. CONCLUSIONS DSOC-guided biopsy sampling was shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathologic diagnosis of indeterminate biliary strictures. (Clinical trial registration number: NCT03140007.).
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Bokemeyer A, Gerges C, Lang D, Bettenworth D, Kabar I, Schmidt H, Neuhaus H, Ullerich H, Lenze F, Beyna T. Digital single-operator video cholangioscopy in treating refractory biliary stones: a multicenter observational study. Surg Endosc 2020; 34:1914-1922. [PMID: 31309312 DOI: 10.1007/s00464-019-06962-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Standard endoscopic treatment might fail to treat biliary stone disease. Here, we investigated the efficacy and safety of recently introduced digital single-operator video cholangioscopy (SOVC) for the treatment of difficult biliary stones. METHODS Digital SOVC procedures, performed in two tertiary referral centers between 2015 and 2018, were retrospectively analyzed. Only patients with a previous failure of endoscopic standard treatment and a SOVC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone removal rate per procedure and per patient. RESULTS In total, 75 examinations with a digital SOVC-assisted biliary stone treatment, performed in 60 patients, were identified. Biliary stones were mainly located extrahepatic (64%) and less frequently intrahepatic (36%). The median stone size was 20 mm (interquartile range [IQR]: 10-25 mm) and the median stone number was 1 (IQR: 1-2). Digital SOVC-based treatment of biliary stone disease was successful in 95% of patients and 15% needed at least two treatment sessions. Evaluated per procedure, a complete stone removal was accomplished in 67% of all examinations (including initial and repeated procedures), while an incomplete stone removal was observed in 33% of cases. The per procedure analyzes revealed that the success rates for a complete stone removal were similar between LL and EHL (66% vs. 68%; p = 0.87). Complications, such as postinterventional cholangitis and pancreatitis occurred in 16% of examinations; however, except from one case, all were mild or moderate and no procedure-associated mortality occurred. CONCLUSIONS Digital SOVC-assisted biliary stone treatment is highly effective even in cases with difficult biliary stones and might be considered the new standard of care for these patients. Furthermore, mild up to moderate complications were intermittently observed which might document the complexity of our included cases.
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Affiliation(s)
- Arne Bokemeyer
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Christian Gerges
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Diana Lang
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Dominik Bettenworth
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Iyad Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Hartmut Schmidt
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Hansjoerg Ullerich
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Frank Lenze
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Torsten Beyna
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.
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Abstract
PURPOSE OF REVIEW Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intrahepatic and/or extrahepatic bile ducts. It is associated with a significantly increased risk of malignancy, particularly cholangiocarcinoma (CCA). In this review, we discuss what is currently known about the epidemiology of and risk factors for CCA in PSC as well as recent advances in its prevention, diagnosis, and surveillance. RECENT FINDINGS An area of major focus has been finding novel biomarkers (in serum, bile, and urine) for CCA. With the advancement of computing power, metabolomic and proteomic approaches, among other methods, may provide enhanced capability for differentiating between benign and malignant bile duct disease. Another area of focus has been the approach to CCA surveillance in PSC; a recent study has found that CCA surveillance in patients with PSC is associated with improved outcomes, including increased survival, thus advocating for its importance. SUMMARY Despite ongoing advancements in the study of PSC-associated CCA, early diagnosis of CCA remains difficult, treatment options are limited, and prognosis is often consequently poor. Continued research in the development of high-accuracy diagnostic tools, novel biomarkers, and surveillance techniques may help to increase the likelihood of diagnosing CCA at earlier stages, when therapeutic options have the highest likelihood of resulting in cure.
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Affiliation(s)
- Brian M Fung
- UCLA-Olive View Internal Medicine Residency Program
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
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Yodice M, Choma J, Tadros M. The Expansion of Cholangioscopy: Established and Investigational Uses of SpyGlass in Biliary and Pancreatic Disorders. Diagnostics (Basel) 2020; 10:132. [PMID: 32121412 PMCID: PMC7151166 DOI: 10.3390/diagnostics10030132] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/13/2022] Open
Abstract
Direct visualization of bile and pancreatic duct pathology is proving to be beneficial in patients where previous techniques have failed. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. It is already known that SpyGlass is beneficial in patients with difficult bile duct stones and indeterminate biliary lesions through the use of targeted lithotripsy and visually guided biopsy. Cholangioscopy allows the visualization of hidden stone and guide wire placement across difficult strictures and selective cannulation of the intrahepatic and cystic ducts. It is also demonstrating its utility in investigational applications such as post-liver transplant and primary sclerosing cholangitis stricture treatment, evaluation of hemobilia, and guided radiofrequency ablation of ductal tumors. In addition to having clinical utility, cholangioscopy may also be cost-effective by limiting the number of repeat procedures. Cholangioscopy overall has similar complication rates compared to other standard endoscopic retrograde cholangioscopy (ERCP) techniques, but there may be higher rates of cholangitis. This could be mitigated with prophylactic antibiotic use, and overall, cholangioscopy has similar complication rates compared to other techniques.
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Affiliation(s)
| | - Joseph Choma
- Albany Gastroenterology Consultants, Albany, NY 12206, USA;
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So H, Park DH. Digital single-operator cholangioscopy for indeterminate biliary stricture: Enthusiasm or still evolving for unmet need? Gastrointest Endosc 2020; 91:394-395. [PMID: 32036945 DOI: 10.1016/j.gie.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/03/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Hoonsub So
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Furnari M, Telese A, Hann A, Lisotti A, Boškoski I, Eusebi LH. New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review. Curr Drug Metab 2020; 21:850-865. [PMID: 32703127 DOI: 10.2174/1389200221666200722145727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/04/2020] [Accepted: 06/02/2020] [Indexed: 12/07/2022]
Abstract
Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.
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Affiliation(s)
- Manuele Furnari
- Department of Internal Medicine, Gastroenterology Unit, Policlinico IRCCS "San Martino", University of Genoa, Genoa, Italy
| | - Andrea Telese
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alexander Hann
- Interventional and Experimental Endoscopy (InExEn), Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
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Pérez-Cuadrado Robles E, Kisoka P, Alexandre B, Deprez PH. A tricky pancreatic stone face to an expanding endoscopic armamentarium: we can lose a battle but not the war. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:880. [PMID: 31595757 DOI: 10.17235/reed.2019.6264/2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 43-year-old female with hereditary chronic pancreatitis presented with increasing pancreatic pain and multiple pancreatic stones, despite extracorporeal shockwave lithotripsy and pancreatic stenting 12 months previously. Direct lithotripsy was performed via endoscopic retrograde cholangio-pancreatography and the stones were further evaluated.
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Affiliation(s)
| | - Paul Kisoka
- Gastroenterology, Grand Hôpital de Charleroi, Belgium
| | | | - Pierre H Deprez
- Gastroenterology, Cliniques Universitaires Saint-Luc, Belgium
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