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1
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Chen YP, Liao YJ, Peng YC, Tung CF, Tsai HJ, Yang SS, Chen CC. Impact of Duodenal Papilla Morphology on the Success of Transpancreatic Precut Sphincterotomy. J Clin Med 2024; 13:6940. [PMID: 39598086 PMCID: PMC11594982 DOI: 10.3390/jcm13226940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2024] [Revised: 11/04/2024] [Accepted: 11/13/2024] [Indexed: 11/29/2024] Open
Abstract
Background: This study aimed to evaluate whether the morphology of the duodenal major papilla is linked to transpancreatic precut sphincterotomy (TPS) failure. Methods: We conducted a retrospective review of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at our institution. The inclusion criteria involved patients with a naïve major duodenal papilla who required TPS due to difficult biliary cannulation. Papilla morphology was classified using Haraldsson's system, as follows: regular (Type 1), small (Type 2), protruding or pendulous (Type 3), and creased or ridged (Type 4). The analysis focused on identifying risk factors for TPS failure and related complications. Results: A total of 103 cases were analyzed, with an overall TPS success rate of 85.44%. There were no significant differences in age, gender, ERCP indications, or the prevalence of juxtapupillary diverticula across the four papilla types. The TPS failure rates by papilla type were Type 1 (10.53%), Type 2 (0%), Type 3 (16.67%), and Type 4 (28%). Type 4 papilla had a significantly higher failure rate compared to Type 1 and Type 2 in the univariate analysis (p = 0.028), but this was not statistically significant in the multivariate analysis (p = 0.052). Age emerged as an independent risk factor for TPS failure. Conclusions: Duodenal papilla morphology may influence the success rate of TPS, with advanced age being a key risk factor for failure. Identifying high-risk factors such as Type 4 papilla and older age can help endoscopists adjust their techniques early, potentially improving outcomes and minimizing complications.
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Affiliation(s)
- Yi-Peng Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
| | - Yi-Jun Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
| | - Yen-Chun Peng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chun-Fang Tung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Hsin-Ju Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
| | - Sheng-Shun Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402202, Taiwan
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung 402202, Taiwan
| | - Chia-Chang Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-P.C.); (Y.-J.L.); (Y.-C.P.); (C.-F.T.); (H.-J.T.); (S.-S.Y.)
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402202, Taiwan
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Iqbal A, Ahmad Z, Aziz M, Alharbi A, Ali H, Al-Chalabi A, Gangwani MK, Dahiya DS, Smith WL, Singh S, Alastal Y, Kobeissy A. Pre-Cut Papillotomy Versus Endoscopic Ultrasound-Rendezvous for Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis. Gastroenterology Res 2024; 17:151-158. [PMID: 39247709 PMCID: PMC11379043 DOI: 10.14740/gr1738] [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: 05/03/2024] [Accepted: 06/28/2024] [Indexed: 09/10/2024] Open
Abstract
Background Various endoscopic techniques are employed to achieve biliary cannulation when confronted with difficult biliary access. Every procedure carries its own risk in terms of bleeding, infection, pancreatitis, and cholangitis. Our meta-analysis aimed to compare pre-cut papillotomy and endoscopic ultrasound (EUS)-rendezvous in terms of technical success rates, and post-procedure pancreatitis and bleeding. Methods We conducted a systematic review and meta-analysis of studies that compared pre-cut papillotomy and EUS-rendezvous. The primary outcome was technical success by achieving biliary cannulation. Secondary outcomes were postoperative pancreatitis and bleeding. A random-effects model was used to calculate the risk ratios (RRs) and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Results Our meta-analysis included four studies comparing pre-cut papillotomy and EUS-rendezvous. The studies included 13,659 total endoscopic retrograde cholangiopancreatography (ERCP) procedures, of whom 1,004 patients underwent alternate biliary cannulation procedures due to difficult biliary cannulation. The mean age of the study population was noted to be 49.5 years and males represented 53.3% of the total participants. Both procedures were similar in terms of technical success (RR: 0.95, 95% CI (0.88, 1.02)). No difference was found between rates of post procedure pancreatitis (RR: 1.82, 95% CI (0.80, 4.15)) and post procedure bleeding (RR: 2.80, 95% CI (0.67, 11.66)). Conclusions There was no difference in technical success of procedure or post-procedure complications such as pancreatitis and bleeding between pre-cut papillotomy and EUS-rendezvous technique. More randomized controlled trials (RCTs) are needed to compare both procedural techniques and complications rates. However, currently, both procedures are equally effective and safe during difficult biliary cannulation in the hands of experienced endoscopists.
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Affiliation(s)
- Amna Iqbal
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Zohaib Ahmad
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Muhammad Aziz
- Division of Gastroenterology, Bon Secours Mercy Health, Toledo, OH, USA
| | | | - Hassam Ali
- Department of Gastroenterology and Hepatology, ECU Health Medical Center, Greenville, NC, USA
| | - Ahmed Al-Chalabi
- Department of Gastroenterology, Creighton University, Omaha, NE, USA
| | | | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology and Motility, The University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Shailendra Singh
- Department of Gastroenterology and Hepatology, West Virginia University, Morgantown, WV, USA
| | - Yaseen Alastal
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Abdallah Kobeissy
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
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3
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Vanella G, Dell'Anna G, van Wanrooij RLJ, Bronswijk M, Voermans RP, Laleman W, van Malenstein H, Fockens P, Van der Merwe S, Arcidiacono PG. Managing dysfunctions and reinterventions in endoscopic ultrasound-guided choledochoduodenostomy with lumen apposing metal stents: Illustrated technical review (with videos). Dig Endosc 2024; 36:481-491. [PMID: 37852797 DOI: 10.1111/den.14708] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with lumen apposing metal stent is emerging both as a rescue strategy and a primary treatment for distal malignant biliary obstruction. The large-scale diffusion of the procedure and improved overall survival of patients with pancreatobiliary neoplasms is resulting in a growing population of long-term EUS-CDS lumen apposing metal stent carriers. Recent studies have reported a need for reintervention during follow-up as high as 55%, and the Leuven-Amsterdam-Milan Study Group classification has been developed, identifying five mechanisms of stent dysfunction and 11 possible rescue strategies aimed at restoring biliary drainage. This illustrated technical review aims to further dissect the recent classification through a comprehensive analysis of nine illustrative cases, offering insights into the pathophysiology underlying dysfunction and clinical reasoning behind rescue interventions, as well as technical considerations and practical tips and tricks. By exploring mechanisms of dysfunction, this review also assists clinicians in selecting the ideal candidates for EUS-CDS while identifying patients deemed high risk for dysfunction or clinical failure.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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McDonagh P, Awadelkarim B, Leeds JS, Nayar MK, Oppong KW. Endoscopic Ultrasound-Guided Gallbladder Drainage for Malignant Biliary Obstruction: A Systematic Review. Cancers (Basel) 2023; 15:2988. [PMID: 37296955 PMCID: PMC10251815 DOI: 10.3390/cancers15112988] [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: 05/02/2023] [Revised: 05/27/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage. METHODS A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events. RESULTS Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78-90%, I2: 0%). The pooled rate of adverse events (95% CI) was 13% (7-19%, I2: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression. CONCLUSION This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures.
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Affiliation(s)
- Padraic McDonagh
- HPB Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK; (P.M.); (B.A.); (J.S.L.); (M.K.N.)
| | - Bidour Awadelkarim
- HPB Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK; (P.M.); (B.A.); (J.S.L.); (M.K.N.)
| | - John S. Leeds
- HPB Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK; (P.M.); (B.A.); (J.S.L.); (M.K.N.)
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK
| | - Manu K. Nayar
- HPB Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK; (P.M.); (B.A.); (J.S.L.); (M.K.N.)
| | - Kofi W. Oppong
- HPB Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK; (P.M.); (B.A.); (J.S.L.); (M.K.N.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK
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5
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Dell'Anna G, Ogura T, Vanella G, Nishikawa H, Lakhtakia S, Arcidiacono PG. Endoscopic ultrasound guided biliary interventions. Best Pract Res Clin Gastroenterol 2022; 60-61:101810. [PMID: 36577530 DOI: 10.1016/j.bpg.2022.101810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5-10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP. This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.
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Affiliation(s)
- Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Hiroki Nishikawa
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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6
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Vanella G, Dell’Anna G, Bronswijk M, van Wanrooij RL, Rizzatti G, Gkolfakis P, Larghi A, van der Merwe S, Arcidiacono PG. Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care. Ann Gastroenterol 2022; 35:441-451. [PMID: 36061163 PMCID: PMC9399569 DOI: 10.20524/aog.2022.0736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022] Open
Abstract
Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUS-guided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancer-related symptoms.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
| | - Giuseppe Dell’Anna
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium (Michiel Bronswijk, Schalk van der Merwe)
- Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium (Michiel Bronswijk)
| | - Roy L.J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands (Roy L.J. van Wanrooij)
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy (Gianenrico Rizzatti, Alberto Larghi)
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (Paraskevas Gkolfakis)
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy (Gianenrico Rizzatti, Alberto Larghi)
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium (Michiel Bronswijk, Schalk van der Merwe)
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
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7
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Maruta S, Sugiyama H, Ogasawara S, Sugihara C, Ouchi M, Kan M, Yamada T, Miura Y, Nagashima H, Takahashi K, Kusakabe Y, Ohyama H, Okitsu K, Ohno I, Mikata R, Sakai Y, Tsuyuguchi T, Kato J, Kato N. "Salvage techniques" are the key to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography. Sci Rep 2022; 12:13627. [PMID: 35948566 PMCID: PMC9365799 DOI: 10.1038/s41598-022-17809-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Although the efficacy and safety of salvage techniques for biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) have been reported, few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with native papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, cannulation success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate using standard technique alone was 62.8%, which increased to 94.3% including salvage techniques. Salvage techniques were frequently required in patients with long oral protrusions (OR 2.38; 95% CI 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Salvage techniques may help to overcome many difficult biliary cannulation cases.
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Affiliation(s)
- Shikiko Maruta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan.
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan.,Translational Research and Development Center, Chiba University Hospital, Chiba, Japan
| | - Chihei Sugihara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Mayu Ouchi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Motoyasu Kan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Toshihito Yamada
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yoshifumi Miura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Hiroki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Koji Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yuko Kusakabe
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Hiroshi Ohyama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Koichiro Okitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Izumi Ohno
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Rintaro Mikata
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Yuji Sakai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | | | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, 260-8670, Japan
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8
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Lambin T, Rivory J, Adham M, Rostain F, Ponchon T, Lafeuille P, Pioche M. Endoscopic biliary access after pancreaticoduodenectomy following Imanaga's procedure. Endoscopy 2022; 54:E360-E361. [PMID: 34374050 DOI: 10.1055/a-1540-6827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Thomas Lambin
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France.,Inserm U1032, Labtau, Lyon, France
| | - Jérôme Rivory
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Mustapha Adham
- Digestive Surgery Unit, Edouard Herriot Hospital, Lyon, France
| | - Florian Rostain
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Thierry Ponchon
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Pierre Lafeuille
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Gastroenterology and Endoscopy Unit, Pavillon L, Edouard Herriot Hospital, Lyon, France.,Inserm U1032, Labtau, Lyon, France
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9
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Spadaccini M, Binda C, Fugazza A, Repici A, Tarantino I, Fabbri C, Cugia L, Anderloni A, on behalf of the Interventional Endoscopy & Ultra Sound (I-EUS) Group. Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:331. [PMID: 35334507 PMCID: PMC8951173 DOI: 10.3390/medicina58030331] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Cecilia Binda
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, AUSL Romagna, Morgagni-Pierantoni Hospital and Bufalini Hospital, 47100 Forli, Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT/UPMC), 90127 Palermo, Italy;
| | - Carlo Fabbri
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, AUSL Romagna, Morgagni-Pierantoni Hospital and Bufalini Hospital, 47100 Forli, Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Luigi Cugia
- Gastroenterology and Digestive Endoscopy Department, Azienda Ospedaliero Universitaria Sassari, 07100 Sassari, Italy;
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
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10
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Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Imamura H, Matsushita I, Kakuma T, Tada S. Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones. Clin Endosc 2021; 55:263-269. [PMID: 34763384 PMCID: PMC8995991 DOI: 10.5946/ce.2021.153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background/Aims Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.
Methods This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.
Results Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.
Conclusions Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, Kumamoto, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Haruo Imamura
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, Fukuoka, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto, Japan
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11
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Pawa R, Pleasant T, Tom C, Pawa S. Endoscopic ultrasound-guided biliary drainage: Are we there yet? World J Gastrointest Endosc 2021; 13:302-318. [PMID: 34512878 PMCID: PMC8394188 DOI: 10.4253/wjge.v13.i8.302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/14/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.
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Affiliation(s)
- Rishi Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Troy Pleasant
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Chloe Tom
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, United States
| | - Swati Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
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12
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Chung HY, Hsu CC, Hung YL, Chen HW, Wong MS, Fu CY, Tsai CY, Chen MY, Wang SY, Hsu JT, Yeh TS, Yeh CN, Jan YY. Alternative application of percutaneous cholecystostomy in patients with biliary obstruction. Abdom Radiol (NY) 2021; 46:2891-2899. [PMID: 33388808 DOI: 10.1007/s00261-020-02898-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/28/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Percutaneous cholecystostomy (PC) is an important modality for acute cholecystitis and has been applied for other clinical scenarios as well. In the present study, we aimed to investigate an alternative use of PC for obstructive jaundice. METHODS From January 2012 to December 2018, eligible subjects were selected from patients undergoing PC in our institute. The characteristics, spectrum of underlying disease, indication for PC performance, details of the procedure, and treatment effect were all investigated. RESULTS During the study period, 1364 patients underwent PC. Seventy patients fulfilled the defined inclusion criteria. While 47 patients were diagnosed with malignant biliary obstruction with or without cholangitis, 23 patients were diagnosed with nonmalignant biliary obstruction and acute cholangitis. There were 63 patients (90%) diagnosed with acute cholangitis. Pancreatic cancer (n = 24, 51%) and advanced malignancy (n = 28, 59%) were noted mostly in the group with malignant biliary obstruction. Treatment effects were proven by laboratory data, including the white blood cell count, C-reactive protein level, and hepatic function. CONCLUSION PC can temporize definitive therapies and serve as an alternative treatment for patients with nonmalignant conditions. For patients with advanced malignancy, PC can serve as a palliative procedure that has a high success rate and low complication rate and effectively relieves biliary obstruction.
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Affiliation(s)
- Hung-Yu Chung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Chieh Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Man Si Wong
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
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Al manasra ARA, Jadallah K, Aleshawi A, Al-Omari M, Elheis M, Reyad A, Fataftah J, Al-Domaidat H. Intractable Biliary Candidiasis in Patients with Obstructive Jaundice and Regional Malignancy: A Retrospective Case Series. Clin Exp Gastroenterol 2021; 14:83-89. [PMID: 33707962 PMCID: PMC7941053 DOI: 10.2147/ceg.s301340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series. METHODS We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures - obtained by PTC - for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed. RESULTS A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy. CONCLUSION We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).
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Affiliation(s)
- Abdel rahman A Al manasra
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Jadallah
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Abdelwahab Aleshawi
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mamoon Al-Omari
- Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mwaffaq Elheis
- Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmad Reyad
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Jehad Fataftah
- Department of Radiology, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Hamzeh Al-Domaidat
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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14
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Lee SH, Lee JM, Han NY, Kim MJ, Park BJ, Sung DJ, Sim KC. Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis. Acta Radiol 2020; 61:1484-1493. [PMID: 32208743 DOI: 10.1177/0284185120909334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important. PURPOSE To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation. MATERIAL AND METHODS A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation. RESULTS Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy. CONCLUSION The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.
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Affiliation(s)
- Sun Hwa Lee
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Min Lee
- Department of Internal Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Na Yeon Han
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ju Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Beom Jin Park
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Deuk Jae Sung
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ki Choon Sim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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15
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Chen PH, Tung CF, Peng YC, Yeh HZ, Chang CS, Chen CC. Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study. BMC Gastroenterol 2020; 20:310. [PMID: 32988368 PMCID: PMC7520951 DOI: 10.1186/s12876-020-01455-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background We investigated whether duodenal major papilla morphology could be a risk factor for failure of selective biliary cannulation (SBC) and post endoscopic retrograde cholangiography and pancreatography (ERCP) complications. Methods A prospectively recorded database was reviewed retrospectively. Patients were included if they received therapeutic ERCP and had naïve major duodenal papilla. We used Haraldsson’s classification for papilla morphology, as follows: Regular (Type 1), Small (Type 2), Protruding or Pendulous (Type 3) and Creased or Ridged (Type 4). Risk factors for failing SBC and post-ERCP complications were analyzed by multivariate analysis. Results A total of 286 cases were included. Age, gender, indications and therapeutic procedures were not different among the four types of papillae. The failure rates of SBC with Type 3 papilla and Type 4 papilla were 11.11% and 6.25%, respectively. In the multivariate analysis, Type 2 papilla (odd ratio 7.18, p = 0.045) and Type 3 papilla (odd ratio 7.44, p = 0.016) were associated with greater SBC failure compared with Type 1 papilla. Malignant obstruction compared to stone (odds ratio 4.45, p = 0.014) and age (odd ratio = 1.06, p = 0.010) were also risk factors for cannulation failure. Type 2 papilla was correlated with a higher rate of post-ERCP pancreatitis (20%, p = 0.020) compared to the other types of papilla However, papilla morphology was not a significant risk factor for any complications in the multivariate analysis. Conclusion Small papilla and protruding or pendulous papilla are more difficult to cannulate compared to regular papilla. Small papilla is associated with a higher rate of post-ERCP pancreatitis.
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Affiliation(s)
- Po-Han Chen
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan
| | - Chun-Fang Tung
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Chung Peng
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hong-Zen Yeh
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Sen Chang
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan
| | - Chia-Chang Chen
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.
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16
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Yue P, Zhu KX, Wang HP, Meng WB, Liu JK, Zhang L, Zhu XL, Zhang H, Miao L, Wang ZF, Zhou WC, Suzuki A, Tanaka K, Li X. Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation. World J Gastroenterol 2020; 26:2403-2415. [PMID: 32476801 PMCID: PMC7243649 DOI: 10.3748/wjg.v26.i19.2403] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/09/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Different types of periampullary diverticulum (PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography (ERCP) cannulation, but the clinical significance of the two current PAD classifications for cannulation is limited.
AIM To verify the clinical value of our newly proposed PAD classification.
METHODS A new PAD classification (Li-Tanaka classification) was proposed at our center. All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.
RESULTS A total of 3564 patients with native papillae were enrolled, including 967 (27.13%) PAD patients and 2597 (72.87%) non-PAD patients. In the Li-Tanaka classification, type I PAD patients exhibited the highest difficult cannulation rate (23.1%, P = 0.01), and type II and IV patients had the highest cannulation success rates (99.4% in type II and 99.3% in type IV, P < 0.001). In a multivariable-adjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio (OR) = 1.87, 95% confidence interval (CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group, the difficulty of cannulation in the type I PAD group according to the Li-Tanaka classification was greater (OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower (OR = 0.27, 95%CI: 0.11-0.66, P < 0.001), while it was higher in the type II PAD group (OR = 4.44, 95%CI: 1.61-12.29, P < 0.01).
CONCLUSION Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.
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Affiliation(s)
- Ping Yue
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The First Clinical Medical School of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Ke-Xiang Zhu
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hai-Ping Wang
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Bo Meng
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
| | - Jian-Kang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02451, United States
| | - Lei Zhang
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Fifth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiao-Liang Zhu
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Fifth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Zhang
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Long Miao
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Zheng-Feng Wang
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Ce Zhou
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Azumi Suzuki
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Xun Li
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Lanzhou 730000, Gansu Province, China
- The First Clinical Medical School of Lanzhou University, Lanzhou 730000, Gansu Province, China
- The Fifth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
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Dalal A, Patil G, Maydeo A. Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center. Dig Endosc 2020; 32:409-416. [PMID: 31385380 DOI: 10.1111/den.13504] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasonography-guided pancreatic ductal intervention (EUS-PDI) serves as a rescue therapy in patients with failure of retrograde access to the pancreatic duct (PD) at the time of endoscopic retrograde pancreatography (ERP). We review our experience of this procedure. METHODS This is a retrospective study of patients who underwent EUS-PDI for an unsuccessful ERP and altered anatomy. RESULTS A total of 44 (65.9% male) patients underwent EUS-PDI with a mean age of 43.5 years, (range: 23-67). Transgastric rendezvous technique was carried out in 23/44 (52.3%), transgastric pancreaticogastrostomy in 18/44 (40.9%) and transduodenal pancreaticobulbostomy in 3/44 (6.8%). Overall technical and clinical success was seen in 88.6% (39/44) and 81.8% (36/44), respectively. Technical success of transgastric rendezvous was 95.6% and that of transgastric pancreaticogastrostomy was 77.8%. Two of seven patients with failure to access the PD had successfully undergone EUS-PD stenting at subsequent attempt. Ten immediate adverse events (AE) were noted which included abdominal pain (n = 4), pancreatitis (n = 2), fever (n = 2), minor bleeding (n = 1), and stripping of wire (n = 1). Delayed AE included stent blockage in 12/39 (30.8%) and spontaneous stent migration in 5/39 (12.8%) which were managed with stent exchange at follow up. The rendezvous technique was associated with fewer AE than transgastric pancreaticogastrostomy. CONCLUSIONS Endoscopic ultrasonography-PDI is an effective treatment modality and salvage therapy in patients with unsuccessful ERP. Technical and clinical success seen with this study is comparable to studies conducted across the world. EUS-PDI needs to show cost-effectiveness in future studies.
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Affiliation(s)
- Ankit Dalal
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, India
| | - Gaurav Patil
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, India
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, India
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Yuen N, O'Shaughnessy P, Thomson A. New classification system for indications for endoscopic retrograde cholangiopancreatography predicts diagnoses and adverse events. Scand J Gastroenterol 2017; 52:1457-1465. [PMID: 28954557 DOI: 10.1080/00365521.2017.1384053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Indications for endoscopic retrograde cholangiopancreatography (ERCP) have received little attention, especially in scientific or objective terms. AIM To review the prevailing ERCP indications in the literature, and to propose and evaluate a new ERCP indication system, which relies on more objective pre-procedure parameters. METHODS An analysis was conducted on 1758 consecutive ERCP procedures, in which contemporaneous use was made of an a-priori indication system. Indications were based on the objective pre-procedure parameters and divided into primary [cholangitis, clinical evidence of biliary leak, acute (biliary) pancreatitis, abnormal intraoperative cholangiogram (IOC), or change/removal of stent for benign/malignant disease] and secondary [combination of two or three of: pain attributable to biliary disease ('P'), imaging evidence of biliary disease ('I'), and abnormal liver function tests (LFTs) ('L')]. A secondary indication was only used if a primary indication was not present. The relationship between this newly developed classification system and ERCP findings and adverse events was examined. RESULTS The indications of cholangitis and positive IOC were predictive of choledocholithiasis at ERCP (101/154 and 74/141 procedures, respectively). With respect to secondary indications, only if all three of 'P', 'I', and 'L' were present there was a statistically significant association with choledocholithiasis (χ2(1) = 35.3, p < .001). Adverse events were associated with an unusual indication leading to greater risk of unplanned hospitalization (χ2(1) = 17.0, p < .001). CONCLUSIONS An a-priori-based indication system for ERCP, which relies on pre-ERCP objective parameters, provides a more useful and scientific classification system than is available currently.
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Affiliation(s)
- Nicholas Yuen
- a Australian National University Medical School , Acton , Australia
| | | | - Andrew Thomson
- a Australian National University Medical School , Acton , Australia.,c Gastroenterology Unit , The Canberra Hospital , Canberra , Australia
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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