Use of texture and color enhancement imaging to identify the pancreatic duct orifice in a patient with a pancreaticojejunal anastomotic stricture

Recent advancements in image-enhanced endoscopy in the pancreatobiliary field

Image-enhanced endoscopy (IEE) has advanced gastrointestinal disease diagnosis and treatment. Traditional white-light imaging has limitations in detecting all gastrointestinal diseases, prompting the development of IEE. In this review, we explore the utility of IEE, including texture and color enhancement imaging and red dichromatic imaging, in pancreatobiliary (PB) diseases. IEE includes methods such as chromoendoscopy, optical-digital, and digital methods. Chromoendoscopy, using dyes such as indigo carmine, aids in delineating lesions and structures, including pancreato-/cholangio-jejunal anastomoses. Optical-digital methods such as narrow-band imaging enhance mucosal details and vessel patterns, aiding in ampullary tumor evaluation and peroral cholangioscopy. Moreover, red dichromatic imaging with its specific color allocation, improves the visibility of thick blood vessels in deeper tissues and enhances bleeding points with different colors and see-through effects, proving beneficial in managing bleeding complications post-endoscopic sphincterotomy. Color enhancement imaging, a novel digital method, enhances tissue texture, brightness, and color, improving visualization of PB structures, such as PB orifices, anastomotic sites, ampullary tumors, and intraductal PB lesions. Advancements in IEE hold substantial potential in improving the accuracy of PB disease diagnosis and treatment. These innovative techniques offer advantages paving the way for enhanced clinical management of PB diseases. Further research is warranted to establish their standard clinical utility and explore new frontiers in PB disease management.

Preoperative risk-stratified analysis: External versus internal pancreatic stents in pancreatoduodenectomy

BACKGROUND

Several risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting.

METHODS

Data from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0-5) and high-risk (preFRS: 6-8) groups.

RESULTS

PreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021).

CONCLUSION

The external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.

TeXture and color enhancement Imaging-assisted precutting: 3 case reports

Backgrounds and Aims

In ERCP, precutting is used when biliary cannulation is challenging. Precutting is a high-risk procedure that can lead to adverse events. TeXture and color enhancement Imaging (TXI) enhances texture, brightness, and color to define subtle tissue differences clearly and may be helpful in precutting. Nevertheless, there are limited video case reports demonstrating precutting using TXI. Here, we review the techniques of TXI-assisted precutting.

Methods

This video article describes TXI-assisted precutting in 3 patients with obstructive jaundice resulting from cancer of the pancreatic head. The existing literature on TXI for biliopancreatic endoscopy also is reviewed.

Results

In all cases, TXI helped in biliary cannulation using precutting. No adverse events were observed in any of the cases.

Conclusions

Despite the roughness of the precut incision surface, TXI was found to improve visibility and significantly helped achieve biliary cannulation.

Efficacy of texture and color enhancement imaging for short-type single-balloon enteroscopy-assisted biliary cannulation in patients with Roux-en-Y gastrectomy: Multicenter study (with video)

OBJECTIVES

Texture and color enhancement imaging (TXI) reportedly improves the identification of the papilla of Vater for selective biliary cannulation compared with white light imaging (WLI). This multicenter study evaluated the efficacy of short-type single-balloon enteroscopy (SBE)-assisted biliary cannulation using a new-generation image-enhanced endoscopy processing system equipped with TXI in patients who underwent Roux-en-Y gastrectomy.

METHODS

Patients with Roux-en-Y gastrectomy with a native papilla, and underwent short SBE-assisted biliary cannulation during endoscopic retrograde cholangiopancreatography-related procedures between January 2019 and April 2023 were retrospectively reviewed. Outcomes of biliary cannulation using TXI and WLI were compared. The primary outcome was time to successful biliary cannulation.

RESULTS

Thirty-three patients underwent biliary cannulation with TXI and 98 underwent WLI. The biliary cannulation success rates and median time to successful biliary cannulation with TXI and WLI were 93.9% (95% confidence interval [CI] 79.8-99.3%) and 83.7% (95% CI 74.8-90.4%), respectively (P = 0.14), and 10 min (interquartile range [IQR] 2.5-23.5) and 18 min (IQR 9.75-24), respectively (P = 0.04). Biliary cannulation with TXI required a shorter cannulation time than that required with WLI. Adverse event rates with TXI and WLI did not differ significantly (P = 0.58). Multivariate linear regression analysis showed that the use of TXI and short length of oral protrusion were associated with a shorter successful biliary cannulation time.

CONCLUSION

Short SBE-assisted biliary cannulation was effective and safe on TXI in patients who underwent Roux-en-Y gastrectomy, and achieved shorter successful biliary cannulation time.

Long-term outcomes and risk factors of pancreatic insufficiency after a pancreatoduodenectomy: A retrospective study

BACKGROUND

An increasing number of patients are achieving long-term survival after pancreatoduodenectomy, meaning that risk assessments of endocrine and exocrine pancreatic insufficiency are needed. Herein, we investigated the risk factors for pancreatic insufficiency after pancreatoduodenectomy by incorporating pancreatic morphologic changes and perioperative factors.

METHODS

Patients who underwent pancreatoduodenectomy between January 2015 and December 2020 were enrolled in this single-center retrospective study. Clinicopathologic, surgical, and pancreatic morphologic factors were collected, and risk factors for exocrine pancreatic insufficiency and endocrine pancreatic insufficiency were analyzed. Exocrine pancreatic insufficiency was defined as steatorrhea requiring pancreatic enzymes and new onset steatosis, and endocrine pancreatic insufficiency was defined as postoperative new-onset diabetes mellitus. Multivariate analysis was performed.

RESULTS

Among the 206 patients enrolled, 14% and 24% developed endocrine pancreatic insufficiency and exocrine pancreatic insufficiency, respectively. Multivariate analysis revealed residual pancreatic stent 1 year postoperatively, lymph node metastasis, and postoperative pancreatic atrophy (P-atrophy) as independent risk factors for exocrine pancreatic insufficiency, whereas preoperative glycated hemoglobin levels, residual pancreatic stent, and postoperative main pancreatic duct dilatation were risk factors for endocrine pancreatic insufficiency. Subgroup analysis of pancreatic ductal adenocarcinoma revealed that exocrine pancreatic insufficiency in patients with pancreatic ductal adenocarcinoma was caused by preoperative decreased pancreatic function (high glycated hemoglobin and a low postoperative pancreatic fistula rate), whereas the high incidence of POPF influenced the development of exocrine pancreatic insufficiency in patients without pancreatic ductal adenocarcinoma.

CONCLUSION

Postoperative pancreatic atrophy and main pancreatic duct dilatation are risk factors for exocrine pancreatic insufficiency I and endocrine pancreatic insufficiency, respectively, and residual pancreatic stent affects both types of pancreatic dysfunction. Improving the surgical approach and stent management may help prevent these late complications.

Visibility of the biliary orifice after precut papillotomy: Comparison between white light imaging and texture and color enhancement imaging

BACKGROUND

Precut papillotomy is performed in cases of difficult biliary cannulation, but identification of the biliary orifice is difficult. Texture and color enhancement imaging (TXI) can enhance the structure, color, and brightness. This study compared TXI and white light imaging (WLI) in visibility of biliary orifices.

METHODS

We retrospectively examined 20 patients who underwent bile duct cannulation using both WLI and TXI after precut papillotomy at our center between 2021 and 2022. On WLI and TXI images displayed in random order, bile duct orifice on precut-incision surface of each image was independently evaluated by eight evaluators. Single-indication accuracy rate of biliary orifices, visibility score rated on a 4-grade scale, and color difference between the biliary orifice and the surrounding tissue were examined.

RESULTS

The single-indication accuracy rate was higher in TXI compared to WLI (50.6% vs. 35.6%, odds ratio 2.26 [95% CI: 1.32-3.89], p = .003). The time to indicate the biliary orifice was comparable between TXI and WLI (median, 9.7 s [range, 2.6-43] vs. 10.9 s [1.5-64], p = .086). Furthermore, the visibility score was higher in TXI than in WLI (median, 3 [interquartile range, 2-3] vs. 2 [2, 3], p < .001), and the color difference between the biliary orifice and surrounding tissue in TXI was more pronounced than in WLI (median, 22.9 [range, 9.39-55.2] vs. 18.0 [6.48-43.0]; p < .001).

CONCLUSIONS

TXI enhanced the color difference and visibility of the biliary orifice after precut and improved single-indication accuracy rate, suggesting that it could be useful for biliary cannulation after precut papillotomy.

Advanced technical tips and recent insights in ERCP using balloon-assisted endoscopy

Pancreatobiliary endoscopic interventions using balloon-assisted endoscopes have been widely acknowledged as the first-line therapy for pancreatobiliary diseases in postoperative patients with reconstructed gastrointestinal anatomy (excluding the Billroth I procedure). However, there are many technical difficulties, and the procedural completion rates vary in a wide range among institutions, indicating the procedural technique is yet to be standardized. This article aims to provide technical tips of procedures and insights into the advanced aspects, including the management of extremely difficult cases and troubleshooting of endoscopic retrograde cholangiopancreatography using balloon endoscopy, along with a review of recent advancements in this field.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Usefulness of texture- and color-enhancement imaging for identifying the bleeding point in a patient with post-endoscopic sphincterotomy bleeding

Video 1Upon reaching the papilla, fresh blood was observed. However, the bleeding point could not be detected on white-light imaging. Therefore, we switched to texture- and color-enhancement imaging to identify the bleeding point. A visible vessel was identified on texture- and color-enhancement imaging. Endoscopic hemostasis was successfully achieved using a hemostatic clip.