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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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Karagyozov P, El-Atrebi K, Boeva I, Tishkov I. Cholangioscopy-guided lithotripsy in the treatment of difficult bile ducts stones - Bulgarian and Egyptian experience. Folia Med (Plovdiv) 2023; 65:582-588. [PMID: 37655376 DOI: 10.3897/folmed.65.e84828] [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: 04/03/2022] [Accepted: 12/07/2022] [Indexed: 09/02/2023] Open
Abstract
Introduction: Up to 10% of bile duct stones are deemed 'difficult' because they cannot be extracted using standard endoscopic techniques. In these situations, cholangioscopy allows for stone fragmentation under direct visual control.
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Affiliation(s)
- Petko Karagyozov
- Acibadem City Clinic Tokuda University Hospital, Sofia, Bulgaria
| | - Kamal El-Atrebi
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | | | - Ivan Tishkov
- Acibadem City Clinic Tokuda University Hospital, Sofia, Bulgaria
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3
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Xie W, Ma Z, Zuo J, Gong J, Yu W, Wang P, Han W, Song Z, Yang T. The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: a multicenter retrospective study. Langenbecks Arch Surg 2023; 408:195. [PMID: 37188992 DOI: 10.1007/s00423-023-02923-3] [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: 08/16/2022] [Accepted: 04/29/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE To analyze the benefits of laparoscopic common bile duct exploration and laparoscopic cholecystectomy (LCBDE + LC) versus endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy following laparoscopic cholecystectomy (ERCP/EST + LC) for difficult common bile duct stones combined with gallstones. METHODS A retrospective analysis of consecutive patients with difficult common bile duct stones combined with gallstones in three hospitals from January 2016 to January 2021 was performed. RESULTS ERCP/EST + LC contributed to reducing postoperative drainage time. However, LCBDE + LC showed a higher rate of complete clearance, along with lower postoperative hospital stays, expenses and incidence of postoperative hyperamylasemia, pancreatitis, re-operation and recurrence. In addition, LCBDE + LC showed safe and feasible performance in the elderly and patients with previous upper abdominal surgery. CONCLUSION It is an effective and safe method for LCBDE + LC for difficult common bile duct stones combined with gallstones.
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Affiliation(s)
- Wangcheng Xie
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhilong Ma
- Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jieliang Zuo
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Gong
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Weidi Yu
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Wang
- Department of General Surgery, Taizhou Fourth People's Hospital, Taizhou, China
| | - Wei Han
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhenshun Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Tingsong Yang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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Facciorusso A, Gkolfakis P, Ramai D, Tziatzios G, Lester J, Crinò SF, Frazzoni L, Papanikolaou IS, Arvanitakis M, Blero D, Lemmers A, Eisendrath P, Fuccio L, Triantafyllou K, Gabbrielli A, Devière J. Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis. Clin Gastroenterol Hepatol 2023; 21:33-44.e9. [PMID: 34666153 DOI: 10.1016/j.cgh.2021.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis. METHODS Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence. RESULTS All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03-1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07-1.45], vs S+EPLBD [RR, 1.23; range, 1.06-1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14-1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events. CONCLUSIONS Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy; Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Janice Lester
- Health Science Library, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Sant Orsola-Malpighi Hospital, Boogna, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Cliniques Universitaires de Bruxelles Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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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: 0] [Impact Index Per Article: 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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6
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Alexandrino G, Lopes L, Fernandes J, Moreira M, Araújo T, Campos S, Loureiro R, Figueiredo L, Lourenço LC, Horta D, Bana E Costa T, Costa P, Canena J. Factors Influencing Performance of Cholangioscopy-Guided Lithotripsy Including Available Different Technologies: A Prospective Multicenter Study with 94 Patients. Dig Dis Sci 2022; 67:4195-4203. [PMID: 34811629 DOI: 10.1007/s10620-021-07305-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/25/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Peroral cholangioscopy (POC)-guided lithotripsy is an effective treatment for difficult biliary stones. A clear definition of factors associated with the efficacy of POC-guided lithotripsy in one session and the performance of electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL) have not clearly emerged. METHODS This was a non-randomized prospective multicenter study of all consecutive patients who underwent POC lithotripsy (using EHL and/or LL) for difficult biliary stones. The primary endpoint of the study was the number of sessions needed to achieve complete ductal clearance and the factors associated with this outcome. Secondary endpoints included the evaluated efficacies of LL and EHL. RESULTS Ninety-four patients underwent 113 procedures of EHL or LL. Complete ductal clearance was obtained in 93/94 patients (98.94%). In total, 80/94 patients (85.11%) achieved stone clearance in a single session. In the multivariate analysis, stone size was independently associated with the need for multiple sessions to achieve complete ductal clearance (odds ratio = 1.146, 95% confidence interval: 1.055-1.244; p = 0.001). Using ROC curves and the Youden index, 22 mm was found to be the optimal cutoff for stone size (95% confidence interval: 15.71-28.28; p < 0.001). The majority of the patients (62.8%) underwent LL in the first session. Six patients failed the first session with EHL after using two probes and therefore were crossed over to LL, obtaining ductal clearance in a single additional session with a single LL fiber. EHL was significantly associated with a larger number of probes (2.0 vs. 1.02) to achieve ductal clearance (p < 0.01). The mean procedural time was significantly longer for EHL than for LL [72.1 (SD 16.3 min) versus 51.1 (SD 10.5 min)] (p < 0.01). CONCLUSIONS POC is highly effective for difficult biliary stones. Most patients achieved complete ductal clearance in one session, which was significantly more likely for stones < 22 mm. EHL was significantly associated with the need for more probes and a longer procedural time to achieve ductal clearance.
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Affiliation(s)
- Gonçalo Alexandrino
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Luís Lopes
- Gastroenterology Department, Hospital de Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal.,School of Medicine, Life and Health Sciences Research Institute (ICVS), Universidade do Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - João Fernandes
- Gastroenterology Department, Hospital de Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal.,Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Marta Moreira
- Gastroenterology Department, Hospital de Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Tarcísio Araújo
- Gastroenterology Department, Hospital de Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Sara Campos
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Rui Loureiro
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Luísa Figueiredo
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | | | - David Horta
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Tiago Bana E Costa
- Gastroenterology Department, Hospital Egas Moniz - Centro Hospital Lisboa Ocidental, Lisbon, Portugal
| | - Patrício Costa
- School of Medicine, Life and Health Sciences Research Institute (ICVS), Universidade do Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal. .,Gastroenterology University Center - Hospital Cuf Tejo, Lisbon, Portugal. .,Gastroenterology Department - Nova Medical School, Faculty of Medical Sciences, Hospital Cuf Tejo, Avenida 24 de Julho, 171A, 1350-352, Lisbon, Portugal. .,Cintesis - Center for Health Technology and Services Research, Porto, Portugal.
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7
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Pereira Lima JC, Moresco GS, Sanmartin IDA, Contin I, Pereira-Lima G, Watte G, Altmayer S, Oliveira dos Santos CE. Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts. World J Gastrointest Endosc 2022; 14:424-433. [PMID: 36051990 PMCID: PMC9329850 DOI: 10.4253/wjge.v14.i7.424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/10/2022] [Accepted: 06/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.
AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.
METHODS Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications.
RESULTS Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively).
CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.
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Affiliation(s)
- Julio Carlos Pereira Lima
- Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil
| | - Giusepe Saifert Moresco
- Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil
| | - Ivan David Arciniegas Sanmartin
- Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil
| | - Isabela Contin
- Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil
| | - Guilherme Pereira-Lima
- Department of Gastroenterology, Endoscopy Division, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital, Porto Alegre 90020-090, RS, Brazil
| | - Guilherme Watte
- Department of Biostatistics and Epidemiology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, RS, Brazil
| | - Stephan Altmayer
- Department of Biostatistics and Epidemiology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre 90619-900, RS, Brazil
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8
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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: 3] [Impact Index Per Article: 1.5] [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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9
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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: 17] [Impact Index Per Article: 8.5] [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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10
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Sanders DJ, Bomman S, Krishnamoorthi R, Kozarek RA. Endoscopic retrograde cholangiopancreatography: Current practice and future research. World J Gastrointest Endosc 2021; 13:260-274. [PMID: 34512875 PMCID: PMC8394185 DOI: 10.4253/wjge.v13.i8.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
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Affiliation(s)
- David J Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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11
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Hao J, Huang X. The Status and Development of Oral Choledochoscopy Diagnosis and Treatment of Biliary Tract Diseases. Int J Gen Med 2021; 14:4269-4277. [PMID: 34393506 PMCID: PMC8360357 DOI: 10.2147/ijgm.s317484] [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] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022] Open
Abstract
Choledochoscopy technology has realized the direct observation of bile duct lesions, and can be loaded with a variety of special accessories to perform the corresponding diagnosis and treatment operations, and has become an important means for the diagnosis of unexplained bile duct stricture and treatment of refractory bile duct stones. With the further enhancement of the imaging quality and operability, the clinical application of choledochoscopy has gradually expanded to the precise positioning of cholangiocarcinoma before surgical resection, the drainage of the gallbladder through the nipple, the removal of the displaced bile duct stent and other fields. This paper briefly reviewed the historical evolution of choledochoscopy and reviewed the latest clinical advances of oral choledochoscopy in the diagnosis and treatment of biliary tract diseases.
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Affiliation(s)
- Jinyong Hao
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
| | - Xiaojun Huang
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
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12
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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: 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: 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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13
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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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14
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Subhash A, Abadir A, Iskander JM, Tabibian JH. Applications, Limitations, and Expansion of Cholangioscopy in Clinical Practice. Gastroenterol Hepatol (N Y) 2021; 17:110-120. [PMID: 34035770 PMCID: PMC8132717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Peroral cholangioscopy (POC) provides minimally invasive, direct endoscopic visualization of the biliary ductal system for both diagnostic and therapeutic purposes. POC has benefited from a number of technologic advances since its first introduction several decades ago. These advances have led to improved utility and expanded functionality, making POC an integral part of managing various bile duct diseases and disorders. Over time, the clinical role of POC has expanded. Novel applications and capabilities are being increasingly appreciated and developed. This article provides an overview of the current state of POC, with a particular focus on digital single-operator cholangioscopy and its strengths, limitations, advances, and emerging applications.
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Affiliation(s)
- Amith Subhash
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Alexander Abadir
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John M. Iskander
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - James H. Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, California
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
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15
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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: 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] [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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16
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Grande G, Cocca S, Bertani H, Caruso A, Pigo' F, Mangiafico S, Russo S, Lupo M, Masciangelo G, Cantu' P, Manta R, Conigliaro R. Dilation assisted stone extraction for complex biliary lithiasis: Technical aspects and practical principles. World J Gastrointest Endosc 2021; 13:33-44. [PMID: 33623638 PMCID: PMC7890407 DOI: 10.4253/wjge.v13.i2.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/27/2020] [Accepted: 01/22/2021] [Indexed: 02/06/2023] Open
Abstract
Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography. Endoscopic sphincterotomy (EST) has been used for the removal of bile duct stones for the past 40 years, providing a wide opening to allow extraction. Up to 15% of patients present with complicated choledocholithiasis. In this context, additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy, intraductal or extracorporeal lithotripsy, or endoscopic papillary large balloon dilation (EPLBD). EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter. EPLBD without EST was introduced as a simplified technique in 2009. Dilation-assisted stone extraction (DASE) is the combination of two techniques: EPLBD and sub-maximal EST. Several studies have reported this technique as safe and effective in patients with large bile duct stones, without any increased risk of adverse events such as pancreatitis, bleeding, or perforation. Nevertheless, it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies. The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE, based on current literature and daily clinical experience in biliary referral centers.
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Affiliation(s)
- Giuseppe Grande
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Silvia Cocca
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Helga Bertani
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Angelo Caruso
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Flavia Pigo'
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Santi Mangiafico
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Marinella Lupo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Graziella Masciangelo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
| | - Paolo Cantu'
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milano 20122, Italy
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia, Perugia 06129, Italy
| | - Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Modena 41126, Italy
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17
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Figueira ERR, Franzini T, Costa TN, Madruga-Neto AC, Guedes HG, Romano VC, Ceconello I, de Moura EGH. Laparoscopic SpyGlass cholangioscopy evaluation during bilioenteric anastomosis for hepatolithiasis, a case report. Int J Surg Case Rep 2020; 78:140-144. [PMID: 33340982 PMCID: PMC7750126 DOI: 10.1016/j.ijscr.2020.12.013] [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] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022] Open
Abstract
Diagnosis and management of benign hepatobiliary diseases are often challenging. SpyGlass cholangioscopy has enhanced the diagnosis of biliary diseases. A multidisciplinary approach can ensure diagnosis and treatment of patients with hepatobiliary diseases. Association of laparoscopic hepaticojejunostomy to SpyGlass cholangioscopy is a safe and minimal invasive procedure.
Introduction Careful evaluation of intrahepatic injury of biliary tract diseases is crucial to assure proper management and estimate disease prognosis. Hepatholithiasis is a rare condition that can be associated to cholestatic liver diseases. Additional tools to improve diagnosis and patient care are of great interest specially if associated to decreased morbidity. Recently the spread of single-operator platforms of cholangioscopy brought this procedure back to scene. Our aim was to identify safety, feasibility and utility of SpyGlass cholangioscopy of biliary tract during laparoscopic hepaticojejunostomy. Presentation of case A 53 years-old man with hepatolithiasis associated to choledolithiasis under treatment with ursodeoxycholic acid and fenofibrate for 8 months, was submitted to laparoscopic hepaticojejunostomy with cholangioscopy for biliary duct evaluation. Spyscope was inserted through a right lateral laparoscopic trocar entering the common bile duct. Examination of intra-hepatic bile ducts showed injury of right biliary. Few microcalculi were visualized. Left biliary ducts presented normal mucosa. Histopathological examination showed a chronic inflammatory process. During the procedure contrasted radiologic images were performed to assure Spyscope location. Following cholangioscopy evaluation, a Roux-en-Y hepaticojejunostomy was performed. To enlarge hepatic duct, a small longitudinal incision was made, and a PDS-5.0 running suture was used for bilioenteric anastomosis. Patient was discharged on postoperative day 6, with drain removal on day 20. Conclusion SpyGlass cholangioscopy during laparoscopic hepaticojejunostomy is feasible leading to minimal additional invasion of the surgical. In this case the method was performed safely, providing detailed examination of injured biliary ducts, adding elements to determine disease prognosis and patient care.
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Affiliation(s)
- Estela Regina Ramos Figueira
- Hospital das Clinicas from University of São Paulo School of Medicine, Division of Digestive Surgery, Sao Paulo, Brazil.
| | - Tomazo Franzini
- Hospital das Clinicas from University of São Paulo School of Medicine, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Thiago Nogueira Costa
- Hospital das Clinicas from University of São Paulo School of Medicine, Division of Digestive Surgery, Sao Paulo, Brazil
| | - Antonio Coutinho Madruga-Neto
- Hospital das Clinicas from University of São Paulo School of Medicine, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Hugo Gonçalo Guedes
- Hospital das Clinicas from University of São Paulo School of Medicine, Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Vitor Carminatti Romano
- Hospital das Clinicas from University of São Paulo School of Medicine, Division of Digestive Surgery, Sao Paulo, Brazil; Hospital das Clinicas from University of São Paulo School of Medicine, Gastrointestinal Endoscopy Unit, São Paulo, Brazil; University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Ivan Ceconello
- Hospital das Clinicas from University of São Paulo School of Medicine, Division of Digestive Surgery, Sao Paulo, Brazil
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18
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Funari MP, Ribeiro IB, de Moura DTH, Bernardo WM, Brunaldi VO, Rezende DT, Resende RH, de Marco MO, Franzini TAP, de Moura EGH. Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials. Clin Res Hepatol Gastroenterol 2020; 44:739-752. [PMID: 32088149 DOI: 10.1016/j.clinre.2019.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/24/2019] [Accepted: 12/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis. AIM To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events. METHODS We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar. RESULTS A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: -0.11 [-0.31, 0.08], P=0.27, I2=86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [-0.03, 0.04], P=0.62, I2=48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: -0.19 [-0.27, -0.12], P<0.00001, I2=0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [-0.01, 0.11], P=0.12, I2=57%), perforation (0.4% vs 0%; RD: 0.00 [-0.01, 0.02], P=0.7, I2=0%) or cholangitis (1.8% vs 3.2%; RD: -0.01 [-0.09, 0.06], P=0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P<0.00001, I2=0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: -0.10 [-0.24, 0.04], P=0.18, I2=61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [-0.02, 0.13], P=0.12, I2=0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD -0.01 [-0.11, 0.09], P=0.82, I2=0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P=0.01). CONCLUSION Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.
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Affiliation(s)
- Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil; Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Daniel Tavares Rezende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Ricardo Hannum Resende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Michele Oliveira de Marco
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Tomazo Antonio Prince Franzini
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
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Bang JY, Sutton B, Navaneethan U, Hawes R, Varadarajulu S. Efficacy of Single-Operator Cholangioscopy-Guided Lithotripsy Compared With Large Balloon Sphincteroplasty in Management of Difficult Bile Duct Stones in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:2349-2356.e3. [PMID: 32057976 DOI: 10.1016/j.cgh.2020.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/23/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although single-operator cholangioscopy (SOC)-guided lithotripsy and large balloon sphincteroplasty (LBS)-based techniques are effective rescue measures, the ideal approach to management of difficult bile duct stones is unclear. We conducted a randomized trial to compare the effectiveness of SOC-guided lithotripsy and LBS-based approaches for endoscopic management of difficult bile duct stones. METHODS Patients with difficult bile duct stones who failed retrieval using balloon or basket were randomly assigned to groups that received SOC-guided laser lithotripsy (SOC-LL, n = 33) or LBS (n = 33), from June 2016 through August 2018. When assigned treatment was unsuccessful, patients underwent mechanical lithotripsy before crossing over to the other group. The main outcome was treatment success, defined as ability to clear the duct in 1 session. Secondary outcomes were adverse events and treatment costs. RESULTS A higher proportion of patients in the SOC-LL group had treatment success (93.9%) than in the LBS group (72.7%; P = .021). On multiple logistic regression analysis, treatment success was significantly associated with use of SOC-LL (odds ratio [OR], 8.7; 95% CI, 1.3-59.3; P = .026), stone to extrahepatic bile duct ratio of 1 or less (OR, 28.8; 95% CI, 1.2-687.6; P = .038), and lack of a tapered bile duct (OR, 26.9; 95% CI, 1.3-558.2; P = .034). There was no significant difference between groups in adverse events (9.1% in the SOC-LL group vs 3.0% in the LBS group, P = .61) or overall treatment cost ($16,684 in the SOC-LL group vs $10,626 in the LBS group; P = .097). CONCLUSIONS In a randomized trial of patients with difficult bile stones that cannot be cleared by standard maneuvers, SOC-guided lithotripsy leads to duct clearance in a significantly higher proportion of patients than LBS-particularly when stone size exceeds the diameter of the extrahepatic bile duct. Adjunct lithotripsy might be required in patients with tapered distal bile duct, because LBS alone is less likely to be successful. ClinicalTrials.gov no: NCT00852072.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | | | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida.
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Galetti F, Moura DTHD, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGHD. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2020; 33:e1491. [PMID: 32609255 PMCID: PMC7325696 DOI: 10.1590/0102-672020190001e1491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. AIM To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. METHODS Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. RESULTS Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). CONCLUSIONS For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
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Affiliation(s)
- Facundo Galetti
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil.,Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Igor Braga Ribeiro
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Mateus Pereira Funari
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Martin Coronel
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Amit H Sachde
- Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Vitor Ottoboni Brunaldi
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tomazo Prince Franzini
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Efficacy of digital single-operator cholangioscopy in the visual interpretation of indeterminate biliary strictures: a systematic review and meta-analysis. Surg Endosc 2020; 34:3321-3329. [PMID: 32342216 DOI: 10.1007/s00464-020-07583-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/18/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Indeterminate biliary strictures remain a significant diagnostic challenge. Digital single-operator cholangioscopy (D-SOC) incorporates digital imaging which enables higher resolution for better visualization and diagnosis of biliary pathology. We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to determine the efficacy of D-SOC in the visual interpretation of indeterminate biliary strictures. MATERIAL AND METHODS Electronic searches were performed using Medline (PubMed), EMBASE, and Cochrane Library. All D-SOC studies that reported the diagnostic performance in visual interpretation of indeterminate biliary strictures and biliary malignancies were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 was used to evaluate the quality of the included studies. All data were extracted and pooled to construct a 2 × 2 table. The visual interpretation of D-SOC was compared to resected surgical specimens or clinical follow-up in the included patients. Pooled sensitivity, specificity, positive predictive value, negative predictive value, prevalence, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and diagnostic odds ratio (OR) were calculated. The summarized receiver operating characteristic (SROC) curve corresponding with the area under the curve (AUC) was also analyzed. RESULTS The search yielded 465 citations. Of these, only six studies with a total of 283 procedures met inclusion criteria and were included in the meta-analysis. The overall pooled sensitivity and specificity of D-SOC in the visual interpretation of biliary malignancies was 94% (95% CI 89-97) and 95% (95%CI 90-98), respectively, while +LR, -LR, diagnostic OR, and AUC were 15.20 (95%CI 5.21-44.33), 0.08 (95%CI 0.04-0.14), 308.83 (95%CI 106.46-872.82), and 0.983, respectively. The heterogeneity among 6 included studies was moderate for specificity (I2 = 0.51) and low for sensitivity (I2 = 0.17) and diagnostic OR (I2 = 0.00). CONCLUSION D-SOC is associated with high sensitivity and specificity in the visual interpretation of indeterminate biliary strictures and malignancies. D-SOC should be considered routinely in the diagnostic workup of indeterminate biliary lesions.
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22
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Is Endoscopic Balloon Dilation Still Associated With Higher Rates of Pancreatitis?: A Systematic Review and Meta-Analysis. Pancreas 2020; 49:158-174. [PMID: 32049951 DOI: 10.1097/mpa.0000000000001489] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The objective of this study was to compare the efficacy and safety of endoscopic papillary balloon dilation (EPBD), endoscopic sphincterotomy (ES), and the combination of large balloon dilation and ES (ES + EPLBD) in the treatment of common bile duct stones, with a special focus on postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials (RCTs) which evaluated at least one of the following outcomes: PEP, complete stone removal in the first ERCP, need for mechanical lithotripsy, recurrence of common bile duct stones, bleeding, and cholangitis. Twenty-five RCTs were selected for analysis. Pancreatitis rates were higher for EPBD than for ES (P = 0.003), as were severe pancreatitis rates (P = 0.04). However, in the 10-mm or greater balloon subgroup analysis, this difference was not shown (P = 0.82). Rates of PEP were higher in the subgroup of non-Asian subjects (P = 0.02), and the results were not robust when RCTs that used endoscopic nasobiliary drainage were omitted. The incidence of pancreatitis was comparable between EPLBD and ES + EPLBD. All 3 approaches were equally efficacious. Nevertheless, the results should be interpreted with caution, because pancreatitis is a multifactorial pathology, and RCTs can have limited generalizability.
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Navaneethan U, Moon JH, Itoi T. Biliary interventions using single-operator cholangioscopy. Dig Endosc 2019; 31:517-526. [PMID: 30689238 DOI: 10.1111/den.13361] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/23/2019] [Indexed: 12/15/2022]
Abstract
Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single-operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single-operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single-operator cholangioscopy techniques in the diagnosis and management of biliary disorders.
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Affiliation(s)
| | - Jong Ho Moon
- Department of Gastroenterology, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
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24
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Indications for Single-Operator Cholangioscopy and Pancreatoscopy: an Expert Review. ACTA ACUST UNITED AC 2019; 17:408-419. [DOI: 10.1007/s11938-019-00237-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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25
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Jin Z, Wei Y, Tang X, Shen S, Yang J, Jin H, Zhang X. Single-operator peroral cholangioscope in treating difficult biliary stones: A systematic review and meta-analysis. Dig Endosc 2019; 31:256-269. [PMID: 30468534 DOI: 10.1111/den.13307] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/19/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Current evidence supporting the utility of single-operator peroral cholangioscope (SOPOC) in the management of difficult bile duct stones is limited. We conducted the present systematic review and meta-analysis to evaluate the efficacy and safety of SOPOC in treating difficult bile duct stones. METHODS We searched studies up to April 2018, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. Quality assessment of the studies was completed with the Newcastle-Ottawa Scale. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverse events. We calculated the pooled estimates with random-effects models. Potential publication bias was assessed. RESULTS Twenty-four studies involving 2786 patients met the inclusion criteria. Pooled proportion of patients with complete stone clearance was 94.3% (95% confidence interval [95% CI]: 90.2-97.5%). Single-session stone clearance was achieved in 71.1% (95% CI: 62.1-79.5%) of the pooled patients. Pooled number of sessions needed for stone clearance was 1.26 (95% CI: 1.17-1.34%). Pooled adverse event rate was 6.1% (95% CI: 3.8-8.7%). Potential publication bias was detected but had no significant influence on the results. CONCLUSIONS Single-operator peroral cholangioscope is an effective and safe treatment for difficult bile duct stones when conventional methods have failed. More randomized controlled trials are warranted to confirm the results.
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Affiliation(s)
- Zheng Jin
- Hangzhou Geriatric Hospital, Hangzhou First People's Hospital Group, Hangzhou, China.,Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Wei
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaowei Tang
- Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Sisi Shen
- The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Yang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hangbin Jin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Zhang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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26
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Mukewar S, Carr-Locke D. Advances in Endoscopic Imaging of the Biliary Tree. Gastrointest Endosc Clin N Am 2019; 29:187-204. [PMID: 30846148 DOI: 10.1016/j.giec.2018.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Direct endoscopic imaging of the biliary tree is increasingly performed by endoscopists since the introduction of digital single-operator cholangioscopy. In parallel, there have been several advances to overcome the challenges associated with direct peroral cholangioscopy with development of multibending cholangioscopes and new devices to enable direct placement of an endoscope into the biliary tree without a supporting duodenoscope. The indications for cholangioscopy are also evolving with newer indications, such as intraductal lithotripsy, foreign body (mostly stent) removal, guide wire cannulation of specific ducts, photodynamic therapy for cholangiocarcinoma, and performance of fluoroscopy-free cholangiography. There has also been progress in image enhancement during cholangioscopy and additional imaging techniques, such as intraductal ultrasound, confocal laser endomicroscopy, and optical coherence tomography.
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Affiliation(s)
- Saurabh Mukewar
- David H. Koch Medical Center, Department of Gastroenterology, Joan & Sanford I. Weill Medical, College of Cornell University, New York Presbyterian Hospital, 1278 York Avenue, 9th Floor, New York, NY 10065, USA.
| | - David Carr-Locke
- David H. Koch Medical Center, Department of Gastroenterology, Joan & Sanford I. Weill Medical, College of Cornell University, New York Presbyterian Hospital, 1278 York Avenue, 9th Floor, New York, NY 10065, USA
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27
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Salerno R, Mezzina N, Ardizzone S. Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care. World J Gastrointest Endosc 2019; 11:219-230. [PMID: 30918587 PMCID: PMC6425281 DOI: 10.4253/wjge.v11.i3.219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/21/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.
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Affiliation(s)
- Raffaele Salerno
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan 20121, Italy
| | - Nicolò Mezzina
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco-Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
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28
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Rodríguez Muñoz S. Cholangioscopy: seeing to believe, seeing to know, seeing to cure. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:745-747. [PMID: 30466291 DOI: 10.17235/reed.2018.5991/2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for the diagnosis and treatment of biliopancreatic disorders, and over one million ERCP procedures are performed each year worldwide. ERCP has always been performed by a group of courageous endoscopists who on a daily basis managed to develop its full diagnostic and therapeutic potential over the technique's 50 years of lifespan, always making the most of radiographic images, ever secretly dreaming of directly viewing the banned, consigned-to-oblivion territory.
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29
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Franzini TAP, Visconti TADC, de Moura EGH. Large biliary stone: Lessons from a difficult case. Dig Endosc 2018; 30:812-813. [PMID: 30085363 DOI: 10.1111/den.13254] [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: 07/10/2018] [Accepted: 08/03/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Tomazo Antônio Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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30
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Abstract
PURPOSE OF REVIEW Every year more than one million people worldwide undergo an endoscopic retrograde cholangiopancreatography (ERCP) for disorders of the bile duct system. This review aims to discuss recent clinical data with regard to single-operator peroral cholangioscopy (POC). RECENT FINDINGS Innovations and technical optimizations of POC devices have extended diagnostic and therapeutic options for patients with complex biliary disease. Most of the currently available clinically relevant data are obtained with the single-operator peroral cholangioscopy (SOC)-system SpyGlass, which in a period of a decade has evolved further to a digital platform with increasing applicability, usefulness and cost-effectiveness. SUMMARY POC allows endoscopists to treat patients with complicated diseases of the gallbladder, liver, biliary tract, and pancreas better. In recent years, this technique was optimized to overcome prior limitations. The implementation of the single-operator SpyGlass Digital System in daily practice becomes a reality. We make an overview of the history of cholangioscopy, the technical evolution, and usefulness of this platform and take a look at its economic impact.
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de Clemente Junior CC, Bernardo WM, Franzini TP, Luz GO, dos Santos MEL, Cohen JM, de Moura DTH, Marinho FRT, Coronel M, Sakai P, de Moura EGH. Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials. World J Gastrointest Endosc 2018; 10:130-144. [PMID: 30147845 PMCID: PMC6107471 DOI: 10.4253/wjge.v10.i8.130] [Citation(s) in RCA: 12] [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: 11/20/2017] [Revised: 03/02/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials.
METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis.
RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), I2 = 11%, P = 0.31].
CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.
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Affiliation(s)
- Cesar Capel de Clemente Junior
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Tomazo Prince Franzini
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Gustavo Oliveira Luz
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Jonah Maxwell Cohen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Fábio Ramalho Tavares Marinho
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Martin Coronel
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo 05403-010, Brazil
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