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Chung HY, Hsu CC, Hung YL, Chen HW, Wong MS, Fu CY, Tsai CY, Chen MY, Wang SY, Hsu JT, Yeh TS, Yeh CN, Jan YY. Alternative application of percutaneous cholecystostomy in patients with biliary obstruction. Abdom Radiol (NY) 2021; 46:2891-2899. [PMID: 33388808 DOI: 10.1007/s00261-020-02898-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/28/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Percutaneous cholecystostomy (PC) is an important modality for acute cholecystitis and has been applied for other clinical scenarios as well. In the present study, we aimed to investigate an alternative use of PC for obstructive jaundice. METHODS From January 2012 to December 2018, eligible subjects were selected from patients undergoing PC in our institute. The characteristics, spectrum of underlying disease, indication for PC performance, details of the procedure, and treatment effect were all investigated. RESULTS During the study period, 1364 patients underwent PC. Seventy patients fulfilled the defined inclusion criteria. While 47 patients were diagnosed with malignant biliary obstruction with or without cholangitis, 23 patients were diagnosed with nonmalignant biliary obstruction and acute cholangitis. There were 63 patients (90%) diagnosed with acute cholangitis. Pancreatic cancer (n = 24, 51%) and advanced malignancy (n = 28, 59%) were noted mostly in the group with malignant biliary obstruction. Treatment effects were proven by laboratory data, including the white blood cell count, C-reactive protein level, and hepatic function. CONCLUSION PC can temporize definitive therapies and serve as an alternative treatment for patients with nonmalignant conditions. For patients with advanced malignancy, PC can serve as a palliative procedure that has a high success rate and low complication rate and effectively relieves biliary obstruction.
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Affiliation(s)
- Hung-Yu Chung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Chieh Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Man Si Wong
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
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Brinne Roos J, Bergenzaun P, Groth K, Lundell L, Arnelo U. Telepresence-teleguidance to facilitate training and quality assurance in ERCP: a health economic modeling approach. Endosc Int Open 2020; 8:E326-E337. [PMID: 32118106 PMCID: PMC7035055 DOI: 10.1055/a-1068-9153] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The aims of this study was to document the clinical and training relevance of endoscopic retrograde cholangiopancreaticography (ERCP) teleguidance (as a clinical model for applied telemedicine) with health economic modeling methodologies. Methods Probabilities and consequences of complications after ERCP performed by either a novice-trainee or supported through teleguidance (TM) by an expert formed the basis of the health economic model. Results The main clinical and economic outcomes originated from the base case scenario representing a low-volume center. In the cohort the patient age was 62 years, 58 % were females, the expert was doing ≥ 250 ERCPs per year and 50 for the novice-trainee. The expert knowledge transferred was set to 50 % and the average complexity grade to 1.98. Given a willingness to pay threshold of 56,180 USD/ quality-adjusted life years (QALY), the probability of cost-effectiveness of TM assistance was 98.9 %. The probability of a QALY gain for patients having an ERCP, to which was added TM, was 91.6 %. Adding TM saved on an average 111.2 USD (95 % CI 959 to 1021 SEK) per patient, and remained cost-effective basically insensitive to the level of willingness to pay. Conclusion Teleguidance during an ERCP procedure has the potential to be the prefered option in many low- to medium-volume hospitals. The main mechanisms behind these effects are positive impact on several adverse patient outcomes, QALY increase, and decreased costs. TM should be considered for integration into future teaching curriculums in advanced upper gastrointestinal endoscopy.
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Affiliation(s)
- Johanna Brinne Roos
- Innovation Centre, Division of Innovation and Development, Karolinska University Hospital, Stockholm, Sweden
| | - Per Bergenzaun
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Groth
- Innovation Centre, Division of Innovation and Development, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Lundell
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm Sweden
- Department of Surgery, Odense University Hospital, J.B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm Sweden
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3
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Aadam AA, Liu K. Endoscopic palliation of biliary obstruction. J Surg Oncol 2019; 120:57-64. [PMID: 31055849 DOI: 10.1002/jso.25483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/07/2019] [Indexed: 02/06/2023]
Abstract
Advanced pancreaticobiliary malignancy tends to be uncurable at presentation and causes significant morbidity for patients. Palliation for malignant biliary obstruction should be minimally invasive, cost-effective, and aim to improve quality of life of patients. Strategies of endoscopic palliation of malignant biliary obstruction can differ based on sites and degree of biliary obstruction with complex decisions of optimal stent type and placement that involve conscientious planning by a multidisciplinary team.
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Affiliation(s)
- A Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin Liu
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lee JC, Kim JS, Kim HW, Cho IK, Lee J, Jang ES, Lee SH, Hwang JH, Kim JW, Jeong SH, Kim J. Outcome of endoscopic retrograde cholangiopancreatography in patients with clinically defined decompensated liver cirrhosis. J Dig Dis 2018; 19:605-613. [PMID: 30126061 DOI: 10.1111/1751-2980.12661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/28/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Decompensated liver cirrhosis (LC) can negatively affect the outcome of endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy and safety of ERCP in patients with clinically defined compensated and decompensated LC. METHODS In a single tertiary hospital, 146 endoscopic sphincterotomy-naive patients with LC who underwent ERCP between 2005 and 2016 were reviewed. Patients with LC who had experienced variceal bleeding, ascites or hepatic encephalopathy were included in the decompensated LC group. Cannulation, technical and clinical successes, and major post-ERCP adverse events including bleeding, pancreatitis, cholangitis and perforation were compared between the two groups. RESULTS Patients were divided into compensated and decompensated LC groups. Their baseline characteristics were not different, except for comorbid malignancy (22.3 % vs 38.5%, P = 0.038) and preprocedural transfusion (7.4% vs 36.5%, P < 0.001). The cannulation (97,9% vs 94.2%, P = 0.348) and technical (95.7% vs 88.5%, P = 0.167) success rates were not different. The clinical success rate was lower in the decompensated LC group (95.7% and 78.8%, P = 0.003), mainly due to comorbid hepatobiliary malignancy. Post-ERCP pancreatitis (6.4% vs 30.8%, P = 0.008) and cholangitis (18.1% vs 32.7%, P = 0.046) rates were higher in the decompensated LC group. CONCLUSIONS Despite lower clinical success rates due to comorbid hepatobiliary malignancy, ERCP in patients with decompensated LC is technically feasible. Because postprocedural cholangitis and pancreatitis are more frequent in patients with decompensated LC, greater procedural precautions are needed in these patients.
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Affiliation(s)
- Jong-Chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Joo Seong Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyoung Woo Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - In Kuk Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jongchan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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5
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Can failure of choledochal cannulation in endoscopic retrograde cholangiopancreatography be prevented? JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.435834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Salet N, Bremmer RH, Verhagen MAMT, Ekkelenkamp VE, Hansen BE, de Jonge PJF, de Man RA. Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data? A retrospective cohort study. BMJ Open 2018; 8:e019405. [PMID: 29496668 PMCID: PMC5855341 DOI: 10.1136/bmjopen-2017-019405] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation. STUDY DESIGN Retrospective analysis of collected data from hospital information systems combined with clinical indicator definitions to define and compare short-term outcomes for three gastrointestinal pathways using the concept of Textbook Outcome. SETTING 62 Dutch hospitals. PARTICIPANTS 45 848 unique gastrointestinal patients discharged in 2015. MAIN OUTCOME MEASURE A broad range of clinical outcomes including length of stay, reintervention, readmission and doctor-patient counselling. RESULTS Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease (n=4369), colonoscopy for inflammatory bowel disease (IBD; n=19 330) and colonoscopy for colorectal cancer screening (n=22 149) were submitted to five suitable clinical indicators per treatment. The percentage of all patients who met all five criteria was 54%±9% (SD) for ERCP treatment. For IBD this was 47%±7% of the patients, and for colon cancer screening this number was 85%±14%. CONCLUSION This study shows that reusing data obtained from hospital information systems combined with clinical indicator definitions can be used to express short-term outcomes using the concept of Textbook Outcome without any excess registration. This information can provide meaningful insight into the clinical care trajectory on the level of individual patient care. Furthermore, this concept can be applied to many clinical trajectories within gastroenterology and beyond for monitoring and improving the clinical pathway and outcome for patients.
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Affiliation(s)
- Nèwel Salet
- VU University Medical Center Amsterdam, Amsterdam, The Netherlands
- LOGEX, Amsterdam, The Netherlands
| | | | - Marc A M T Verhagen
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Vivian E Ekkelenkamp
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Bettina E Hansen
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rob A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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7
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Rodrigues-Pinto E, Macedo G, Baron TH. Training pathways and competency assessment in endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review. Am J Gastroenterol 2017; 112:537-554. [PMID: 28139655 PMCID: PMC5659272 DOI: 10.1038/ajg.2016.610] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/01/2016] [Indexed: 12/11/2022]
Abstract
In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.
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Varadarajulu S, Bang JY. Role of Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Clinical Assessment of Pancreatic Neoplasms. Surg Oncol Clin N Am 2016; 25:255-72. [PMID: 27013363 DOI: 10.1016/j.soc.2015.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Accurate diagnosis and staging of pancreatic neoplasms is essential for surgical planning and identification of locally advanced and metastatic disease that is incurable by surgery. The ability to position the endoscopic ultrasonography (EUS) transducer close to the pancreas combined with the use of fine-needle aspiration enables the accurate diagnosis of pancreatic cysts and solid masses. EUS is also increasingly being used to procure core tissue for molecular analysis that facilitates personalized treatment of pancreatic cancer. Various therapeutic interventions can be undertaken under EUS guidance. This article focuses on the applications of EUS and endoscopic retrograde cholangiopancreatography in pancreatic neoplasms.
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Affiliation(s)
- Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA.
| | - Ji Young Bang
- Division of Gastroenterology-Hepatology, Indiana University, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
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Lee TH, Park DH. Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16582-16595. [PMID: 25469026 PMCID: PMC4248201 DOI: 10.3748/wjg.v20.i44.16582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/11/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
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Prichard D, Byrne MF. Endoscopic ultrasound guided biliary and pancreatic duct interventions. World J Gastrointest Endosc 2014; 6:513-24. [PMID: 25400865 PMCID: PMC4231490 DOI: 10.4253/wjge.v6.i11.513] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/10/2014] [Accepted: 10/23/2014] [Indexed: 02/05/2023] Open
Abstract
When endoscopic retrograde cholangio-pancreatography fails to decompress the pancreatic or biliary system, alternative interventions are required. In this situation, endosonography guided cholangio-pancreatography (ESCP), percutaneous radiological therapy or surgery can be considered. Small case series reporting the initial experience with ESCP have been superseded by comprehensive reports of large cohorts. Although these reports are predominantly retrospective, they demonstrate that endoscopic ultrasound (EUS) guided biliary and pancreatic interventions are associated with high levels of technical and clinical success. The procedural complication rates are lower than those seen with percutaneous therapy or surgery. This article describes and discusses data published in the last five years relating to EUS-guided biliary and pancreatic intervention.
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12
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Mehta PP, Sanaka MR, Parsi MA, Albeldawi MJ, Dumot JA, Lopez R, Zuccaro G, Vargo JJ. Association of procedure length on outcomes and adverse events of endoscopic retrograde cholangiopancreatography. Gastroenterol Rep (Oxf) 2014; 2:140-4. [PMID: 24759343 PMCID: PMC4020131 DOI: 10.1093/gastro/gou009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/16/2014] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The aims of this study were to determine the effects of length of procedure on endoscopic retrograde cholangiopancreatography (ERCP) outcomes and adverse events. METHODS All ERCP procedures, performed by experienced advanced endoscopists, in patients without prior papillary intervention from 2006 to 2008 were reviewed. Procedures were arbitrarily divided into two groups: shorter procedures (SP), with a duration shorter than the overall mean procedure length, and longer procedures (LP), with a duration longer than overall mean procedure length. Length of procedure was defined as the time from endoscope insertion to endoscope removal. RESULTS Two hundred and ninety-five procedures were included in the analysis. Mean procedure length was 45.6 ± 30.1 min. One hundred and seventy-seven procedures (60%) were SP and 118 (40%) were LP. There were no differences between the groups with regard to patients' ages, genders, race, or trainee participation. SP cases were more likely to be biliary vs pancreatic or bi-ductal evaluations (P = 0.03). LP had significantly higher complexity scores (34% with >3 vs 13%; P = 0.046) and were more likely to require pre-cut papillotomy (39% vs 15%; P < 0.001). There was no significant difference between the groups in overall completion rates (91.5% LP vs 96% SP; P = 0.10) or adverse events (10.2% LP vs 6.2% SP; P = 0.21). However, LP cases were associated with higher rates of post-ERCP bleeding (4.2% vs 0.6%; P = 0.029). CONCLUSION There was no significant difference in outcomes or overall adverse events between shorter and longer ERCP procedures. However, longer procedures were associated with higher procedure complexity, higher utilization of pre-cut technique, and increased risk of bleeding.
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Affiliation(s)
- Paresh P. Mehta
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Madhusudhan R. Sanaka
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Mansour A. Parsi
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Mazen J. Albeldawi
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - John A. Dumot
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Zuccaro
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - John J. Vargo
- Digestive Disease Institute, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland OH, USA and Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
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Balik E, Eren T, Keskin M, Ziyade S, Bulut T, Buyukuncu Y, Yamaner S. Parameters That May Be Used for Predicting Failure during Endoscopic Retrograde Cholangiopancreatography. JOURNAL OF ONCOLOGY 2013; 2013:201681. [PMID: 23861683 PMCID: PMC3686147 DOI: 10.1155/2013/201681] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023]
Abstract
Aim. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for the diagnosis and treatment of hepatic, biliary tract, and pancreatic disorders. However, failure during cannulation necessitates other interventions. The aim of this study was to establish parameters that can be used to predict failure during ERCP. Methods. A total of 5884 ERCP procedures performed on 5079 patients, between 1991 and 2006, were retrospectively evaluated. Results. Cannulation was possible in 4482 (88.2%) patients. For each one-year increase in age, the cannulation failure rate increased by 1.01-fold (P = 0.002). A history of previous hepatic biliary tract surgery caused the cannulation failure rate to decrease by 0.487-fold (P < 0.001). A tumor infiltrating the ampulla, the presence of pathology obstructing the gastrointestinal passage, and peptic ulcer increased the failure rate by 78-, 28-, and 3.47-fold, respectively (P < 0.001). Conclusions.Patient gender and duodenal diverticula do not influence the success of cannulation during ERCP. Billroth II and Roux-en-Y gastrojejunostomy surgeries, a benign or malignant obstruction of the gastrointestinal system, and duodenal ulcers decrease the cannulation success rate, whereas a history of previous hepatic biliary tract surgery increases it. Although all endoscopists had equal levels of experience, statistically significant differences were detected among them.
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Affiliation(s)
- Emre Balik
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Millet Caddesi, Sehremini, Capa, Fatih, 34093 Istanbul, Turkey
| | - Tunc Eren
- Department of General Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Metin Keskin
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Millet Caddesi, Sehremini, Capa, Fatih, 34093 Istanbul, Turkey
| | - Sedat Ziyade
- Department of Thoracic Surgery, Istanbul Bezmialem Vakif University, Istanbul, Turkey
| | - Turker Bulut
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Millet Caddesi, Sehremini, Capa, Fatih, 34093 Istanbul, Turkey
| | - Yilmaz Buyukuncu
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Millet Caddesi, Sehremini, Capa, Fatih, 34093 Istanbul, Turkey
| | - Sumer Yamaner
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Millet Caddesi, Sehremini, Capa, Fatih, 34093 Istanbul, Turkey
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Abstract
Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.
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Affiliation(s)
- Yan G Bakman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
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Swan MP, Alexander S, Moss A, Williams SJ, Ruppin D, Hope R, Bourke MJ. Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation. Clin Gastroenterol Hepatol 2013; 11:430-436.e1. [PMID: 23313840 DOI: 10.1016/j.cgh.2012.12.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. METHODS We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. RESULTS Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. CONCLUSIONS Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.
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Affiliation(s)
- Michael P Swan
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
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Muraki T, Arakura N, Kodama R, Yoneda S, Maruyama M, Itou T, Watanabe T, Maruyama M, Matsumoto A, Kawa S, Tanaka E. Comparison of carbon dioxide and air insufflation use by non-expert endoscopists during endoscopic retrograde cholangiopancreatography. Dig Endosc 2013; 25:189-96. [PMID: 23368405 DOI: 10.1111/j.1443-1661.2012.01344.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is subject to several complications that include a lengthy procedure time, technical difficulty, and active bowel movement induced by air insufflation. In ERCP carried out by non-expert endoscopists who are prone to excessive luminal insufflation, insufflation with carbon dioxide (CO2 ) may provide better and safer outcomes. We aimed to assess the efficacy and safety of CO2 insufflation during ERCP by non-expert endoscopists. METHODS This study included 208 consecutive patients who received ERCP, excluding those in poor general health or with obstructive lung disease. The first operator for each patient was a non-expert endoscopist having done 50 or fewer ERCP procedures. Primary outcomes were the changes in cardiopulmonary state during ERCP. Secondary outcomes were ERCP complications. We designed a single-center, randomized, prospective, double-blind, controlled trial with CO2 and air insufflation during ERCP. RESULTS CO2 insufflation did not affect overall procedure progression or results. A positive correlation was observed between procedure time and change in maximal systolic blood pressure from baseline among patients in the air insufflation group, but not in the CO2 insufflation group (correlation coefficient 0.408 vs 0.114, change in the maximal systolic blood pressure from baseline +4.2 vs+1.2 mmHg/10 min). This was consistent with our findings in patients treated by the first operator alone. The occurrence rate of post-ERCP pancreatitis tended to be lower in the CO2 group than the air group (4/102 [3.9%]vs 0/106 [0%], P = 0.056). CONCLUSIONS CO2 insufflation during ERCP by non-expert endoscopists is recommended from the standpoints of efficacy and safety.
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Affiliation(s)
- Takashi Muraki
- Department of Medicine, Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan.
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Sarkaria S, Lee HS, Gaidhane M, Kahaleh M. Advances in endoscopic ultrasound-guided biliary drainage: a comprehensive review. Gut Liver 2012; 7:129-36. [PMID: 23560147 PMCID: PMC3607765 DOI: 10.5009/gnl.2013.7.2.129] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 04/03/2012] [Accepted: 05/01/2012] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.
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Affiliation(s)
- Savreet Sarkaria
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Coté GA, Singh S, Bucksot LG, Lazzell-Pannell L, Schmidt SE, Fogel E, McHenry L, Watkins J, Lehman G, Sherman S. Association between volume of endoscopic retrograde cholangiopancreatography at an academic medical center and use of pancreatobiliary therapy. Clin Gastroenterol Hepatol 2012; 10:920-4. [PMID: 22387254 DOI: 10.1016/j.cgh.2012.02.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/14/2012] [Accepted: 02/22/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many advances have been made in pancreatobiliary imaging and endoscopy techniques. However, little is known about trends in use of endoscopic retrograde cholangiopancreatography (ERCP). METHODS We performed a retrospective cohort study that analyzed data from 33,596 ERCPs performed at Indiana University Medical Center from 1994 to 2009. Data from all patients were entered into an endoscopy database. We compared changes in patient demographics, indications for ERCP, and utilization of specific ERCP therapies during this time period. RESULTS The annual volume of ECRP increased steadily from 1175 in 1994 to 2802 in 2009 (P < .0001). Of all patients, 33.9% had previously undergone an ERCP at a different facility; 42.3% of these were unsuccessful. The odds of having undergone a failed ERCP at another facility increased slightly each year (odds ratio, 1.02; P < .001). Among patients who had a failed ERCP elsewhere, the success rate at Indiana University Medical Center was 96.1%. The frequency of patients with American Society of Anesthesiologists class ≥3 (odds ratio, 1.12; P < .001) who received anesthesia-administered sedation increased each year (odds ratio, 1.25; P < .001). Most ERCPs were performed for common bile duct stones or strictures and suspected sphincter of Oddi dysfunction (77.2%). The most rapid increase was among procedures for common bile duct strictures or leaks, pancreatic duct stones or strictures, and suspected sphincter of Oddi dysfunction. Rates of biliary sphincterotomy did not change (P = .252), but the frequency of pancreatic sphincterotomy, common bile duct, or pancreatic duct stent placement and pancreatic duct stricture dilation increased during this time (P < .001 for each). CONCLUSIONS At a referral center, ERCP has become increasingly complex. From 1994 to 2009, increasing numbers of ERCPs have been performed for patients with more comorbidities, higher-grade disease, history of failed ERCPs, and on those receiving endotherapy.
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Affiliation(s)
- Gregory A Coté
- Indiana University School of Medicine, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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Iwashita T, Lee JG. Endoscopic ultrasonography-guided biliary drainage: rendezvous technique. Gastrointest Endosc Clin N Am 2012; 22:249-58, viii-ix. [PMID: 22632947 DOI: 10.1016/j.giec.2012.04.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The success rate of deep biliary cannulation is high but still not perfect in endoscopic retrograde cholangiopancreatography (ERCP), even with aggressive techniques. With the development of linear-array echoendoscopes, the endoscopic ultrasonography-guided rendezvous technique (EUS-RV) has recently emerged as a salvage method for failed biliary cannulation. This review of current literature establishes that EUS-RV is a feasible and safe technique and should be considered as an alternative to percutaneous or surgical approaches. The availability of a percutaneous salvage (if EUS-RV fails) and well-trained endoscopists for both ERCP and EUS are mandatory in minimizing the potential complications of this procedure.
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Affiliation(s)
- Takuji Iwashita
- Division of Gastroenterology and Hepatology, H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, 101 The City Drive, Building 22C, First Floor, Orange, CA 92868, USA
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Swan MP, Bourke MJ, Williams SJ, Alexander S, Moss A, Hope R, Ruppin D. Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2011; 17:4993-8. [PMID: 22174549 PMCID: PMC3236589 DOI: 10.3748/wjg.v17.i45.4993] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/26/2011] [Accepted: 06/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center.
METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP.
RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017).
CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.
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Park DH, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc 2011; 74:1276-84. [PMID: 21963067 DOI: 10.1016/j.gie.2011.07.054] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 07/18/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND EUS-guided biliary drainage (EUS-BD) has been proposed as an effective alternative for percutaneous transhepatic biliary drainage (PTBD) after failed ERCP. To date, the risk factors for adverse events and long-term outcomes of EUS-BD with transluminal stenting (EUS-BDS) have not been fully explored. OBJECTIVE To evaluate risk factors for adverse events and long-term outcomes of EUS-BDS. DESIGN Prospective follow-up study. SETTING Tertiary-care academic center. PATIENTS This study involved 57 consecutive patients with malignant or benign biliary obstruction undergoing EUS-BDS after failed ERCP. INTERVENTION EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy with transluminal stenting (EUS-CDS). MAIN OUTCOME MEASUREMENTS Risk factors for postprocedure and late adverse events and clinical outcomes of EUS-BDS. RESULTS The overall technical and functional success rates, respectively, in the EUS-BDS group were 96.5% (intention-to-treat, n = 55/57) and 89% (per-protocol, n = 49/55). Postprocedure adverse events developed after EUS-BDS in 11 patients (20%, n = 11/55). This included bile peritonitis (n = 2), mild bleeding (n = 2), and self-limited pneumoperitoneum (n = 7). In multivariate analysis, needle-knife use was the single risk factor for postprocedure adverse events after EUS-BDS (odds ratio 12.4; P = .01). A late adverse event in EUS-BDS was distal stent migration (7%, n = 4/55). The mean stent patencies with EUS-HGS and EUS-CDS were 132 days and 152 days, respectively. LIMITATIONS Single-operator performed, nonrandomized study. CONCLUSION EUS-HGS and EUS-CDS may be relatively safe and can be used as an alternative to PTBD after failed ERCP. Both techniques offer durable and comparable stent patency. The use of a needle-knife for fistula dilation in EUS-BDS should be avoided if possible.
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Affiliation(s)
- Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Mehta PP, Vargo JJ, Dumot JA, Parsi MA, Lopez R, Zuccaro G. Does anesthesiologist-directed sedation for ERCP improve deep cannulation and complication rates? Dig Dis Sci 2011; 56:2185-90. [PMID: 21274625 DOI: 10.1007/s10620-011-1568-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 01/05/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVES While some gastroenterologists provide their own sedation for endoscopic retrograde cholangiopancreatography (ERCP), others utilize anesthesiologists. There is limited information comparing cannulation success and complication rates between these two approaches. Theoretically, anesthesiologist-directed sedation (ADS) may lead to an improved deep cannulation rate by virtue of using deeper and more constant levels of sedation and by removing the minute-by-minute medication management and physiologic monitoring responsibilities from the endoscopy team. AIMS To compare ERCP deep cannulation success and complications between gastroenterologist-directed sedation (GDS) and ADS. METHODS All ERCPs completed by senior advanced endoscopists at a tertiary referral center over a 2-year period were reviewed. During the first year, all ERCP sedation was performed with GDS utilizing a narcotic and a benzodiazepine. Due to a change in division policy and practice, during the second year, all ERCP sedation was provided by ADS. Patients with prior papillary interventions were excluded. Demographics, procedure indications, deep cannulation success, sedation provider, and procedural complications were recorded. RESULTS A total of 367 patients were studied: 178 (48.5%) GDS and 189 (51.5%) ADS. There was no difference in the groups with respect to race, age, and gender. Four patients (2.3%) in the GDS group could not be sedated. There were two deaths, one in each group; one death was due to cholangitis/sepsis and the other was due to post-ERCP pancreatitis. The overall cannulation success rates were similar between the two groups (94.4% vs. 95.2%, P = 0.36). CONCLUSIONS Deep ductal cannulation rates between GDS and ADS are similar.
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Affiliation(s)
- Paresh P Mehta
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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Komaki T, Kitano M, Sakamoto H, Kudo M. Endoscopic ultrasonography-guided biliary drainage: evaluation of a choledochoduodenostomy technique. Pancreatology 2011; 11 Suppl 2:47-51. [PMID: 21464587 DOI: 10.1159/000323508] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (CDS) is as an alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with biliary obstruction when endoscopic retrograde biliary drainage (ERBD) is unsuccessful. PURPOSE We reviewed our experience and technique in patients undergoing EUS-CDS. PATIENTS Over a 2-year period to December 2008, 15 patients with unsuccessful ERBD underwent EUS-CDS. METHODS EUS-guided needle puncture was performed to access the bile duct from the duodenal bulb. After cholangiography, a guidewire was inserted through the needle and directed to the hepatic hilum. The punctured fistula was then dilated with a biliary dilator and a plastic stent was inserted. RESULTS The technical success rate of EUS-CDS was 93% (14/15 patients); 1 patient underwent an EUS-guided rendezvous approach because the choledochoduodenal fistula could not be dilated. Decompression of the bile duct was achieved in all patients. Complications included cholangitis in 4 patients, self-limiting local peritonitis in 2 and distal stent migration in 1 patient. The median follow-up time was 125 days and the median duration of stent patency was 99 days. CONCLUSION EUS-CDS may be effective for patients following unsuccessful ERBD and offers an attractive alternative to PTBD.
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Affiliation(s)
- Takamitsu Komaki
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osakasayama, Japan
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.
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Affiliation(s)
- Sean P Lynch
- Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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25
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Sun JG, Faulx AL. ERCP and fluoroscopy use: is experience the difference? Gastrointest Endosc 2010; 72:66-7. [PMID: 20620273 DOI: 10.1016/j.gie.2010.03.1116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 03/22/2010] [Indexed: 12/10/2022]
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Shami VM, Kahaleh M. Endoscopic ultrasound-guided cholangiopancreatography and rendezvous techniques. Dig Liver Dis 2010; 42:419-24. [PMID: 19897427 DOI: 10.1016/j.dld.2009.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 09/24/2009] [Indexed: 12/11/2022]
Abstract
Endoscopic ultrasound-guided cholangiopancreatography (EUCP) has become an alternative to percutaneous drainage or surgery in patients with obstructive jaundice or pancreatic obstruction after failed conventional ERCP. The different techniques of biliary and pancreatic drainage are described and the literature is reviewed. Due to the technical complexity associated with this procedure, it should be reserved for endoscopists at tertiary care centers with advanced training in both EUS and ERCP.
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Affiliation(s)
- Vanessa M Shami
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA 22908-0708, United States
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Abstract
The foundation of skills for the performance of natural orifice translumenal endoscopic surgery (NOTES) lies in the training for general surgery (especially laparoscopy) and flexible gastrointestinal endoscopy. Physicians wishing to practice NOTES need to acquire or have both skill sets, or need to partner together to blend complementary capabilities with colleagues. In the future, however, a new cadre of NOTES specialists may emerge who will have developed individual expertise in the full spectrum of NOTES knowledge base requirements. This article highlights a body of knowledge and skills needed to become a NOTES proceduralist and review the current training paradigms for gastrointestinal endoscopists and surgeons.
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Affiliation(s)
- L Campbell Levy
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
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DeWitt J, McGreevy K, Sherman S, LeBlanc J. Utility of a repeated EUS at a tertiary-referral center. Gastrointest Endosc 2008; 67:610-9. [PMID: 18279866 DOI: 10.1016/j.gie.2007.09.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 09/17/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The utility of a repeated EUS by experts is not known. OBJECTIVE To define the utility of a repeated EUS for the same indication. DESIGN A retrospective case series. SETTING Tertiary-referral hospital in Indianapolis, Indiana. PATIENTS Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital. INTERVENTIONS A repeated EUS. MAIN OUTCOME MEASUREMENTS Clinical impact of a repeated EUS. RESULTS Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed. LIMITATIONS A retrospective design; a small number of nonpancreatic indications. CONCLUSIONS In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202-5121, USA
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Lo SK. Intramural incision during ERCP: turning a complication into a positive experience? Gastrointest Endosc 2008; 67:634-5. [PMID: 18279863 DOI: 10.1016/j.gie.2007.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 08/27/2007] [Indexed: 02/08/2023]
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Boix J, Lorenzo-Zúñiga V, Moreno de Vega V, Cabré E, Añaños FE, Domènech E, Gassull MA. Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP. Surg Endosc 2007; 22:1678-85. [DOI: 10.1007/s00464-007-9690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 10/15/2007] [Indexed: 11/29/2022]
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Artifon ELA, Chaves DM, Ishioka S, Souza TF, Matuguma SE, Sakai P. Echoguided hepatico-gastrostomy: a case report. Clinics (Sao Paulo) 2007; 62:799-802. [PMID: 18209925 DOI: 10.1590/s1807-59322007000600023] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102:1781-8. [PMID: 17509029 DOI: 10.1111/j.1572-0241.2007.01279.x] [Citation(s) in RCA: 695] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To provide health-care providers, patients, and physicians with an exhaustive assessment of prospective studies on rates of complications and fatalities associated with endoscopic retrograde cholangiopancreatography (ERCP). METHODS We searched MEDLINE (1977-2006) for prospective surveys on adult patients undergoing ERCP. "Grey literature" was sought by looking at cited references to identify further relevant studies. Data on postprocedural pancreatitis, bleeding, infections, perforations, and miscellaneous events as well as their associated fatalities were extracted independently by two reviewers. Sensitivity analysis was performed to test for data consistency between multicenter versus single center studies, and old (1977-1996) versus recent (1997-2005) reports. RESULTS In 21 selected surveys, involving 16,855 patients, ERCP-attributable complications totaled 1,154 (6.85%, CI 6.46-7.24%), with 55 fatalities (0.33%, CI 0.24-0.42%). Mild-to-moderate events occurred in 872 patients (5.17%, CI 4.83-5.51%), and severe events in 282 (1.67%, CI 1.47-1.87%). Pancreatitis occurred in 585 subjects (3.47%, CI 3.19-3.75%), infections in 242 (1.44%, CI 1.26-1.62%), bleeding in 226 (1.34%, CI 1.16-1.52%), and perforations in 101 (0.60%, CI 0.48-0.72%). Cardiovascular and/or analgesia-related complications amounted to 173 (1.33%, CI 1.13-1.53%), with 9 fatalities (0.07%, CI 0.02-0.12%). As compared with old reports, morbidity rates increased significantly in most recent studies: 6.27%versus 7.51% (P(c)= 0.029). CONCLUSIONS ERCP remains the endoscopic procedure that carries a high risk for morbidity and mortality. Complications continue to occur at a relatively consistent rate. The majority of events are of mild-to-moderate severity.
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Affiliation(s)
- Angelo Andriulli
- Gastroenterology Unit, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
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Kahaleh M. EUS-Guided Cholangio Drainage and Rendezvous Techniques. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2006.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Varadarajulu S, Kilgore ML, Wilcox CM, Eloubeidi MA. Relationship among hospital ERCP volume, length of stay, and technical outcomes. Gastrointest Endosc 2006; 64:338-47. [PMID: 16923479 DOI: 10.1016/j.gie.2005.05.016] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Accepted: 05/04/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND The relationship between hospital procedure volume and outcome has been recognized for various specialties and procedures. Although increasingly used and in existence for 40 years, to date, data on the relationship between hospital volume and outcome of ERCP are scant. OBJECTIVE We sought to examine health-related outcomes after ERCP in relation to hospital procedure volume. DESIGN Secondary analysis of a national administrative database. We used the National Inpatient Sample (NIS) database to evaluate health-related outcomes among patients who underwent ERCP from 1998 to 2001. MAIN OUTCOME MEASUREMENTS Logistic and multiple regression models were used to estimate the association of hospital ERCP volume with length of stay (LOS), rates of procedural failure, and mortality. Fixed effect models were used to adjust for all time invariant hospital characteristics for each hospital within the dataset. RESULTS Data from 2629 hospitals that performed 199,625 ERCPs were evaluated. The median number of ERCPs performed in participating hospitals was 49 per year (range, 1-1004), with 25% of hospitals performing > or =100 ERCPs per year and 5% performing > or =200 per year. Significant trends in the relationship between volume and outcome were observed with respect to LOS and procedural failure: the median LOS was lower in high-volume (> or =200 ERCP/y) than low-volume (< or =100 ERCP/y) hospitals (6.9 vs 7.8 days, p < 0.0001) and the mean difference in expected LOS was 1.08 days (p < 0.0001). Multivariate regressions with hospital level fixed effects found significant negative relationships between procedure volume and procedure failure rates, but no significant effect on inpatient mortality rates was detected. LIMITATIONS NIS database permits analyses of only inpatient ERCPs. It precludes analysis of procedural complications, reinterventions, and influence of individual provider volume on outcomes. CONCLUSIONS Inpatients who undergo ERCP at high-volume hospitals have shorter LOS and lower procedural failure rates than those undergoing ERCP at low-volume hospitals. These findings have important implications for health care policy decision making and resource utilization.
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Affiliation(s)
- Shyam Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc 2006; 64:52-9. [PMID: 16813803 DOI: 10.1016/j.gie.2006.01.063] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Accepted: 01/15/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Interventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful. OBJECTIVE We reviewed our experience and technique used for this procedure. DESIGN Over a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC. SETTING Tertiary care center offering ERCP and interventional EUS. PATIENTS Twenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC. INTERVENTION EUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished. MAIN OUTCOME MEASUREMENTS Efficacy and safety of IEUC for biliary decompression. RESULTS IEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding. LIMITATIONS Single-center experience of 2 operators. CONCLUSIONS IEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.
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Affiliation(s)
- Michel Kahaleh
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA 22908, USA
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Goldberg E, Titus M, Haluszka O, Darwin P. Pancreatic-duct stent placement facilitates difficult common bile duct cannulation. Gastrointest Endosc 2005; 62:592-6. [PMID: 16185975 DOI: 10.1016/j.gie.2005.04.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 04/27/2005] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cannulation of the common bile duct can be difficult in certain instances. Difficult cannulation has been demonstrated to be a risk factor for post-ERCP pancreatitis. We report a technique to facilitate difficult cannulation that uses a pancreatic-duct stent to guide biliary cannulation. METHODS A retrospective review of all ERCPs performed at our institution from October 1, 2000 to June 30, 2004 (1638) was performed to identify all cases in which a pancreatic-duct stent was placed to guide common bile duct cannulation. Charts on these patients then were reviewed to assess cannulation success and complications. In addition, indications for the ERCP and previously failed cannulation attempts by outside physicians were documented. OBSERVATIONS Thirty-nine patients had pancreatic-duct stents placed as an aid to guide common bile duct cannulation. Successful cannulation of the bile duct was achieved in 38 of the 39 patients (97.4%) Procedure-related pancreatitis occurred in two patients and was mild in both. There were no procedure-related deaths. CONCLUSIONS In cases of difficult common bile duct cannulation, placement of a pancreatic-duct stent as a guide to aid common bile duct cannulation appears to be an effective and safe technique.
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Affiliation(s)
- Eric Goldberg
- Division of Gastroenterology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN 55415, USA
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Czakó L, Takács T, Morvay Z, Csernay L, Lonovics J. Diagnostic role of secretin-enhanced MRCP in patients with unsuccessful ERCP. World J Gastroenterol 2004; 10:3034-8. [PMID: 15378788 PMCID: PMC4576267 DOI: 10.3748/wjg.v10.i20.3034] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To evaluate the value of MR cholangiopancreatography (MRCP) in patients in whom endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessfully performed by experts in a tertiary center.
METHODS: From January 2000 to June 2003, 22 patients fulfilled the inclusion criteria. The indications for ERCP were obstructive jaundice (n = 9), abnormal liver enzymes (n = 8), suspected chronic pancreatitis (n = 2), recurrent acute pancreatitis (n = 2), or suspected pancreatic cancer (n = 1). The reasons for the ERCP failure were the postsurgical anatomy (n = 7), duodenal stenosis (n = 3), duodenal diverticulum (n = 2), and technical failure (n = 10). MRCP images were evaluated before and 5 and 10 min after i.v. administration of 0.5 IU/kg secretin.
RESULTS: The MRCP images were diagnosed in all 21 patients. Five patients gave normal MR findings and required no further intervention. MRCP revealed abnormalities (primary sclerosing cholangitis, chronic pancreatitis, cholangitis, cholecystolithiasis or common bile duct dilation) in 10 patients, who were followed up clinically. Four patients subsequently underwent laparotomy (hepaticojejunostomy in consequence of common bile duct stenosis caused by unresectable pancreatic cancer; hepaticotomy + Kehr drainage because of insufficient biliary-enteric anastomosis; choledochoj-ejunostomy, gastrojejunostomy and cysto-Wirsungo gastrostomy because of chronic pancreatitis, or choledochojejunostomy because of common bile duct stenosis caused by chronic pancreatitis). Three patients participated in therapeutic percutaneous transhepatic drainage. The indications were choledocholithiasis with choledochojejunostomy, insufficient biliary-enteric anastomosis, or cholangiocarcinoma.
CONCLUSION: MRCP can assist the diagnosis and management of patients in whom ERCP is not possible.
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Affiliation(s)
- László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary.
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Kowalski T, Kanchana T, Pungpapong S. Perceptions of gastroenterology fellows regarding ERCP competency and training. Gastrointest Endosc 2003; 58:345-9. [PMID: 14528206 DOI: 10.1067/s0016-5107(03)00006-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The adequacy of ERCP training in the United States may be suboptimal because many training programs do not provide fellows with the exposure to the procedures necessary to achieve competence. METHODS A short survey questionnaire, which assesses the training program, the personal ERCP experience, the perceptions regarding training adequacy, and the post-training practice plans, was sent to all fellows graduating from gastroenterology training programs. RESULTS Graduating fellows performed a median of 140 ERCPs and 35 sphincterotomies during training, with an associated median comfort level for independently performing sphincterotomy of 7.5 on a scale of 1 to 10. The median estimated success rate for independent free cannulation was 75%. Based on nonparametric correlation and regression analysis, 180 ERCPs would be necessary to achieve a free cannulation rate of 80% and 69 sphincterotomies to achieve a comfort level of 8 on a scale of 1 to 10. Thirty-six percent of fellows achieved the number of procedures and cannulation success determined by this study to indicate procedural competence. Sixty-four percent of fellows did not achieve procedural competence and 33% reported inadequate ERCP training. Nevertheless, 91% of fellows expected to perform unsupervised ERCP after training. CONCLUSIONS The results of this study are consistent with those of previously published studies demonstrating that 160 to 200 ERCP procedures are necessary to achieve competence to perform ERCP. The majority of graduating fellows do not achieve an acceptable success rate during training, yet still intend to perform ERCP after training.
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Affiliation(s)
- Thomas Kowalski
- Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Lehman GA. What are the determinants of success in utilization of ERCP in the setting of pancreatic and biliary diseases? Gastrointest Endosc 2002. [PMID: 12447283 DOI: 10.1016/s0016-5107(02)70027-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Glen A Lehman
- Department of Medicine-Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Abstract
With current treatment, survival of greater than 1 year should be anticipated for many patients with pancreatic cancer. Cure rates (5-year survival) of greater than 10% have been achieved even for unresectable disease. Obstructive jaundice is managed successfully with endoscopic placement of a plastic stent early in the evaluation of a patient with suspected regional pancreatic cancer, and a metal wall stent is reserved for patients with known 1997 AJCC stage IVB carcinoma or nonoperative patients. Relief of biliary obstruction allows improvement in liver function and more time to evaluate tumor stage accurately to determine initial treatment (see Fig. 1). A cost-effective algorithm to determine accurate stage and treatment can start with the size of the mass on initial imaging studies. EUS-guided FNA represents a significant improvement over CT scan-guided FNA to make a tissue diagnosis. Small pancreatic masses that would be resected regardless of whether an FNA is positive or negative require only an EUS evaluation to establish an early resectable stage. Tumors reliably staged as unresectable by nonoperative imaging methods including EUS are treated with chemotherapy with or without concurrent radiotherapy because median survival of these patients is 2 years in some series. Tumors can be resected after neoadjuvant chemoradiotherapy. For chronic pain or gastric outlet obstruction not responding or treatable by chemoradiotherapy, endoscopically guided celiac plexus nerve block and stenting improve the quality of life for patients with pancreatic cancer. A team approach is required to achieve the objectives of improved quality of life, prolonged survival, and possible cure for pancreatic cancer. The optimal combination and sequencing of staging methods, including EUS, specialized CT scan, MR imaging, intraoperative findings, and pathologic evaluations, would improve selection of patients for potential curative resection. Interpretations of disease stage based on each of these methods may overlap but are not identical and are operator dependent. Rather than reliance on any single standard, clinical judgment and communication among the team are paramount to providing optimal care for patients with a pancreatic neoplasm.
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Affiliation(s)
- Harry Snady
- Pancreatobiliary Treatment Group, EUS Imaging, 22 East 88th Street, New York, NY 10128, USA. www.eusimaging.com
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