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Li T, Hao LX, Lv C, Li XJ, Ji XD, Chen M, Liu C, Bie LK, Gong B. Long-term outcomes of endoscopic papillary large-balloon dilation (12-15 mm) with or without limited sphincterotomy for removal of bile duct stones. Hepatobiliary Pancreat Dis Int 2022:S1499-3872(22)00154-0. [PMID: 35851505 DOI: 10.1016/j.hbpd.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Limited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12-15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones. METHODS Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed. RESULTS Basic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up was 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357-6.640; P = 0.007) was an independent risk factor for stone recurrence. CONCLUSIONS The application of a large balloon (12-15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.
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Affiliation(s)
- Tao Li
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Li-Xiao Hao
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Chan Lv
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Xing-Jia Li
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Xiao-Dan Ji
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Meng Chen
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Chang Liu
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Li-Ke Bie
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Biao Gong
- Department of Gastroenterology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China.
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Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol 2021; 27:7597-7611. [PMID: 34908801 PMCID: PMC8641054 DOI: 10.3748/wjg.v27.i44.7597] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/23/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.
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Affiliation(s)
- Alberto Tringali
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Deborah Costa
- Gastroenterology and Endoscopy Unit, Department of Medicine, Conegliano Hospital, ULSS 2 Marca Trevigiana, Conegliano 31015, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano 20089, Milan, Italy
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Revision of the common bile duct in a combined PTCD/ERC approach - A case report. Int J Surg Case Rep 2021; 82:105854. [PMID: 33848925 PMCID: PMC8044378 DOI: 10.1016/j.ijscr.2021.105854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/22/2022] Open
Abstract
Bile duct stone patients with altered anatomy should be treated in medical centers. Interdisciplinary approach of combined ERC/PTCD is an alternative for stone removal. The combined PTCD/ERC approach can cause in intraabdominal adhesions.
Introduction and importance The endoscopic retrograde cholangiography (ERC) represents the standard treatment for choledocholithiasis. However, ERC in patients with previous gastrectomy and anastomosis is difficult due to altered access. Case presentation In our case, we report on a patient with previous gastrectomy and Y-Roux-anastomosis suffering from choledocholithiasis. Operative revision with simultaneous cholecystectomy failed. In a combined procedure of percutaneous transhepatic cholangiodrainage (PTCD) and endoscopic cholangiography the stone removal of the common bile duct was finally successful. Clinical discussion There are some approaches for treatment of choledocholithiasis in pre-operated patients. However, prospective multi-center studies for complication and success rates are not available due to the rarity of such cases. Conclusion Interdisciplinary procedures seem to be the safest and most promising way to succeed in the treatment of choledocholithiasis in challenging cases.
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Zhu F, Guan Y, Wang J. Efficacy and safety of the rotatable sphincterotome during ERCP in patients with prior Billroth II gastrectomy (with videos). Surg Endosc 2021; 35:4849-4856. [PMID: 33733322 DOI: 10.1007/s00464-021-08417-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Selective biliary cannulation (SBC) is currently accepted as the first challenge of endoscopic retrograde cholangiopancreatography (ERCP), especially in patients with altered anatomy such as Billroth II gastrectomy. A rotatable sphincterotome (RS) might be considered useful for guiding the directional axis of SBC. This study aimed to evaluate the efficacy and safety of RS for biliary cannulation in patients with prior Billroth II gastrectomy. METHODS This is a retrospective cohort study conducted to compare the efficacy and safety between RS (RS group) and conventional sphincterotome of pulling arciform knife (PAF, PAF group). The success rate of SBC and endoscopic sphincterotomy (EST) were evaluated in both the groups. Moreover, the outcomes of the procedure and adverse events were also compared between the two groups. RESULTS Eighty-six consecutive prior Billroth II gastrectomy patients who underwent ERCP with RS or PAF during the study period were enrolled. After excluding 7 patients, there were 41 patients in the RS group and 38 in the PAF group. The baseline characteristics were similar in both the groups. There was no significant difference in the clinical success rates of SBC in RS group (95.12%) versus PAF group (84.21%), (P = 0.1082). Successful SBC within 5 min was 87.80% in RS group and 23.68% in PAF group (P < 0.0001). The success rate of EST was 89.74% in RS group and 28.13% in PAF group (P < 0.0001). The incidence of post-ERCP pancreatitis (PEP) showed significant differences between RS (2.44%) and PAF groups (21.05%; P = 0.0061). CONCLUSIONS Although RS has comparable success rates of SBC over PAF in patients with prior Billroth II gastrectomy, RS has facilitated the procedure by increasing the success rate of EST and SBC within 5 min, and the incidence of PEP was lowered as well.
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Affiliation(s)
- Feng Zhu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China.
| | - Yaping Guan
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Jing Wang
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
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A comparative study of side-viewing duodenoscope and forward-viewing gastroscope to perform endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Surg Endosc 2020; 35:4222-4230. [PMID: 32860133 DOI: 10.1007/s00464-020-07904-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/17/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND/AIM Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is a difficult procedure. Although different endoscopes are used in these patients, comparative studies are limited. The aim of this study was to assess the efficacy and the safety of the forward-viewing gastroscope compared with the side-viewing duodenoscope. MATERIALS AND METHODS This study was conducted on 75 Billroth II gastrectomy patients who underwent ERCP by the same experienced endoscopist. Procedures were performed using side-viewing duodenoscope in the first 41 patients and forward-viewing gastroscope in the subsequent 34 patients. The success and complication rates of ERCP were compared between the two groups. RESULTS Afferent loop intubation was achieved in 39 patients (95.1%) in the side-viewing duodenoscope group and in 34 patients (100%) in the forward-viewing gastroscope group (P = 0.49). The rates of reaching the papilla was 70.7% (n = 29) and 91.1% (n = 31), respectively (P = 0.06). Cannulation success rate after reaching the papilla was 100% in the side-viewing duodenoscope group and 90.3% in the forward-viewing gastroscope group. In the side-viewing duodenoscope group, 11 patients underwent sphincterotomy (EST), 14 patients underwent both EST and endoscopic papillary balloon dilatation (EPBD), and 4 patients underwent only EPBD. All but one patients in the forward-viewing gastroscope group underwent EPBD without EST. The technical and the clinical success rate did not statistically differ between the groups (70.7% vs. 82.3%, 68.3% vs. 79.4%, respectively). Adverse events included jejunal perforation in one patient (2.4%) in the side-viewing duodenoscope group, and pancreatitis in one patient (2.9%) in the forward-viewing gastroscope group (P > 0.05). CONCLUSION This study indicates that forward-viewing gastroscope is as effective as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Furthermore, EPBD without prior EST appears to be a safe and effective procedure in these patients.
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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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Caglar E, Atasoy D, Tozlu M, Altınkaya E, Dogan S, Senturk H. Experience of the Endoscopists Matters in Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients. Clin Endosc 2019; 53:82-89. [PMID: 31476843 PMCID: PMC7003014 DOI: 10.5946/ce.2019.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Altered anatomy is a challenge in endoscopic retrograde cholangiopancreatography (ERCP) for patients with Billroth II anastomosis. In this study, we investigated the overall success and role of endoscopist experience.
Methods Data of patients who underwent ERCP between 2014 and 2018 after a previous Billroth II operation were retrieved retrospectively from 2 tertiary ERCP centers. The procedures were performed by 2 endoscopists with different levels of experience. Clinical success was defined as extraction of the stone, placement of a stent through a malignant stricture, and clinical and laboratory improvements in patients.
Result Seventy-five patients were included. The technical success rate was 83% for the experienced endoscopist and 75% for the inexperienced endoscopist (p=0.46). The mean (±standard deviation) procedure time was 23.8±5.7 min for the experienced endoscopist and 40.68±6.07 min for the inexperienced endoscopist (p<0.001). In total, 3 perforations (4%) were found. The rate of afferent loop perforation was 6.25% (1/16) for the inexperienced endoscopist and 0% (0/59) for the experienced endoscopist (p=0.053).
Conclusions ERCP in patients who had undergone Billroth II gastrectomy was time consuming for the inexperienced endoscopist who should beware of the unique adverse events related to ERCP in patients with altered anatomy.
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Affiliation(s)
- Erkan Caglar
- Department of Gastroenterology, Kayseri Training and Education Hospital, Kayseri, Turkey
| | - Deniz Atasoy
- Department of General Surgery, İstinye University, Gaziosmanpasa Medical Park Hospital, Istanbul, Turkey
| | - Mukaddes Tozlu
- Department of Gastroenterology, Sakarya University Medical Faculty, Sakarya, Turkey
| | - Engin Altınkaya
- Department of Gastroenterology, Kayseri Training and Education Hospital, Kayseri, Turkey
| | - Serkan Dogan
- Department of Gastroenterology, Kayseri Training and Education Hospital, Kayseri, Turkey
| | - Hakan Senturk
- Department of Gastroenterology, Faculty of Medicine, Bezmialem University, Istanbul, Turkey
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Li JS, Zou DW, Jin ZD, Shi XG, Chen J, Li ZS, Liu F. Predictive factors for extraction of common bile duct stones during endoscopic retrograde cholangiopancreatography in Billroth II anatomy patients. Surg Endosc 2019; 34:2454-2459. [PMID: 31376008 DOI: 10.1007/s00464-019-07039-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/24/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in Billroth II anatomy patients is still a technical challenge and factors affecting stone extraction have not yet been clarified. This study aimed to analyze our experience and evaluate potential factors affecting CBD stone extraction. METHODS A retrospective analysis of CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from August 1999 to December 2017, was conducted. The outcomes of ERCP and potential factors affecting stone extraction were examined. RESULTS A total of 227 patients were enrolled, and 176 patients (77.5%) achieved technical success. The success rate of duodenal ampullary access and selective biliary cannulation was 84.1% (191/227) and 92.1% (176/191), respectively. The mean CBD diameter was 15 mm (range 6-35 mm), and the largest stone size was 13 mm (range 4-36 mm). CBD stones were ultimately removed in 137 patients (77.8%), and 105 patients (59.7%) for the first session. Mechanical lithotripsy was used in 17 patients (9.7%). The overall ERCP-related complication rate was 6.3% (11/176), including bleeding in 3 patients (1.7%) and mild pancreatitis in 6 patients (3.4%). The multivariate analysis indicated that CBD stone number ≥ 2 (OR 2.171; 95% CI 1.095-4.306; p = 0.027), and the largest CBD stone size ≥ 12 mm (OR 3.646; 95% CI 1.833-7.251; p < 0.001) were patient-related risk factors for failed stone removal; while the use of endoscopic papillary (large) balloon dilation (EPBD/EPLBD) (OR 0.291; 95% CI 0.147-0.576; p < 0.001) was a procedure-related protective factor for successful stone extraction. CONCLUSIONS ERCP is safe and effective for extraction of CBD stones in Billroth II anatomy patients. The number and the largest size of CBD stones, and the use of EPBD/EPLBD are predictive factors for CBD stone extraction.
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Affiliation(s)
- Jia-Su Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xin-Gang Shi
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jie Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Middle Yanchang Road No. 301, Shanghai, 200072, China.
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Park TY, Song TJ. Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review. World J Gastroenterol 2019; 25:3091-3107. [PMID: 31293344 PMCID: PMC6603814 DOI: 10.3748/wjg.v25.i24.3091] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/03/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.
AIM To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.
METHODS A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.
RESULTS A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).
CONCLUSION The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul 04551, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, South Korea
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The Feasibility of Conventional Forward-viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients With Altered Gastrointestinal Anatomy. Surg Laparosc Endosc Percutan Tech 2019; 29:216-219. [PMID: 30720694 DOI: 10.1097/sle.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has been commonly used for biliopancreatic diseases of patients with normal gastrointestinal (GI) anatomy with a success rate of >90%. However, this procedure may also be necessary in patients with altered GI anatomy such as Billroth II or Roux-en-Y reconstructions. Performing ERCP in these patients may pose extreme technical challenges, and increase the risk of complications. The aim of this study was to analyze the feasibility of ERCP using forward-viewing endoscopy in patients with altered GI anatomy. MATERIALS AND METHODS Twenty-three patients with previous gastric resections and GI anastomosis, who underwent ERCP between 2012 and 2017, were included in this retrospective study. The major indication for ERCP was choledocholithiasis in 19 patients, and the others were acute cholangitis, sphincter Oddi dysfunction, and biliary pancreatitis. The sedation was induced using a combination of midazolam and propofol, and all procedures were performed using a forward-viewing endoscope. RESULTS Among the 23 patients, 14 were male individuals and 9 were female individuals, with an average age of 62 (range: 58 to 73) years. The median procedure time was 24 (range: 19 to 43) minutes. The success rate of bile duct cannulation was 91.3% (21/23 patients) and that of stone extirpation was 89.4% (17/19 patients with choledocholithiasis). Plastic stents were placed in the 2 patients in whom stone extirpation was not successfully performed. ERCP was repeated in these patients 8 weeks after the initial approach, and stone extraction procedures were successfully completed. The only procedure-related complication was edematous pancreatitis, which was observed in 1 patient (4.7%). The mean length of hospitalization was 2 (range: 1 to 5) days. CONCLUSIONS Forward-viewing endoscopes can be effectively used in patients with altered GI anatomy by facilitating the access to the papilla and bile duct cannulation without increasing the incidence of complications.
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Köksal AŞ, Eminler AT, Parlak E. Biliary endoscopic sphincterotomy: Techniques and complications. World J Clin Cases 2018; 6:1073-1086. [PMID: 30613665 PMCID: PMC6306628 DOI: 10.12998/wjcc.v6.i16.1073] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/20/2018] [Accepted: 11/26/2018] [Indexed: 02/05/2023] Open
Abstract
Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.
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Affiliation(s)
- Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University, School of Medicine, Ankara 41000, Turkey
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Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients. Hepatobiliary Pancreat Dis Int 2018; 17:546-552. [PMID: 30126827 DOI: 10.1016/j.hbpd.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/26/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. METHODS This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. RESULTS A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. CONCLUSION Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.
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Li T, Wen J, Bie LK, Lu Y, Gong B. Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth II gastrectomy patients. Hepatobiliary Pancreat Dis Int 2018; 17:257-262. [PMID: 29628337 DOI: 10.1016/j.hbpd.2018.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic papillary balloon dilation (EPBD) for common bile duct (CBD) stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients. METHODS The records of patients with previous Billroth II gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography (ERCP) between July 1, 2008 and September 1, 2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events, and stone recurrence were analyzed. RESULTS A total of 83 patients with previous Billroth II gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth II gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients (85.7%). ERCP-related adverse events was in 3 ERCP procedures (5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients (12.2%) had stone recurrence after a median period of 22.5 months (range 6-71 months) from the end of stone removal treatment. Female [odds ratio (OR) = 11.352; 95% confidence interval (95% CI): 1.040-123.912; P = 0.046] and previous mechanical lithotripsy (OR = 13.423; 95% CI: 1.070-168.434; P = 0.044) were significantly associated with stone recurrence. CONCLUSIONS At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth II gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.
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Affiliation(s)
- Tao Li
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Jun Wen
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Li-Ke Bie
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Yi Lu
- Digestive Endoscopy Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Biao Gong
- Department of Gastroenterology, Digestive Endoscopy Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China.
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14
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Park TY, Bang CS, Choi SH, Yang YJ, Shin SP, Suk KT, Baik GH, Kim DJ, Yoon JH. Forward-viewing endoscope for ERCP in patients with Billroth II gastrectomy: a systematic review and meta-analysis. Surg Endosc 2018; 32:4598-4613. [PMID: 29777352 DOI: 10.1007/s00464-018-6213-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/09/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The forward-viewing endoscope has been increasingly used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent Billroth II gastrectomy. This study intended to assess efficacy and safety of the forward-viewing endoscope for ERCP in Billroth II gastrectomy patients compared with conventional side-viewing endoscope using a systematic review and meta-analysis. METHODS A systematic review was conducted for studies that evaluated the outcomes of ERCP for patients with Billroth II gastrectomy. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for non-randomized studies. The publication bias was assessed. RESULTS In total, 25 studies (1 randomized, 18 retrospective, 1 prospective, and 5 case series studies) with 2446 patients (499 forward-viewing and 1947 side-viewing endoscopes) were analyzed. The pooled afferent loop intubation rate was higher with the forward-viewing endoscope (90.3%, 95% confidence interval (CI) 85.6-93.6 vs. 86.8%, 95% CI 82.8-89.9%). The pooled selective cannulation rate was higher with the side-viewing endoscope (92.3%, 95% CI 88.0-95.2 vs. 91.1%, 95% CI 87.2-93.9%). The pooled bowel perforation rate was higher with the side-viewing endoscope (3.6%, 95% CI 2.3-5.7 vs. 3.0%, 95% CI 1.7-5.3%). The pooled pancreatitis rate was higher with the forward-viewing endoscope (5.4%, 95% CI 3.6-8.0 vs. 2.5%, 95% CI 2.3-5.7%). The pooled bleeding rate was higher with the forward-viewing endoscope (3.0%, 95% CI 1.6-5.5 vs. 2.0%, 95% CI 1.4-3.0%). The heterogeneity among the studies was not significant. The publication bias was minimal. CONCLUSION This meta-analysis indicates that the forward-viewing endoscope is as safe and effective as conventional side-viewing endoscope for ERCP in patients with Billroth II gastrectomy.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, 9 Mareunnae-ro, Jung-gu, Seoul, South Korea.
| | - Chang Seok Bang
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sang Hyeon Choi
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Young Joo Yang
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Suk Pyo Shin
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jai Hoon Yoon
- Department of Internal Medicine, Gwangmyeong Sungae Hospital, Gwangmyeong, South Korea
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Itoi T, Ryozawa S, Katanuma A, Okabe Y, Kato H, Horaguchi J, Tsuchiya T, Gotoda T, Fujita N, Yasuda K, Igarashi Y, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation. Dig Endosc 2018; 30:293-309. [PMID: 29411902 DOI: 10.1111/den.13029] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironori Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takuji Gotoda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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16
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Nakai Y, Kogure H, Yamada A, Isayama H, Koike K. Endoscopic management of bile duct stones in patients with surgically altered anatomy. Dig Endosc 2018; 30 Suppl 1:67-74. [PMID: 29658650 DOI: 10.1111/den.13022] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/11/2018] [Indexed: 12/13/2022]
Abstract
Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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17
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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18
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Park CH, Jung JH, Nam E, Kim EH, Kim MG, Kim JH, Park SW. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc 2018; 87:43-57.e10. [PMID: 28756105 DOI: 10.1016/j.gie.2017.07.038] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although various endoscopic techniques have been introduced for successful removal of common bile duct (CBD) stones, the optimal method is not yet clear. We aimed to compare the efficacy of different endoscopic techniques for CBD stone removal. METHODS We searched for all relevant randomized controlled trials published until June 2017, examining the outcomes of endoscopic techniques for CBD stone removal, including endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and EST with balloon dilatation (ESBD). A Bayesian network meta-analysis was performed. RESULTS Twenty-five studies with 3726 patients were included in the meta-analysis. ESBD had a higher successful rate of stone removal in the first endoscopic session than EPBD (odds ratio [OR] [95% credible interval {CrI}], 2.09 [1.07-4.16]). Mechanical lithotripsy was less common in ESBD than in EPBD (OR [95% CrI], .45 [.25-.83]). EPBD revealed a lower risk of bleeding than both EST and ESBD (OR [95% CrI], vs EST, .06 [.008-.23]; vs ESBD, .12 [.01-.64]). The pooled incidences of bleeding were 3.0% (95% confidence interval [CI], 1.8%-5.2%), 1.1% (95% CI, .6%-2.0%), and 2.0% (95% CI, .9%-4.4%) in the EST, EPBD, and ESBD groups, respectively. Pancreatitis tended to be more common in EPBD than in both EST and ESBD (OR [95% CrI]: vs EST, 1.49 [.84-2.59]; vs ESBD, 1.49 [.61-3.57]). CONCLUSION The efficacy of ESBD in stone removal during the first endoscopic session was superior to that of EPBD. Pancreatitis in ESBD and EST tended to be less common than in EPBD, although this difference was not statistically significant. However, ESBD and EST carried a higher risk of bleeding than EPBD.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Eunwoo Nam
- Biostatistical Consulting and Research Lab, Medical Research Coordinating Center, Hanyang University, Seoul, Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Gang Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Gyeonggi-do, Korea
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19
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Xu XD, Chen B, Dai JJ, Qian JQ, Xu CF. Minor endoscopic sphincterotomy followed by large balloon dilation for large choledocholith treatment. World J Gastroenterol 2017; 23:5739-5745. [PMID: 28883699 PMCID: PMC5569288 DOI: 10.3748/wjg.v23.i31.5739] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/29/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate early and late outcomes of endoscopic papillary large balloon dilation (EPLBD) with minor endoscopic sphincterotomy (mEST) for stone removal.
METHODS A total of 149 consecutive patients with difficult common bile duct (CBD) stones (diameter ≥ 10 mm or ≥ 3 stones) underwent conventional endoscopic sphincterotomy (EST) or mEST plus EPLBD from May 2012 to April 2016. Their demographic, laboratory and procedural data were collected, and pancreaticobiliary complications were recorded.
RESULTS Sixty-nine (94.5%) of the patients in the EPLBD + mEST group and 64 (84.2%) in the conventional EST group achieved stone clearance following the first session (P = 0.0421). The procedure time for EPLBD + mEST was shorter than for EST alone (42.1 ± 13.6 min vs 47.3 ± 11.8 min, P = 0.0128). The overall rate of early complications in the EPLBD + mEST group (11%) was lower than in the EST group (21.1%); however, the difference was not significant (P = 0.0938). The cumulative recurrence rate of cholangitis and CBD stones between the two groups was also similar. The procedure time was independently associated with post-endoscopic retrograde cholangiopancreatography pancreatitis (OR = 6.374, 95%CI: 1.193-22.624, P = 0.023), CBD stone diameter ≥ 16 mm (OR = 7.463, 95%CI: 2.705-21.246, P = 0.0452) and use of mechanical lithotripsy (OR = 9.913, 95%CI: 3.446-23.154, P = 0.0133) were independent risk factors for stone recurrence.
CONCLUSION EPLBD with mEST is more effective than EST alone for difficult CBD stone removal, with shorter procedure time and fewer early complications.
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Affiliation(s)
- Xiao-Dan Xu
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Bo Chen
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Jian-Jun Dai
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Jian-Qing Qian
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, Changshu 215500, Jiangsu Province, China
| | - Chun-Fang Xu
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University, Soozhou 215000, Jiangsu Province, China
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20
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Shuaib A, Kokaj J, Makdisi Y, Pichler G, Husain A, Asfar S. Time-Resolved Laser-Induced Fluorescence Spectroscopy as a Guidance Tool for Laser Lithotripsy of Gallbladder Stones. Photomed Laser Surg 2017; 35:498-504. [PMID: 28727952 DOI: 10.1089/pho.2017.4271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although laser lithotripsy for fragmentation of gallbladder stones has been applied successfully in many clinical situations, this approach has two major limitations: (1) the potential to damage or perforate the bile duct and (2) the efficiency can be affected by the chemical composition of the gallstones. The present study evaluated the use of time-resolved laser-induced fluorescence spectroscopy to classify stone types and distinguish stone from tissue. MATERIALS AND METHODS Ex vivo time-resolved laser-induced fluorescence analysis (excitation wavelength λex = 400 nm and emission wavelength = 450-700 nm) of 54 gallbladder stones and seven gallbladder tissue samples was conducted. The spectral and temporal parameters were analyzed using linear discrimination analysis (LDA) to differentiate stone from tissue and to classify different stone types using two wavelength regions (λ1 = 510-530 nm and λ2 = 550-570 nm). RESULTS Examination of 54 gallbladder stones and seven gallbladder tissue samples showed a significant difference in spectral- and temporal-derived parameters. The data were classified using LDA, and the overall accuracy was 94.88%, 84.39%, and 85.79% for both spectral and temporal parameters, only spectral parameters, and only temporal parameters, respectively. CONCLUSIONS Our findings establish the feasibility of using time-resolved laser-induced fluorescence spectroscopy as a tool to identify gallbladder stone types and as a stone-tissue detection system to improve the effectiveness of laser lithotripsy procedures and reduce the risk of damaging biliary tract tissues.
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Affiliation(s)
- Ali Shuaib
- 1 Biomedical Engineering Unit, Department of Physiology, Faculty of Medicine, Kuwait University , Kuwait
| | - Jahja Kokaj
- 2 Department of Physics, Faculty of Science, Kuwait University , Kuwait
| | - Yacoub Makdisi
- 2 Department of Physics, Faculty of Science, Kuwait University , Kuwait
| | - Goran Pichler
- 2 Department of Physics, Faculty of Science, Kuwait University , Kuwait
| | - Abdullah Husain
- 3 Department of Surgery, Mubarak Al-Kabeer Hospital , Jabirya, Kuwait
| | - Sami Asfar
- 3 Department of Surgery, Mubarak Al-Kabeer Hospital , Jabirya, Kuwait .,4 Department of Surgery, Faculty of Medicine, Kuwait University , Kuwait
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Abdelhafez M, Frimberger E, Klare P, Haller B, Schmid RM, von Delius S. Comparison of endoscopic sphincterotomy techniques after Billroth II gastrectomy using a novel mechanical simulator. Surg Endosc 2017; 31:5342-5347. [PMID: 28597287 DOI: 10.1007/s00464-017-5613-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 05/16/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS A postsurgical anatomy renders endoscopic sphincterotomy (EST) more challenging. Although different EST techniques for such a situation exist, comparative studies are lacking. The aim of the study was to compare the efficacy of different EST techniques using a novel mechanical simulator. METHODS Ten expert endoscopists performed 6 different EST techniques on a novel mechanical Billroth II (BII) simulator in a random sequence. The EST techniques were (1) standard sphincterotome used with a side-viewing endoscope, (2) BII sphincterotome used with a side-viewing endoscope, (3) needle-knife EST guided by biliary endoprosthesis used with a side-viewing endoscope, (4) standard sphincterotome used with a forward-viewing endoscope, (5) BII sphincterotome used with a forward-viewing endoscope, and (6) needle-knife EST guided by biliary endoprosthesis used with a forward-viewing endoscope. The results of videotaped ESTs were evaluated by a blinded expert and duration for each EST modality was calculated. RESULTS Needle-knife EST guided by endoprosthesis was rated superior to EST using a BII sphincterotome (p = 0.017) or a standard sphincterotome (p < 0.001). EST using the BII sphincterotome was significantly faster than EST with the needle knife (p = 0.004) and the standard sphincterotome (p = 0.005). There were no differences between the use of a forward-viewing endoscope and a side-viewing endoscope. CONCLUSION In an ex vivo model for EST in B II gastrectomy needle-knife EST guided by endoprosthesis achieved superior ratings in comparison to the use of a BII sphincterotome, although it was more time-consuming. A standard sphincterotome should not be used for such a procedure.
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Affiliation(s)
- Mohamed Abdelhafez
- Klinik und Poliklinik für Innere Medizin 2, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Eckart Frimberger
- Klinik und Poliklinik für Innere Medizin 2, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Peter Klare
- Klinik und Poliklinik für Innere Medizin 2, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin 2, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Stefan von Delius
- Klinik und Poliklinik für Innere Medizin 2, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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Goyal D, Kasapoglu B, Thosani N. Endoscopic retrograde cholangiopancreatography in surgically altered anatomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Deepinder Goyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Benan Kasapoglu
- Department of Gastroenterology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, McGovern Medical School, UTHealth, Houston, TX, USA
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Sakai Y, Tsuyuguchi T, Mikata R, Sugiyama H, Yasui S, Miyazaki M, Yokosuka O. Utility of endoscopic retrograde cholangiopancreatography on biliopancreatic diseases in patients with Billroth II-reconstructed stomach. World J Gastrointest Endosc 2017; 9:127-132. [PMID: 28360974 PMCID: PMC5355759 DOI: 10.4253/wjge.v9.i3.127] [Citation(s) in RCA: 2] [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: 06/15/2016] [Revised: 08/03/2016] [Accepted: 01/03/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To examine the utility of endoscopic retrograde cholangiopancreatography (ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach.
METHODS For 26 cases of biliopancreatic diseases in patients with Billroth II-reconstructed stomach, ERCP was conducted using a straight-view scope or a retrograde oblique-viewing endoscope. All the cases were patients aiming at selective insertion into the bile duct. One patient aimed at diagnosis, and 25 patients aimed at treatment. The cases in which the endoscope reached the duodenal papilla and anastomosis, and insertion into the bile duct became possible, were considered successful.
RESULTS The rate of reaching the duodenal papilla and anastomosis was 84.7% (22/26 patients). Among the cases without reaching the duodenal papilla and anastomosis, there were 2 in which the endoscope did not pass due to tumor-induced duodenal infiltration. In 1 case, the fiber did not reach the duodenal papilla due to long afferent loop. The success rate of insertion into the bile duct in patients in which the endoscope reached the duodenal papilla and anastomosis was 90.9% (20/22 patients), and the success rate of procedures including treatment was 86.3% (19/22 patients). After treatment, mild cholangitis was observed in 1 patient (4.5%, 1/22 patients) but relieved conservatively. No other accidental symptom was observed.
CONCLUSION It was considered that the ERCP for biliopancreatic diseases in patients with Billroth II-reconstructed stomach will become a less invasive, safe and useful examination and treatment approach.
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Abstract
Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.
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Affiliation(s)
| | - Sun Qiang
- b Department of General Surgery , Jing'an District Center Hospital of Shanghai (Huashan Hospital Fudan University Jing'an Branch) , Shanghai , PR China
| | - Yin Bao-Bing
- c Department of General Surgery , Huashan Hospital, Fudan University , Shanghai , PR China
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Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan. Am J Gastroenterol 2016; 111:1750-1758. [PMID: 27670601 DOI: 10.1038/ajg.2016.420] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy. METHODS This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study. RESULTS A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery. CONCLUSIONS ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.
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Park CH. Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients. Clin Endosc 2016; 49:506-509. [PMID: 27894185 PMCID: PMC5152788 DOI: 10.5946/ce.2016.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/03/2016] [Accepted: 10/13/2016] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in post-gastrectomy patients with Billroth II (BII) reconstruction and Roux-en-Y (RY) reconstruction presents a challenge to therapeutic endoscopists. Major difficulties, including intubation to the ampulla of Vater, selective cannulation, and ampullary intervention, must be overcome in these patients. Recent data have shown that device-assisted ERCP allows for high success rates in these patients because various devices are useful for overcoming major difficulties. Therefore, good knowledge of postoperative anatomy and various devices is mandatory before performing ERCP procedures for post-gastrectomy patients.
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Affiliation(s)
- Chang-Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Clinical evaluation of double-channel gastroscope for endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. GASTROENTEROLOGY REVIEW 2016; 11:163-169. [PMID: 27713777 PMCID: PMC5047970 DOI: 10.5114/pg.2016.61370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 04/10/2015] [Indexed: 12/24/2022]
Abstract
Aim To evaluate the use of a double-channel gastroscope in patients with Billroth II gastrectomy to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. Material and methods From January 2008 to December 2013, 18 patients with Billroth II gastrectomy were enrolled in this study. Endoscopic retrograde cholangiopancreatography was performed using a straight forward gastroscope with double working channel (4.2-mm diameter, 2.8-mm diameter). Results The success rate of selective cannulation and accomplishment of planned procedures was 15 out of 18 patients (83.3%), and no serious complications were encountered. Conclusions The double-channel gastroscope appears to be useful in performing endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy.
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Outcomes of ERCP in Billroth II gastrectomy patients. Gastrointest Endosc 2016; 83:1193-201. [PMID: 26546981 DOI: 10.1016/j.gie.2015.10.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/25/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP is a difficult procedure to perform in Billroth II gastrectomy patients because of altered anatomy. We investigated the outcomes and risk factors for adverse events with ERCP using a cap-fitted forward-viewing endoscope with endoscopic papillary balloon dilation (EPBD) in Billroth II gastrectomy patients. METHODS The records for Billroth II gastrectomy patients who underwent ERCP using a cap-fitted forward-viewing endoscope with EPBD at 5 institutions between August 2008 and April 2014 were retrospectively reviewed. The outcomes and risk factors for adverse events resulting from this treatment were analyzed. RESULTS In total, 165 patients were identified. ERCP was technically successful in 144 patients (87.3%) and clinically successful in 141 patients (85.5%). Adverse events occurred in 38 patients (23.0%): perforation in 3 cases (1.8%), pancreatitis in 13 cases (7.9%), and asymptomatic hyperamylasemia in 22 patients (13.3%). In univariate analysis, ≥2 ERCP sessions, periampullary diverticulum, and common bile duct (CBD) stone size ≥ 12 mm were found to be associated with ERCP-related adverse events. In multivariate analysis, ≥2 ERCP sessions (odds ratio [OR], 4.762; 95% confidence interval [CI], 1.472-15.402; P = .009) and a CBD stone size ≥ 12 mm (OR, 3.213; 95% CI, 1.140-9.057; P = .027) were significant. CONCLUSIONS ERCP using a cap-fitted forward-viewing endoscope with EPBD is feasible in Billroth II gastrectomy patients. In patients with ≥2 ERCP sessions or a CBD stone size ≥ 12 mm, special attention should be paid to the possible occurrence of significant adverse events.
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Enestvedt BK, Kothari S, Pannala R, Yang J, Fujii-Lau LL, Hwang JH, Konda V, Manfredi M, Maple JT, Murad FM, Woods KL, Banerjee S. Devices and techniques for ERCP in the surgically altered GI tract. Gastrointest Endosc 2016; 83:1061-75. [PMID: 27103361 DOI: 10.1016/j.gie.2016.03.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/04/2016] [Indexed: 02/08/2023]
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Kim TH, Kim JH, Seo DW, Lee DK, Reddy ND, Rerknimitr R, Ratanachu-Ek T, Khor CJL, Itoi T, Yasuda I, Isayama H, Lau JYW, Wang HP, Chan HH, Hu B, Kozarek RA, Baron TH. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc 2016; 83:37-47. [PMID: 26232360 DOI: 10.1016/j.gie.2015.06.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/11/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Tae Hyeon Kim
- Department of Gastroenterology, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nageshwar D Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Christopher J L Khor
- Department of Gastroenterology and Hepatology, National University Health System, Tan Tock Seng Hospital, Singapore
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - James Y W Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Easler JJ, Sherman S. Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:657-75. [PMID: 26431596 DOI: 10.1016/j.giec.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Biliary disease is a common cause of acute pancreatitis. Risk stratification for persistent pancreatobiliary obstruction is important for selecting a treatment approach. Most common bile duct stones are extracted with standard endoscopic techniques. However, prior foregut surgery, stones with extreme morphologic attributes, and at difficult positions within the biliary system are technically challenging and predict a need for advanced biliary endoscopic techniques. Surgical common bile duct exploration at the time of cholecystectomy is appropriate in centers with experience. We outline the options and approach for the clinician to successfully identify and manage patients with symptomatic choledocholithiasis with or without biliary pancreatitis.
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Affiliation(s)
- Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.
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Shimatani M, Takaoka M, Tokuhara M, Miyoshi H, Ikeura T, Okazaki K. Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy. World J Gastrointest Endosc 2015; 7:617-627. [PMID: 26078830 PMCID: PMC4461936 DOI: 10.4253/wjge.v7.i6.617] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/14/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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Xu XD, Dai JJ, Qian JQ, Wang WJ. Prevention of pancreatitis after papillary balloon dilatation by nasobiliary drainage: a randomized controlled trial. Dig Dis Sci 2015; 60:1087-91. [PMID: 25322952 DOI: 10.1007/s10620-014-3400-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic papillary balloon dilation (EPBD) was associated with a higher rate of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). AIM The purpose of this study was to determine whether placement of an endoscopic nasobiliary drainage (ENBD) catheter can also prevent PEP after EPBD. METHODS A total of 93 patients, who with proven common bile duct (CBD) stones, received EPBD were enrolled this trial. They were randomly divided into ENBD group (n = 45) and no-ENBD group (n = 48) according whether undergone an ENBD procedure after EPBD. Their demographics, laboratory, procedural data were collected, and pancreaticobiliary complications were followed. RESULTS The number of patients with serum amylase levels above the normal upper limit (>180 U/L) did not differ between groups. However, compared with ENBD group, more patients in No-ENBD group had levels greater than three times the normal limit (>540 U/L) (11/48 vs 3/45, P = 0.0285), and more patients developed to PEP (7/48 vs 0/45, P = 0.0250). During follow-up, the numbers of patients undergone cholecystectomy, cholangitis and recurrence of CBD stones were similar. There was also no significant difference in the cumulative rate of recurrent pancreaticobiliary complications between the two groups (P = 0.452). CONCLUSIONS EPBD followed by insertion of an ENBD catheter can prevent PEP, and routine ENBD catheter placement is recommended after an EPBD procedure.
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Affiliation(s)
- Xiao-Dan Xu
- Changshu Affiliated Hospital of Suzhou Universit, Changshu, China,
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37
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Itokawa F, Itoi T, Sofuni A, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Umeda J, Tanaka R, Tonozuka R, Honjyo M, Moriyasu F, Kasuya K, Tsuchida A. Mid-term outcome of endoscopic sphincterotomy combined with large balloon dilation. J Gastroenterol Hepatol 2015; 30:223-9. [PMID: 24995677 DOI: 10.1111/jgh.12675] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Endoscopic sphincterotomy (ES) combined with large balloon dilation (ESLBD) can be useful for extracting large and multiple bile duct stones. Although there are many studies on the feasibility and short-term outcome, there are few reports about mid- to long-term outcome after ESLBD. The aim of our study is to prospectively evaluate the mid-term outcome of ESLBD. METHODS One hundred eighty-three patients who underwent ESLBD between November 2006 and May 2012 were included. The patients were followed up periodically after the procedure until April 2013. Papillary dilation was performed at the time of initial ES or prior ES. Early and late adverse events and stone recurrence were evaluated in this study. RESULTS The patients' mean age was 76.6 ± 10.7 years. Surgically altered anatomy was present: Billroth I gastrectomy (2), Billroth II gastrectomy (13), and gastrectomy with Roux-en Y reconstruction (18). Seventy-eight (42.6%) patients had periampullary diverticulum. Prior ES had been performed in 40 (21.9%) patients. The mean follow-up period was 43.5 ± 19.7 months (range 11-78). Eight (4.4%) patients had stone recurrence. There was rare stone recurrence after initial ESLBD treatment and native gastrointestinal anatomy. Univariate and multivariate analyses showed that prior ES and previous history of stone recurrence were predictive of stone recurrence (P < 0.001). CONCLUSION At mid-term outcome, ESLBD is associated with a low rate of recurrent bile duct stones, although long-term follow up is needed.
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Affiliation(s)
- Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Efficacy and safety of endoscopic papillary large balloon dilation for large bile duct stones in elderly patients. Dig Dis Sci 2014; 59:2299-307. [PMID: 24771320 DOI: 10.1007/s10620-014-3156-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/05/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive interventions for choledocholithiasis are preferable in elderly patients because they tend to have multiple underlying disorders or a decreased activity of daily living. Endoscopic sphincterotomy and endoscopic papillary balloon dilation have been recognized as first-line treatments for choledocholithiasis excluding difficult cases such as large stones or multiple stones. Recently, the safety and efficacy of endoscopic papillary large balloon dilation (EPLBD) for difficult choledocholithiasis cases have been reported, although scarcely in elderly patients. AIMS To investigate whether EPLBD can be safety and effectively performed in patients aged 75 years or older. METHODS The medical records of 165 patients who underwent EPLBD from November 2006 to August 2013 were analyzed retrospectively. The patients were divided into 2 groups: Group A (≥ 75 years); Group B (<75 years). RESULTS Some underlying diseases were significantly more common in Group A than in Group B (P < 0.05). However, there was no significant difference in the success rates in the first session (96.2 vs 95.0 %, P = 0.970) and in the final success rates (100 % in both groups) between Group A and Group B. The adverse event rates (2.9 vs 5.0 %, P = 0.783) and recurrence rates of choledocholithiasis (6.7 vs 10.0 %, P = 0.444) were not significantly different. Regarding patients with an altered anatomy, the EPLBD outcome was not significantly different. CONCLUSION EPLBD can be safely performed for elderly patients similarly to younger patients.
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Jun BG, Lee TH, Jeong S, Hwang JC, Yang MJ, Song TJ, Choi HJ, Moon JH, Park SH. One-step transfistula large versus conventional balloon dilation following precut fistulotomy in difficult biliary cannulation for the removal of biliary stones: a multicenter retrospective study. J Gastroenterol Hepatol 2014; 29:1551-6. [PMID: 25273620 DOI: 10.1111/jgh.12564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones. METHODS This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications. RESULTS A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation (P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation (P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively (P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307). CONCLUSIONS One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation.
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Affiliation(s)
- Baek Gyu Jun
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan and Bucheon, South Korea
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Masoni L, Mari FS, Pietropaolo V, Onorato M, Meucci M, Brescia A. Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique. World J Surg 2014; 37:1258-62. [PMID: 23474857 DOI: 10.1007/s00268-013-1992-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. METHODS We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. RESULTS In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days. CONCLUSION Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.
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Affiliation(s)
- Luigi Masoni
- Department of Medical and Surgical Sciences and Translational Medicine, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
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Kim TN, Kim TN. Endoscopic papillary large balloon dilation for the retrieval of bile duct stones after prior Billroth II gastrectomy. Saudi J Gastroenterol 2014; 20:128-33. [PMID: 24705151 PMCID: PMC3987153 DOI: 10.4103/1319-3767.129478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy. MATERIALS AND METHODS From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice. RESULTS Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered. CONCLUSIONS EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.
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Affiliation(s)
- Tae-Nyeun Kim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Yeungnam University College of Medicine, Daegu, Republic of Korea,Address for correspondence: Dr. Tae-Nyeun Kim, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 705-717, 317-1 Daemyung-dong, Nam-gu, Daegu, Republic of Korea. E-mail:
| | - Tae-Nyeun Kim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Park SB, Kim HW, Kang DH, Choi CW, Yoon KT, Cho M, Song BJ. Sphincterotomy by triple lumen needle knife using guide wire in patients with Billroth II gastrectomy. World J Gastroenterol 2013; 19:9405-9409. [PMID: 24409069 PMCID: PMC3882415 DOI: 10.3748/wjg.v19.i48.9405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/25/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the usefulness of a guide wire and triple lumen needle knife for removing stones in Billroth II (B-II) gastrectomy patients.
METHODS: Endoscopic sphincterotomy in patients with B-II gastrectomy is challenging. We used a new guide wire technique involving sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy. This technique was performed in nine patients between August 2010 and June 2012. Sphincterotomy as described above was performed. Adequate sphincterotomy, successful stone removal, and complications were investigated prospectively.
RESULTS: Sphincterotomy by triple lumen needle knife using guide wire was successful in all nine patients. Sphincterotomy started towards the 4-5 o’clock direction and continued to the upper margin of the papillary roof. Complete stone removal in one session was achieved in all patients. There were no procedure related complications, such as bleeding, pancreatitis, or perforation.
CONCLUSION: In patients with B-II gastrectomy, guide wire using sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy seems to be an effective and safe procedure for the removal of common bile duct stones.
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Shimatani M, Takaoka M, Okazaki K. Tips for double balloon enteroscopy in patients with Roux-en-Y reconstruction and modified child surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E22-8. [PMID: 24307491 DOI: 10.1002/jhbp.53] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)-related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP-related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB-ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB-ERCP and provide several tips for insuring a successful procedure.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
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[Endoscopic retrograde cholangiopancreatography in patients with anatomic abnormalities of the stomach due to surgery]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:609-15. [PMID: 24099857 DOI: 10.1016/j.gastrohep.2013.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/30/2013] [Accepted: 08/05/2013] [Indexed: 01/28/2023]
Abstract
INTRODUCTION In patients who have undergone partial gastric resections, the difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) is increased due to the resulting anatomic abnormality. AIM To review our experience of ERCP in patients with Billroth II gastrectomy and other types of gastrectomy (Billroth I and indeterminate) in our center. MATERIAL AND METHODS We included all patients with Billroth II gastrectomy or other types of gastrectomy undergoing ERCP in a 19-year period. RESULTS We included 233 patients (91% men and 9% women) from 1993 to 2012. A total of 88.4% of the patients had undergone Billroth II and 11.6% had undergone other types of gastrectomy, with an ERCP success rate of 51.9% and 55.6%, respectively. The most common causes of failure were inability to cannulate (44%) and failure to identify the papilla (39.6%). The final diagnosis was choledocholithiasis in 31.8%. The mean number of sessions was 1.09. The complications rate was 2.6%. CONCLUSIONS The success of ERCP is influenced by the technical difficulty. For this reason, the success rate in our center was slightly over 50%, but with few complications.
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Seo YR, Moon JH, Choi HJ, Kim DC, Lee TH, Cha SW, Cho YD, Park SH, Kim SJ. Papillary balloon dilation is not itself a cause of post-endoscopic retrograde cholangiopancreatography pancreatitis; results of anterograde and retrograde papillary balloon dilation. J Gastroenterol Hepatol 2013; 28:1416-21. [PMID: 23701518 DOI: 10.1111/jgh.12277] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The mechanism of pancreatitis development following endoscopic papillary balloon dilation (EPBD) remains unknown. Antegrade dilation with percutaneous transhepatic papillary balloon dilation (PTPBD) allows the removal of bile duct stones or fragments during percutaneous choledochoscopic lithotomy, with less mechanical trauma to the papilla than with EPBD-mediated stone removal. METHODS A total of 56 patients with bile duct stones underwent antegrade dilation with PTPBD from March 2006 to February 2011. A total of 208 patients with common bile duct stones underwent retrograde dilation with EPBD during the same period. The conditions of papillary balloon dilation were identical in both groups. The frequencies of pancreatitis and hyperamylasemia were compared in both groups. RESULTS Pancreatitis occurred in 14 (6.7%) of 208 patients in the EPBD group (mild, nine; moderate, four; severe, one). There was no case of pancreatitis among 56 patients in the PTPBD group (P < 0.05). Hyperamylasemia developed in significantly more patients treated in the EPBD group (62, 29.8%) compared with the PTPBD group (4, 7.1%; P < 0.05). Complete bile duct clearance was achieved in 98.2% of PTPBD group and 97.1% of EPBD group. CONCLUSIONS The rates of post-procedural pancreatitis and hyperamylasemia were significantly higher after retrograde dilation with EPBD than after antegrade dilation with PTPBD for the removal of bile duct stones. Although the mechanism of pancreatitis following papillary balloon dilation remains unclear, post-EPBD pancreatitis may be associated with procedures before and after balloon dilation similar to mechanical lithotripsy rather than balloon dilation itself.
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Affiliation(s)
- Yu Ri Seo
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon and Seoul, Korea
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Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25:376-85. [PMID: 23650878 DOI: 10.1111/den.12118] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/21/2013] [Indexed: 12/12/2022]
Abstract
Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
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Zhao HC, He L, Zhou DC, Geng XP, Pan FM. Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy. World J Gastroenterol 2013; 19:3883-3891. [PMID: 23840129 PMCID: PMC3699051 DOI: 10.3748/wjg.v19.i24.3883] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis.
METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term complications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyzing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined as P < 0.05. Risk of bias was evaluated using a funnel plot.
RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBD group were younger (OR = -1.16, 95%CI: -1.49 to 0.84, P < 0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Compared with EST, the total stone clearance in the EPBD group decreased (OR = 0.64, 95%CI: 0.42 to 0.96, P = 0.03), the use of stone extraction baskets significantly increased (OR = 1.91, 95%CI: 1.41 to 2.59, P < 0.01), and the incidence of pancreatitis significantly increased (OR = 2.79, 95%CI: 1.74 to 4.45, P < 0.0001). The incidence of bleeding (OR = 0.12, 95%CI: 0.04 to 0.34, P < 0.01) and cholecystitis (OR = 0.41, 95%CI: 0.20 to 0.84, P = 0.02) significantly decreased. The stone recurrence rate also was significantly reduced in EPBD (OR = 0.48, 95%CI: 0.26 to 0.90, P = 0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis.
CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone clearance rate and risk of bleeding was lower with EPBD compared to EST.
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Jang HW, Lee KJ, Jung MJ, Jung JW, Park JY, Park SW, Song SY, Chung JB, Bang S. Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: a single center experience. Dig Dis Sci 2013; 58:1737-43. [PMID: 23392745 DOI: 10.1007/s10620-013-2580-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 01/15/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Endoscopic treatment of difficult common bile duct (CBD) stones (diameter ≥ 10 mm, or four or more) is difficult in patients who have undergone Billroth II (B-II) gastrectomy. Endoscopic sphincterotomy (EST) can be particularly troublesome due to anatomical changes effected by the gastrectomy. AIM We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with large-diameter dilation balloons in the treatment of difficult CBD stones in patients who have undergone B-II gastrectomy. MATERIALS AND METHODS From June 2006 to April 2011, patients with difficult CBD stones and who had undergone B-II gastrectomy previously were included in this study. EPLBD was performed with a 10-18 mm balloon catheter. When selective cannulation through the sphincter was possible, EPLBD was performed without EST. EPLBD was otherwise performed after fistulotomy with needle knife. RESULTS A total of 40 patients (32 male) underwent EPLBD for the retrieval of CBD stones, and concurrent fistulotomy was performed in seven patients. The median diameter of CBD was 13 mm (range 10-20 mm) and the balloon was 12 mm (range 10-17 mm). CBD stones were successfully removed in all patients. In only three patients, repeated sessions of ERCP were required for complete removal of CBD stones. Mechanical lithotripsy was required in only one case. Acute complications from EPLBD included mild pancreatitis in two patients (5.0 %). Severe complications, including perforation and bleeding, were not observed. Late complications included stone recurrence in one patient (2.5 %) and cholecystitis in four patients (10.0 %). CONCLUSIONS In cases of B-II gastrectomy, EPLBD without EST is a safe and highly effective technique for the retrieval of difficult CBD stones. EPLBD should be considered as an alternative tool to conventional EST.
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Affiliation(s)
- Hui Won Jang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, South Korea
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Zippi M, De Felici I, Pica R, Traversa G, Occhigrossi G. Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience. World J Clin Cases 2013; 1:19-24. [PMID: 24303455 PMCID: PMC3845931 DOI: 10.12998/wjcc.v1.i1.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/12/2013] [Accepted: 03/23/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.
METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon®, Cook Ireland Ltd. and CRE®, Microvasive, Boston Scientific Co., Natick, MA, United States).
RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.
CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.
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Lee A, Shah JN. Endoscopic approach to the bile duct in the patient with surgically altered anatomy. Gastrointest Endosc Clin N Am 2013; 23:483-504. [PMID: 23540972 DOI: 10.1016/j.giec.2012.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy can be technically challenging, because of three main problems that must be overcome: (1) endoscopically traversing the altered luminal anatomy, (2) cannulating the biliary orifice from an altered position, and (3) performing biliary interventions with available ERCP instruments. This article addresses the most common and most challenging variations in anatomy encountered by a gastroenterologist performing ERCP. It also highlights the innovations and progress that have been made in coping with these anatomic variations, with special attention paid to altered anatomy from bariatric surgery.
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Affiliation(s)
- Alexander Lee
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA 94143, USA
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