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Xu X, Guan L, Wu Y, Ke H, Zhao Y, Liu P. One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis. Front Surg 2022; 9:1005771. [PMID: 36439532 PMCID: PMC9681810 DOI: 10.3389/fsurg.2022.1005771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations. Methods We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program. Results The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend. Conclusion This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.
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Affiliation(s)
- Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Lulu Guan
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanbin Zhao
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Gastroenterology, The People’s Hospital of Longhua, Shenzhen, China
- Correspondence: Pi Liu
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Siau K, Keane MG, Steed H, Caddy G, Church N, Martin H, McCrudden R, Neville P, Oppong K, Paranandi B, Rasheed A, Sturgess R, Hawkes ND, Webster G, Johnson G. UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography. Endosc Int Open 2022; 10:E37-E49. [PMID: 35047333 PMCID: PMC8759929 DOI: 10.1055/a-1629-7540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1-2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.
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Affiliation(s)
- Keith Siau
- Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Grant Caddy
- Department of Gastroenterology, South Eastern Health and Social Care Trust, Northern Ireland, UK
| | - Nick Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Scotland
| | - Harry Martin
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Peter Neville
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Kofi Oppong
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ashraf Rasheed
- Department of Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Richard Sturgess
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Neil D Hawkes
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College London Hospitals, London, UK
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Madani S, Taghavi R, Saiidi M, Vafaeimanesh J. Bilateral pneumothorax: The cause of hypoxia during endoscopic retrograde cholangiopancreatography. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:S426-S430. [PMID: 34760098 PMCID: PMC8559637 DOI: 10.22088/cjim.12.0.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 11/09/2020] [Accepted: 11/24/2020] [Indexed: 11/07/2022]
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is recognized as a significant diagnostic and therapeutic procedure for the administration of different pancreatic and biliary problems. This procedure runs a considerable risk of complications despite its substantial safety. The rate of significant inconveniences is reported to range from 5.4% to 23.0% and the general mortality from 0.1 to 1%. Post-ERCP pneumothorax is an uncommon complication that is usually underestimated Case Presentation: In the present study, we report a 65-year-old woman who develops hypoxemia during the ERCP. Based on the obtained results, it was revealed that this patient had perforation-related bilateral pneumothorax and hypoxemia. Conclusion: Based on the obtained results, it was revealed that this patient had perforation-related bilateral pneumothorax and hypoxemia.
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Affiliation(s)
- Saeed Madani
- Clinical Development Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Rohallah Taghavi
- Clinical Development Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Mohammad Saiidi
- Clinical Development Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Jamshid Vafaeimanesh
- Clinical Development Research Center, Qom University of Medical Sciences, Qom, Iran.,Qom Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Qom, Iran
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EUS and ERCP in the Same Session for Biliary Stones: From Risk Stratification to Treatment Strategy in Different Clinical Conditions. MEDICINA-LITHUANIA 2021; 57:medicina57101019. [PMID: 34684056 PMCID: PMC8539296 DOI: 10.3390/medicina57101019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89-94% and 94-95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients' outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis.
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Zhang CC, Ganion N, Knebel P, Bopp C, Brenner T, Weigand MA, Sauer P, Schaible A. Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study. BMC Anesthesiol 2020; 20:131. [PMID: 32466744 PMCID: PMC7254733 DOI: 10.1186/s12871-020-01048-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/24/2020] [Indexed: 12/28/2022] Open
Abstract
Background Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. To date, there is lack of consensus regarding who should administer sedation in these patients. Several studies have investigated the safety and efficacy of non-anesthesiologist-administered sedation for ERCP; however, data regarding anesthesiologist-administered sedation remain limited. This prospective single-center study investigated the safety and efficacy of anesthesiologist-administered sedation and the rate of successful performed ERCP procedures. Methods The study included 200 patients who underwent ERCP following anesthesiologist-administered sedation with propofol and remifentanil. Procedural data, oxygen saturation, systolic blood pressure (SBP), heart rate, recovery score, patient and endoscopist satisfaction, as well as 30-day mortality and morbidity data were analyzed. Results Sedation-related complications occurred in 36 of 200 patients (18%) and included hypotension (SBP < 90 mmHg) and hypoxemia (O2 saturation < 90%) in 18 patients (9%) each. Most events were minor and did not necessitate discontinuation of the procedure. However, ERCP was terminated in 2 patients (1%) secondary to sedation-related complications. Successful cannulation was performed in all patients. The mean duration of the examination was 25 ± 16 min. Mean recovery time was 14 ± 10 min, and high post-procedural satisfaction was observed in both, patients (mean visual analogue scale [VAS] 9.6 ± 0.8) and endoscopists (mean VAS 9.3 ± 1.3). Conclusion This study suggests that anesthesiologist-administered sedation is safe in patients undergoing ERCP and is associated with a high rate of successful ERCP, shorter procedure time, and more rapid post-anesthesia recovery, with high patient and endoscopist satisfaction.
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Affiliation(s)
- Chengcheng C Zhang
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Nicole Ganion
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Department of General Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Bopp
- Department of Anesthesiology, GRN Hospital Schwetzingen, Schwetzingen, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Anja Schaible
- Department of General Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Xu LM, Hu DM, Tang W, Wei SH, Chen W, Chen GQ. Adenomyoma of the distal common bile duct demonstrated by endoscopic ultrasound: A case report and review of the literature. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i21.3598] [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: 02/04/2023] Open
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Xu LM, Hu DM, Tang W, Wei SH, Chen W, Chen GQ. Adenomyoma of the distal common bile duct demonstrated by endoscopic ultrasound: A case report and review of the literature. World J Clin Cases 2019; 7:3615-3621. [PMID: 31750345 PMCID: PMC6854403 DOI: 10.12998/wjcc.v7.i21.3615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/20/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adenomyomatous hyperplasia of the distal common bile duct (CBD) is very rare, with only scarce case reports in the literature. Diagnosis is usually based on imaging findings, and endoscopic biopsy is very difficult before operation. It is believed that adenomyomatous hyperplasia has little or no risk of malignant transformation.
CASE SUMMARY A 68-year-old woman with abdominal pain in the right upper quadrant was referred to our hospital. Abdominal ultrasonography in the emergency ward revealed acute cholecystitis and dilated CBD. Laboratory findings showed elevated levels of transaminases, phosphatase, and γ-glutamyltranspeptidase. Pharmaceutical treatment for 3 d did not relieve the symptoms. Magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) showed proximal bile duct dilatation but could not identify the cause. Endoscopic ultrasonography (EUS) demonstrated a mixed echogenic mass in the distal CBD. During surgery, a firm mass was found in the distal CBD and the Whipple procedure was performed with the initial concern of malignancy. Histology showed diffuse adenomyomatous hyperplasia.
CONCLUSION EUS may be a useful choice to diagnose adenomyoma of the distal CBD before operation, especially in patients with ambiguous MRCP/CT findings.
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Affiliation(s)
- Li-Ming Xu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Duan-Min Hu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Wen Tang
- Endoscopy Center, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Shao-Hua Wei
- Department of Hepatological Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Wei Chen
- Department of Hepatological Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Guang-Qiang Chen
- Imaging Department, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
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Feng Q, Li C, Zhang S, Tan CL, Mai G, Liu XB, Chen YH. Recurrence and survival after surgery for pancreatic cancer with or without acute pancreatitis. World J Gastroenterol 2019; 25:6006-6015. [PMID: 31660036 PMCID: PMC6815799 DOI: 10.3748/wjg.v25.i39.6006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/12/2019] [Accepted: 09/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In pancreatic cancer, acute pancreatitis (AP) is a serious morbidity, but its negative effect on long-term outcomes remains to be elucidated.
AIM To investigate the effects of AP on the tumor recurrence pattern of pancreatic ductal adenocarcinoma (PDAC) and tumor-specific survival.
METHODS The medical records of 219 patients with curative pancreatectomy for pancreatic cancer at the Pancreatic Surgery Center of West China Hospital from July 2012 to December 2016 were analyzed retrospectively. The severity of acute pancreatitis was classified according to the Atlanta classification of AP. The patient demographics and tumor characteristics were assessed. Early recurrence was defined as a relapse within 12 mo after surgery. Overall and disease-free survival and recurrence patterns were analyzed. Mild acute pancreatitis was excluded because its negative effects can be negligible.
RESULTS Early recurrence in AP group was significantly higher than in non-AP group (71.4% vs 41.2%; P = 0.009). Multivariate analysis of postoperative early recurrence showed that moderate or severe AP was an independent risk factor for an early recurrence [odds ratio (OR): 4.13; 95% confidence interval (CI): 1.41-12.10; P = 0.01]. The median time to recurrence was shorter in patients with AP than in those without (8.4 vs 12.8 mo; P = 0.003). Multivariate analysis identified AP as an independent prognostic factor for overall survival [relative risk (RR): 2.35; 95%CI: 1.45-3.83] and disease-free survival (RR: 2.24; 95%CI: 1.31-3.85) in patients with PDAC.
CONCLUSION Patients with moderate or severe acute pancreatitis developed recurrences earlier than those without. Moderate or severe AP is associated with shorter overall and disease-free survival of patients with PDAC.
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Affiliation(s)
- Qian Feng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Cheng Li
- Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Sheng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang 453100, Henan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Gang Mai
- Department of Hepatobiliary Surgery, Deyang People's Hospital, Deyang 618000, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Pekgöz M. Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment. World J Gastroenterol 2019; 25:4019-4042. [PMID: 31413535 PMCID: PMC6689803 DOI: 10.3748/wjg.v25.i29.4019] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/19/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.
AIM To study the published evidence and systematically review the literature on the prevention and treatment for PEP.
METHODS A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms “Post endoscopic retrograde cholangiopancreatography pancreatitis” AND “prevention” through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.
RESULTS 726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.
CONCLUSION Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.
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Affiliation(s)
- Murat Pekgöz
- Department of Gastroenterology, VM Medical Park Bursa Hospital, Bursa 16022, Turkey
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Keil R, Drábek J, Lochmannová J, Šťovíček J, Koptová P, Wasserbauer M, Frýbová B, Šnajdauf J, Matouš J, Kotalová R, Rygl M, Hlava Š. ERCP in infants, children, and adolescents-Different roles of the methods in different age groups. PLoS One 2019; 14:e0210805. [PMID: 30653580 PMCID: PMC6336232 DOI: 10.1371/journal.pone.0210805] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children. METHODS Data were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records. RESULTS We performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations. CONCLUSIONS Our study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.
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Affiliation(s)
- Radan Keil
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jiří Drábek
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jindra Lochmannová
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jan Šťovíček
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Petra Koptová
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Martin Wasserbauer
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Barbora Frýbová
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jiří Šnajdauf
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Jan Matouš
- 2 Department of Internal Medicine Charles University, 3 Faculty of Medicine, FNKV, Prague, Czech Republic
| | - Radana Kotalová
- Department of Pediatry, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Michal Rygl
- Department of Pediatric Surgery, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
| | - Štěpán Hlava
- Department of Internal Medicine, Charles University, 2 Faculty of Medicine, University Hospital Motol, Prague, Czech Republic
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Katzarov AK, Dunkov ZI, Popadiin I, Katzarov KS. How to measure quality in endoscopic retrograde cholangiopancreatography (ERCP). ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:265. [PMID: 30094251 DOI: 10.21037/atm.2018.05.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called "Quality measures" which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist. Further research is required regarding quality measures improvement and information exchange in the global ERCP quality network.
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Affiliation(s)
| | - Zdravko Ivanov Dunkov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Ivan Popadiin
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
| | - Krum Sotirov Katzarov
- Clinic of Gastroenterology and Hepatology, Military Medical Academy, Sofia, Bulgaria
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Jovanovic I, Mönkemüller K. Quality in endoscopy training-the endoscopic retrograde cholangiopancreatography case. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:264. [PMID: 30094250 DOI: 10.21037/atm.2018.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most advanced therapeutic procedures in gastrointestinal endoscopy. It is highly operator-dependent procedure requiring specific, knowledge-based training in order to achieve competence. Strategies for assessing competency of trainees and those in practice include numbers of procedures performed, and subjective or objective assessment by a mentor or self-assessment by the trainee. However, it is still not clear how to measure the quality in (ERCP) training in an objective and reproducible way, so far. Thus, in this article, we will discuss issues related to training in ERCP and provide experience based discussion on how to best approach and master this complex and risky procedure.
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Affiliation(s)
- Ivan Jovanovic
- Clinic for Gastroenterology and Hepatology, University of Belgrade Medical School, Belgrade, Serbia.,Clinical Center of Serbia, University of Belgrade Medical School, Belgrade, Serbia
| | - Klaus Mönkemüller
- Division of Gastroenterology, Department of Visceral Surgery, Helios Frankenwaldklinik Kronach, Kronach, Germany
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Sotoudehmanesh R, Nejati N, Farsinejad M, Kolahdoozan S. Efficacy of Endoscopic Ultrasonography in Evaluation of Undetermined Etiology of Common Bile Duct Dilatation on Abdominal Ultrasonography. Middle East J Dig Dis 2016; 8:267-272. [PMID: 27957289 PMCID: PMC5145293 DOI: 10.15171/mejdd.2016.35] [Citation(s) in RCA: 14] [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] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The cause of common bile duct (CBD) dilatation cannot be determined by imaging modalities in many patients. The aim of this study was to assess the value of endoscopic ultrasonography (EUS) in detecting the cause of CBD dilatation in patients in whom ultrasonography could not demonstrate the cause of dilation. METHODS Prospectively, 152 consecutive patients who were referred for evaluation of dilated CBD (diameter ≥7 mm) of undetermined origin by ultrasonography were included in this study. All the patients underwent EUS. Final diagnoses were determined by using endoscopic retrograde cholangiopancreatography (ERCP), EUS-guided fine needle aspiration (FNA), surgical exploration, or follow-up for at least 10 months. Patients with choledocholithiasis were referred for ERCP and sphincterotomy, and patients with operable tumors were referred for surgery.Patients with inoperable tumors underwent biliary stenting with or without tchemoradiotherapy. RESULTS 152 patients (54% female) with dilated CBD were included. Mean (±SD) age of the patients was 60.4 (±17.3) years. The mean CBD diameter for all study group in transabdominal ultrasonography and EUS were 11.7 millimeter and 10.1 millimeter, respectively. Most of the patients with dilated CBD and abnormal liver function test (LFT) had an important finding in EUS and follow-up diagnosis including peri-ampullary tumors. Mean diameter of CBD in patients with and without abnormal LFT were 10.5 IU/L and 12.1 IU/L, respectively. Final diagnoses included choledocholithiasis in 32 (21.1%),passed CBD stone in 35 (23%), opium-induced CBD dilation in 14 (9.2%), post-cholecystectomy states in 20 (13.1%), ampullary adenoma/carcinoma in 15 (15.8%), cholangiocarcinoma in 14 (9.2%), and pancreatic head cancer in9 (5.9%) patients. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS for patients with abnormal EUS were 89.5%, 100.0%, 100.0%, 91.2%, and 90.9%, respectively. CONCLUSION After diagnosis of CBD dilation by transabdominal ultrasonography, EUS may be a reasonable choice for determining the etiology of dilated CBD and tumor staging.
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Affiliation(s)
- Rasoul Sotoudehmanesh
- Professor. Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran,Iran
| | - Naimeh Nejati
- Gastroenterologist. Baghyatallah hospital, Tehran,Iran
| | - Maryam Farsinejad
- Research Fellow. Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran,Iran
| | - Shadi Kolahdoozan
- Research Fellow. Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran,Iran
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Barreras González JE, Torres Peña R, Ruiz Torres J, Martínez Alfonso MÁ, Brizuela Quintanilla R, Morera Pérez M. Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open 2016; 4:E1188-E1193. [PMID: 27857966 PMCID: PMC5111834 DOI: 10.1055/s-0042-116144] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims: Overall, 5 % to 15 % of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. There is no clear consensus on the best therapeutic approach (endoscopic versus surgical). Patients and methods: A prospective randomized controlled clinical trial was performed to compare three treatment options for patients with choledocholithiasis at the National Center for Minimally Invasive Surgery in Havana, Cuba from November 2007 to November 2011. The patients were randomized in three groups. Group I: patients who underwent intraoperative cholangiography (IOC) to confirm the choledocholithiasis followed by laparoscopic cholecystectomy (LC) associated with intraoperative endoscopic retrograde cholangiopancreatography (ERCP), group II: patients who underwent preoperative ERCP followed by LC during the same hospital admission and group III: patients who underwent IOC to confirm the choledocholithiasis followed by LC associated with laparoscopic common bile duct exploration (LCBDE). Results: A total of 300 patients with suspected choledocholithiasis were included in the trial and were randomized. As a result, a total of 134 patients were diagnosed with the presence of choledocholithiasis and treated during the study period. There were no significant differences in success rates of ductal stone clearance, but retained stone, postoperative complications and length of hospital stay were better in group I. Conclusions: Intraoperative ERCP/ES shows a higher rate of common bile duct stones clearance, a shorter hospital stay, and lower morbidity, but further research with a larger study population is necessary to determine the additional benefits of this procedure. The results to date suggests that in appropriate patients, single-stage treatments are the best options.
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Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.,Corresponding author Javier Ernesto Barreras González, MD, PhD Department of Laparoscopic and Endoscopic SurgeryNational Center for Minimally Invasive SurgeryPárraga Street b/ San Mariano and Vista AlegreLa Víbora10 de OctubreHavanaCuba+537-649-0150
| | - Rafael Torres Peña
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Julián Ruiz Torres
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Miguel Ángel Martínez Alfonso
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Raúl Brizuela Quintanilla
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Maricela Morera Pérez
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
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Berent A, Weisse C, Schattner M, Gerdes H, Chapman P, Kochman M. Initial experience with endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting for treatment of extrahepatic bile duct obstruction in dogs. J Am Vet Med Assoc 2015; 246:436-46. [PMID: 25632818 DOI: 10.2460/javma.246.4.436] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe techniques for endoscopic retrograde cholangiography (ERC) and endoscopic retrograde biliary stenting of the common bile duct (CBD) for minimally invasive treatment of extrahepatic bile duct obstruction (EHBDO) in dogs. DESIGN Experimental study and clinical report. ANIMALS 7 healthy research dogs and 2 canine patients. PROCEDURES ERC and endoscopic retrograde biliary stenting were performed in healthy purpose-bred research dogs and client-owned dogs with a diagnosis of EHBDO that underwent an attempted biliary stent procedure. Research dogs were euthanized after completion of the procedure and underwent necropsy. With dogs under general anesthesia, the pylorus was cannulated with a side-view duodenoscope, and the duodenum was entered. The major duodenal papilla (MDP) and minor duodenal papilla were then identified, and the MDP was cannulated. Endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting were attempted with the aid of endoscopy and fluoroscopy in all dogs. Procedure time, outcome for duodenal and MDP cannulation, and success of stent placement were recorded. RESULTS Endoscopic retrograde cholangiography was successfully performed in 5 of 7 research dogs and in 1 of 2 patients. Biliary stenting was achieved in 4 of 7 research dogs and 1 of 2 patients, with a polyurethane (n = 4) or self-expanding metallic stent (1). One patient had a mass such that visualization of the MDP was impossible and no attempt at biliary cannulation could be made. After placement, stent patency was documented by means of contrast cholangiography and visualization of biliary drainage into the duodenum intra-operatively. No major complications occurred during or after the procedure in any patient. Follow-up information 685 days after stent placement in 1 patient provided evidence of biliary patency on serial repeated ultrasonography and no evidence of complications. CONCLUSIONS and CLINICAL RELEVANCE ERC and endoscopic retrograde biliary stenting were successfully performed in a small group of healthy dogs and 1 patient with EHBDO, but were technically challenging procedures. Further investigation of this minimally invasive technique for the treatment of EHBDO in dogs is necessary before this may be considered a viable alternative to current treatment methods.
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Affiliation(s)
- Allyson Berent
- Department of Diagnostic Imaging and Interventional Radiology, Animal Medical Center, 510 E 62nd St, New York, NY 10065
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Mohammad Alizadeh AH, Afzali ES, Behzad C, Mousavi M, Mirsattari D, Doagoo SZ, Zali MR. Is ESR Important for Predicting Post-ERCP Pancreatitis? CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2015; 8:23-7. [PMID: 26005364 PMCID: PMC4426942 DOI: 10.4137/cgast.s18938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/30/2014] [Accepted: 12/03/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP). AIM To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population. MATERIALS AND METHODS Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria. RESULTS Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method. CONCLUSIONS Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.
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Affiliation(s)
| | | | - Catherine Behzad
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
| | - Mirhadi Mousavi
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
| | - Dariush Mirsattari
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
| | - Siavash Zafar Doagoo
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
| | - Mohammad Reza Zali
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
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Giefer MJ, Kozarek RA. Technical outcomes and complications of pediatric ERCP. Surg Endosc 2015; 29:3543-50. [PMID: 25673350 DOI: 10.1007/s00464-015-4105-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/28/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients is safe, but because the total number of cases reported in the literature remains small, questions remain regarding safety and outcomes of this procedure in children. METHODS Pediatric patients who underwent ERCP were identified from diagnostic to billing codes. Medical records were examined for age, gender, diagnosis codes, indication, type of sedation, findings, interventions, and complications. Descriptive statistics were prepared for data including frequencies, percentages for categorical variables, and means and standard deviations for quantitative variables. Extensions of logistic regression were used to examine the relationship between demographic and clinical characteristics and post-ERCP pancreatitis. RESULTS Four hundred and twenty-five ERCPs were performed on 276 pediatric patients. Patient's age ranged from 72 days to 18 years, and there was equal gender distribution. Targeted duct cannulation was achieved in over 95% of cases, and therapeutic interventions were common (81.3%). The most common indications were biliary obstruction (43.3%) and chronic pancreatitis (26.8%). The most common complication was post-ERCP pancreatitis which occurred in 26 cases (7.7%), and the majority was mild by consensus definition. Procedural characteristics significantly associated with post-ERCP pancreatitis included: pancreatogram, pancreatic sphincterotomy, pancreatic duct stenting, and pancreatic duct stricture dilation. Immediate post-sphincterotomy bleeding occurred twice (1.1%), and both cases were successfully treated during the procedure. There was one instance of a possible delayed sphincterotomy bleed. No mortality was observed. CONCLUSIONS This retrospective review is one of the larger ERCP series reported in the pediatric population and adds to the growing body of literature supporting that ERCP can be safely applied in younger patients by skilled endoscopists. The complication rate found in this series closely parallels that observed in adults. Prospective studies of pediatric ERCP are still required to more definitively define the safe and appropriate use of this procedure in children.
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Affiliation(s)
- Matthew J Giefer
- Pediatrics - Gastroenterology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Richard A Kozarek
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, WA, 98105, USA
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Thaker AM, Mosko JD, Berzin TM. Post-endoscopic retrograde cholangiopancreatography pancreatitis. Gastroenterol Rep (Oxf) 2014; 3:32-40. [PMID: 25406464 PMCID: PMC4324870 DOI: 10.1093/gastro/gou083] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Acute pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). It is reported to occur in 2–10% of unselected patient samples and up to 40% of high-risk patients. The purpose of this article is to review the evidence behind the known risk factors for post-ERCP pancreatitis, as well as the technical and medical approaches developed to prevent it. There have been many advances in identifying the causes of this condition. Based on this knowledge, a variety of preventive strategies have been developed and studied. The approach to prevention begins with careful patient selection and performing ERCP for specific indications, while considering alternative diagnostic modalities when appropriate. Patients should also be classified by high-risk factors such as young age, female sex, suspected sphincter of Oddi dysfunction, a history of post-ERCP pancreatitis, and normal serum bilirubin, all of which have been identified in numerous research studies. The pathways of injury that are believed to cause post-ERCP pancreatitis eventually lead to the common endpoint of inflammation, and these individual steps can be targeted for preventive therapies through procedural techniques and medical management. This includes the use of a guide wire for cannulation, minimizing the number of cannulation attempts, avoiding contrast injections or trauma to the pancreatic duct, and placement of a temporary pancreatic duct stent in high-risk patients. Administration of rectal non-steroidal anti-inflammatory agents (NSAIDs) in high-risk patients is the proven pharmacological measure for prevention of post-ERCP pancreatitis. The evidence for or against numerous other attempted therapies is still unclear, and ongoing investigation is required.
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Affiliation(s)
- Adarsh M Thaker
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jeffrey D Mosko
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Lopes L, Dinis-Ribeiro M, Rolanda C. Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"? Gastrointest Endosc 2014; 80:634-641. [PMID: 24814775 DOI: 10.1016/j.gie.2014.03.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/07/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. OBJECTIVE To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). DESIGN Single-center, prospective cohort study. SETTING University-affiliated hospital. PATIENTS A total of 350 patients with a naïve papilla. INTERVENTIONS Standard biliary cannulation followed by needle-knife fistulotomy (NKF). MAIN OUTCOME MEASUREMENTS Biliary cannulation rate, NKF success, adverse events, and ERCP duration. RESULTS The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001). LIMITATIONS Single-center study design, referral center. CONCLUSIONS If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.
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Affiliation(s)
- Luís Lopes
- Department of Gastroenterology, Hospital of Santa Luzia, Viana do Castelo, Portugal; Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Mário Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Carla Rolanda
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal; Department of Gastroenterology, Hospital of Braga, Braga, Portugal
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Zhao LN, Yu T, Li CQ, Lai Y, Chen QK. Somatostatin administration prior to ERCP is effective in reducing the risk of post-ERCP pancreatitis in high-risk patients. Exp Ther Med 2014; 8:509-514. [PMID: 25009610 PMCID: PMC4079433 DOI: 10.3892/etm.2014.1733] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Somatostatin has been extensively studied for the prophylaxis of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, the results remain controversial. The present retrospective cohort study aimed to investigate the efficacy of pre- and post-ERCP somatostatin administration in the prevention of post-ERCP pancreatitis (PEP). All ERCP procedures performed at one hospital between January 2009 and December 2012 were reviewed. They were divided into three groups based on somatostatin administration: pre-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting 1 h prior to ERCP), post-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting immediately following ERCP), and control group (no somatostatin administration). Out of a total of 304 cases, 81 received pre-ERCP somatostatin; 126 received post-ERCP somatostatin and 97 were not administered somatostatin. Pre-ERCP somatostatin was effective in reducing the incidence of PEP compared with that in the control group (4.9 vs. 16.5%; P=0.017). This benefit was significant in high-risk patients (8.9 vs. 26.0%; P=0.035), but not in low-risk patients (0 vs. 6.4%; P=0.254). Post-ERCP somatostatin was not effective in preventing PEP in high- or low-risk patients. In conclusion, pre-ERCP somatostatin may be effective in reducing the risk of PEP in high-risk patients, but not in low-risk patients. Post-ERCP somatostatin did not reveal a benefit in high- or low-risk patients. However, large randomized controlled trials are required to further confirm these findings.
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Affiliation(s)
- Li-Na Zhao
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Tao Yu
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Chu-Qiang Li
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Yu Lai
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Qi-Kui Chen
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
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Cotton PB, Durkalski V, Romagnuolo J, Pauls Q, Fogel E, Tarnasky P, Aliperti G, Freeman M, Kozarek R, Jamidar P, Wilcox M, Serrano J, Brawman-Mintzer O, Elta G, Mauldin P, Thornhill A, Hawes R, Wood-Williams A, Orrell K, Drossman D, Robuck P. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA 2014; 311:2101-9. [PMID: 24867013 PMCID: PMC4428324 DOI: 10.1001/jama.2014.5220] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy. OBJECTIVE To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predictive of pain relief. DESIGN, SETTING, AND PATIENTS Multicenter, sham-controlled, randomized trial involving 214 patients with pain after cholecystectomy without significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis randomly assigned (August 6, 2008-March 23, 2012) to undergo sphincterotomy or sham therapy at 7 referral medical centers. One-year follow-up was blinded. The final follow-up visit was March 21, 2013. INTERVENTIONS After ERCP, patients were randomized 2:1 to sphincterotomy (n = 141) or sham (n = 73) irrespective of manometry findings. Those randomized to sphincterotomy with elevated pancreatic sphincter pressures were randomized again (1:1) to biliary or to both biliary and pancreatic sphincterotomies. Seventy-two were entered into an observational study with conventional ERCP managemeny. MAIN OUTCOMES AND MEASURES Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention. RESULTS Twenty-seven patients (37%; 95% CI, 25.9%-48.1%) in the sham treatment group vs 32 (23%; 95% CI, 15.8%-29.6%) in the sphincterotomy group experienced successful treatment (adjusted risk difference, -15.6%; 95% CI, -28.0% to -3.3%; P = .01). Of the patients with pancreatic sphincter hypertension, 14 (30%; 95% CI, 16.7%-42.9%) who underwent dual sphincterotomy and 10 (20%; 95% CI, 8.7%-30.5%) who underwent biliary sphincterotomy alone experienced successful treatment. Thirty-seven treated patients (26%; 95% CI,19%-34%) and 25 patients (34%; 95% CI, 23%-45%) in the sham group underwent repeat ERCP interventions (P = .22). Manometry results were not associated with the outcome. No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 15 patients (11%) after primary sphincterotomies and in 11 patients (15%) in the sham group. Of the nonrandomized patients in the observational study group, 5 (24%; 95% CI, 6%-42%) who underwent biliary sphincterotomy, 12 (31%; 95% CI, 16%-45%) who underwent dual sphincterotomy, and 2 (17%; 95% CI, 0%-38%) who did not undergo sphincterotomy had successful treatment. CONCLUSIONS AND RELEVANCE In patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy vs sham did not reduce disability due to pain. These findings do not support ERCP and sphincterotomy for these patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00688662.
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Affiliation(s)
| | | | | | - Qi Pauls
- Medical University of South Carolina, Charleston
| | | | | | | | | | | | | | | | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | | | | | | | | | - Robert Hawes
- Medical University of South Carolina, Charleston12Florida Hospital, Orlando
| | | | - Kyle Orrell
- Medical University of South Carolina, Charleston
| | - Douglas Drossman
- University of North Carolina and Drossman Gastroenterology PLLC, Chapel Hill
| | - Patricia Robuck
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Kim K, Kim SJ, Kim IJ, Kim DU, Kim H, Kim S, Ahn SH. Factors Associated with Diffusely Increased Splenic F-18 FDG Uptake in Patients with Cholangiocarcinoma. Nucl Med Mol Imaging 2014; 48:137-43. [PMID: 24900154 PMCID: PMC4028471 DOI: 10.1007/s13139-013-0246-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/17/2013] [Accepted: 10/21/2013] [Indexed: 02/03/2023] Open
Abstract
Objectives Although diffuse splenic 18F-fluorodeoxyglucose (F-18 FDG) uptake exceeding hepatic activity, is considered abnormal, its clinical significance is rarely discussed in the literature. The aim of this study was to determine the contributing factors causing diffusely increased splenic FDG uptake in patients with cholangiocarcinoma. Methods From January 2010 to March 2013, 140 patients (84 men, 56 women) were enrolled in this study. All patients had been diagnosed with cholangiocarcinoma and underwent F-18 FDG positron emission tomography/computed tomography (PET/CT) for the pretreatment staging work up. Clinical records were reviewed retrospectively. Various hematological parameters, C-reactive protein (CRP) level, CEA, CA19-9, pancreatic enzymes and liver function tests were conducted within 2 days after the F-18 FDG PET/CT study. Results Diffuse splenic uptake was observed in 23 patients (16.4%). Of those, 19 patients (82.6%) underwent endoscopic retrograde cholangiopancreastography (ERCP) 7 days before F-18 FDG PET/CT. The CRP level (p < 0.001) and white blood cell count (p = 0.023) were significantly higher in the group of patients with diffuse splenic FDG uptake. The hemoglobin (p < 0.001) and the hematocrit (p < 0.001) were significantly lower in patients with diffuse splenic FDG uptake. Pancreatic enzymes, liver function test results, and tumor markers were not significantly different between the patients who did or did not have diffusely increased splenic FDG uptake. The significant factors for diffuse splenic F-18 FDG uptake exceeding hepatic F-18 FDG uptake on multivariate analysis included: performing ERCP before F-18 FDG PET-CT (odds ratio [OR], 77.510; 95% CI, 7.624-132.105), and the presence of leukocytosis (OR, 12.436; 95% CI, 2.438-63.445) or anemia (OR, 1.211; 95% CI, 1.051-1.871). Conclusion In conclusion, our study demonstrated that concurrent inflammation could be associated with diffusely increased splenic FDG uptake. We suggest that performing ERCP before F-18 FDG PET/CT could cause acute inflammation which may induce splenic FDG activity.
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Affiliation(s)
- Keunyoung Kim
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Seong-Jang Kim
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
- />Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- />Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, 1-10, Ami-dong, Seo-gu Busan, Republic of Korea 602-739
| | - In-Joo Kim
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
- />Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Uk Kim
- />Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Heeyoung Kim
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Sojung Kim
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Hyun Ahn
- />Department of Nuclear Medicine, Pusan National University Hospital, Busan, Republic of Korea
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Abstract
Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.
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Affiliation(s)
- Daniel Cucher
- Department of Surgery, College of Medicine, University of Arizona, PO Box 245005, Tucson, AZ 85724, USA
| | - Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Donald J Green
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Tun Jie
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA
| | - Evan S Ong
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA.
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Carriere V, Conway J, Evans J, Shokoohi S, Mishra G. Which patients with dilated common bile and/or pancreatic ducts have positive findings on EUS? JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:168-171. [PMID: 23687603 DOI: 10.4161/jig.23739] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/27/2012] [Accepted: 08/03/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with dilated common bile duct (CBD) (>7mm) and/or pancreatic duct (PD) on abdominal imaging are often referred for endoscopic ultrasound (EUS). In many cases, the EUS shows no obvious etiology for the dilated ducts. OBJECTIVE Find clinical factors that may predict which patients are more likely to have positive findings on EUS to explain the etiologies for the dilated ducts. DESIGN Retrospective database analysis. SETTING Tertiary-care university hospital. PATIENTS Patients referred for EUS for dilated CBD and/or PD from January 2004 to February 2010 were included in this study. Only patients without an obvious etiology for the dilated ducts on abdominal imaging were included. INTERVENTIONS An EUS was performed by using either a radial echoendoscope or a linear endoscope to evaluate the common bile duct and/or the pancreatic duct. When appropriate fine needle aspiration of the mass or cyst was performed. MAIN OUTCOME MEASUREMENTS The characteristics of patients who had positive findings on EUS to explain the etiology of their dilated PD and/or CBD. RESULTS A total of 140 patients were included in the study with a mean age of 64 years, 51 (36%) male and 115 (82%) white. The majority of our patients had a presenting symptom of abdominal pain 105 (75%). 49 (36%) had elevated AST or ALT, 25 (8%) had an elevated bilirubin and 13 (23%) had an elevated lipase. EUS findings explained the dilated ducts in 54 (39%) of our patients, most common diagnoses included: CBD stone in 11 (8%), non-calcific chronic pancreatitis in 9 (6%), pancreatic mass in 8 (6%), IPMN in 7 (5%). On bivarate analysis patients who were older (p = 0.006), male (p = 0.001), had elevated LFTs (p = <0.001), had elevated lipase (p = 0.021) or had dilated CBD and PD (p = 0.007) were more likely to have an etiology for their dilated duct(s) discovered on EUS. LIMITATIONS A retrospective study with a small number of patients. CONCLUSION Older patients, males and those patients presenting with concurrent elevations in the AST/ALT and/or lipase were more likely to have an underlying etiology discovered on EUS. Furthermore, EUS may detect an undiagnosed pancreatic malignancy in patients presenting with unexplained duct dilation.
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Affiliation(s)
- Vernon Carriere
- Wake Forest Baptist Hospital, Winston Salem, NC, United States
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Kahaleh M. Spyglass direct visualization system. Clin Endosc 2012; 45:316-8. [PMID: 22977826 PMCID: PMC3429760 DOI: 10.5946/ce.2012.45.3.316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 07/20/2012] [Accepted: 07/20/2012] [Indexed: 12/22/2022] Open
Abstract
Although endoscopic retrograde cholangiopancreatography is considered the gold standard to manage biliary disorders, it has its own limitations. The single-operator cholangioscopy (SOC) system (Spyglass) may offer an interesting compromise for most advanced biliary endoscopists, in terms of size (10 Fr diameter) and complexity of use. SOC is a great step toward intraductal visualization and therapy but the best is yet to come.
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Affiliation(s)
- Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Trivedi PJ, Tse D, Al-Bakir I, D'Costa H. Appropriate patient selection in the management of common bile duct stones: when not to do ERCP. ISRN SURGERY 2012; 2012:286365. [PMID: 22779000 PMCID: PMC3384886 DOI: 10.5402/2012/286365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 04/20/2012] [Indexed: 12/02/2022]
Abstract
Background. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive and accurate for diagnosing intra common bile duct stones (ICSs). However, given limited access, routine utilisation for investigating all patients with gallstone disease is neither practical nor cost-effective. Conversely, many individuals proceed directly to endoscopic retrograde cholangiopancreatography (ERCP), an invasive test with appreciable complications. Aim. Identify factors associated with ICS in order to improve risk-stratification for MRCP/ERCP. Methods. All patients having undergone cholecystectomy between November 2007 and October 2008 were reviewed. High-risk features for ICS were predefined, and their true presence confirmed by ERCP or intraoperative cholangiogram. Multivariate logistic regression was performed on candidate risk features. Results. Of 231 patients, 10.4% had ICS. Defining a high-risk group with "both" biochemical and ultrasound risk factors predicted ICS with 92% specificity and also bore strong association (OR 8.88). However, isolated hyperbilirubinaemia, ultrasound impression of CBD stones, and clinical risk factors did not (OR 1.10, 0.97, and 1.26). Normal liver biochemistry and normal ultrasound had a NPV of 99.5% for ICS. Conclusions. Ultrasound impression of CBD calculi without ductal dilatation is not predictive of ICS. Patients with normal liver biochemistry and normal CBD diameter on ultrasound are unlikely to have ICS and should not proceed to ERCP.
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Affiliation(s)
- Palak Jitendrakumar Trivedi
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Department of Gastroenterology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Donald Tse
- Department of Clinical Radiology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Ibrahim Al-Bakir
- Department of Surgery, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
| | - Horace D'Costa
- Department of Clinical Radiology, Horton General Hospital, Oxford Road, Banbury OX16 9AL, UK
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John A, Mattar K, John AS, Khairat M, Al Kaabi S. Therapeutic biliary and pancreatic endoscopy in Qatar- a five year retrospective audit. Qatar Med J 2012; 2012:20-5. [PMID: 25003036 PMCID: PMC3991044 DOI: 10.5339/qmj.2012.2.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 12/01/2012] [Indexed: 11/24/2022] Open
Affiliation(s)
- Anil John
- Department of GI/Endoscopy, HMC, Doha, Qatar
| | | | - Anjum Susan John
- Department of Clinical Research, Medical Research Center, HMC, Doha, Qatar
| | | | - Saad Al Kaabi
- Department of Division of GI/Endoscopy, HMC, Doha, Qatar
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Rábago LR, Ortega A, Chico I, Collado D, Olivares A, Castro JL, Quintanilla E. Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy? World J Gastrointest Endosc 2011; 3:248-55. [PMID: 22195234 PMCID: PMC3244943 DOI: 10.4253/wjge.v3.i12.248] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 08/24/2011] [Accepted: 12/01/2011] [Indexed: 02/05/2023] Open
Abstract
In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.
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Affiliation(s)
- Luis R Rábago
- Luis R Rábago, Alejandro Ortega, Inmaculada Chico, David Collado, Ana Olivares, Jose Luis Castro, Elvira Quintanilla, Department of Gastroenterology, Severo Ochoa Hospital, Leganes, 28911 Madrid, Spain
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Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital. Surg Endosc 2011; 26:1028-34. [PMID: 22083324 DOI: 10.1007/s00464-011-1990-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 09/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP. PATIENTS AND METHODS This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique. RESULTS Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days). CONCLUSIONS Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.
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Pancreas divisum: a differentiated surgical approach in symptomatic patients. World J Surg 2011; 35:1360-6. [PMID: 21472371 DOI: 10.1007/s00268-011-1076-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Some patients with pancreas divisum (PD) develop symptoms of recurrent pancreatitis. This is probably caused by insufficient drainage of the pancreatic duct. We report the results of our follow-up of patients who underwent surgery for symptomatic pancreas divisum according to an individualized surgical approach. METHODS Between October 2001 and April 2009, 28 patients with symptomatic pancreas divisum were operated at the University Hospital of Heidelberg. According to the localization and type of morphological changes of the pancreas, patients received a reinsertion of the papilla (SP; n=11), duodenum-preserving pancreatic head resection (DPPHR; n=10), pylorus-preserving Whipple (ppWhipple; n=4), or other pancreatic resections (n=3). Hospitalization, morbidity, mortality, pain course, and patient satisfaction were analyzed. RESULTS Before surgery, patients received a median of three endoscopic interventions and were hospitalized for 77 days. The median postoperative follow-up was 4.1 years. Surgical morbidity was 11% and mortality 0%. We performed an SP when the pancreas was soft (n=10). When the pancreas was inflammatory altered, a DPPHR was performed in ten, ppW in four, segmental resection in two, and SP and pancreatic left resection in one case. A redo operation for persisting symptoms was needed in six patients (3 soft and 3 altered pancreas). Compared with the preoperative situation, pain was significantly reduced in the follow-up (median Visual Analogue Scale 0 vs. 10). Ninety-six percent of patients were without symptoms during the follow-up. CONCLUSIONS The individualized surgical approach for patients with symptomatic PD achieves significant reduction of pain in all patients. Reinsertions of the papilla should be performed as a first surgical intervention in patients with a soft pancreas when symptoms persist despite adequate endoscopic treatment. DPPHR should be performed when fibrotic alterations of the pancreas are present.
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31
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Cotton PB. Are low-volume ERCPists a problem in the United States? A plea to examine and improve ERCP practice-NOW. Gastrointest Endosc 2011; 74:161-6. [PMID: 21704815 DOI: 10.1016/j.gie.2011.03.1233] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/20/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Peter B Cotton
- Medical University of South Carolina, Charleston, SC, USA
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32
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Yii CY, Chou JW, Peng YC, Chow WK. Application of a wire-guided side-viewing duodenoscope in total esophagectomy with colonic interposition. World J Gastroenterol 2011; 17:1787-90. [PMID: 21483642 PMCID: PMC3072646 DOI: 10.3748/wjg.v17.i13.1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 11/03/2010] [Accepted: 11/10/2010] [Indexed: 02/06/2023] Open
Abstract
Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay treatment for bile duct disease. The procedure is difficult per se, especially when a side-viewing duodenoscope is used, and when the patient has altered anatomical features, such as colonic interposition. Currently, there is no consensus on the standard approach for therapeutic ERCP in patients with total esophagectomy and colonic interposition. We describe a novel treatment design that involves the use of a side-viewing duodenoscope to perform therapeutic ERCP in patients with total esophagectomy and colonic interposition. A gastroscope was initially introduced into the interposed colon and a radio-opaque standard guidewire was advanced to a distance beyond the papilla of Vater, before the gastroscope was withdrawn. A side-viewing duodenoscope was then introduced along the guidewire under fluoroscopic guidance. After cannulation into the papilla of Vater, endoscopic retrograde cholangiography (ERC) revealed a filling defect (maximum diameter: 15 cm) at the distal portion of the common bile duct (CBD). This defect was determined to be a stone, which was successfully retrieved by a Dormia basket after complete sphincterotomy. With this treatment design, it is possible to perform therapeutic ERCP in patients with colonic interposition, thereby precluding the need for percutaneous drainage or surgery.
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Liao Z, Hu LH, Li ZS, Zuo CJ, Wang L, Jin G, Zou DW, Jin ZD, Li SD, Liu F, Chen J, Zhan XB, Yuan JH, Wang LW, Wang D. Multidisciplinary team meeting before therapeutic ERCP: A prospective study with 1,909 cases. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:64-69. [PMID: 21776428 DOI: 10.4161/jig.1.2.15047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the effect of multidisciplinary team meeting (MDTM) on the success rate and complications of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for hepato-pancreato-biliary diseases. METHODS All patients undergoing their first therapeutic ERCP over a 21-month period of time in a tertiary care medical center were included. Generally, patients scheduled for ERCP on Friday, Saturday, Sunday, and Monday were subject to MDTM group, and those on Tuesday, Wednesday, and Thursday were allocated to the control group. For each MDTM case, an MDTM was held on the Tuesday prior to the scheduled ERCP. At the meeting, the cases were discussed by a team consisting of chief physicians, radiologists, endoscopists, anesthetists, and surgeons, and a decision was made on the schedule of ERCP. For control cases, a clinical team of one chief physician and two attending physicians made the decision. RESULTS From April 2006 to December 2007, 912 and 997 ERCP procedures were allocated to the MDTM and control groups, respectively. There was no significant difference in the baseline characteristics and indications between the two groups. Although the success rates were not significantly different between MDTM and control groups (82.9% vs. 84.8%, P=0.321), MDTM was significantly associated with a decreased overall complication rate of (6.9% vs. 12.0%, p<0.001) and severe complication rate (0.4% vs. 2.5%, p=0.035). CONCLUSIONS Pre-ERCP MDTM decreases the frequency and severity of ERCP-related complications, with similar success rate, compared to routine practice.
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Affiliation(s)
- Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chang-Jing Zuo
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Li Wang
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Gang Jin
- Department of Hepato-Pancreato-Biliary Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shu-De Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Feng Liu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jie Chen
- Department of Anesthetists, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xian-Bao Zhan
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jin-Hua Yuan
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Luo-Wei Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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An appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease in children: our institutional experience in 231 cases. Surg Endosc 2011; 25:2536-40. [PMID: 21359895 DOI: 10.1007/s00464-011-1582-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 01/10/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool used by clinicians in the diagnosis and management of pancreaticobiliary disease. The safety and utility of ERCP for adults has been well documented. However, experience with ERCP for pediatric patients remains limited. This study aimed to examine the utility and safety of ERCP for diagnosis and therapy in pediatric surgical conditions. METHODS An institutional review board-approved retrospective chart review of all children younger than 21 years who underwent ERCP at a single children's hospital between 1992 and 2008 was performed. Age, sex, medical history, presenting symptoms, laboratory values, and discharge diagnoses were recorded. The ERCP findings, interventions performed, complications, and associated surgical procedures also were recorded. RESULTS A total of 231 ERCPs were performed for 167 children (98 girls and 69 boys) ages 62 days to 21 years. The mean patient age was 11.4 years, with 11% (n = 18) of the ERCPs performed for children younger than 2 years. Common indications for ERCP included chronic or recurrent pancreatitis (n = 106), acute pancreatitis (n = 42), and choledocholithiasis (n = 26). Additional indications included choledochal cyst (n = 2), congenital biliary obstruction (n = 2), and malignant biliary obstruction (n = 1). Therapeutic interventions were performed in 159 cases (69%) including sphincterotomy (n = 96), stone extraction (n = 55), and stent insertion (n = 52). Complications occurred for only 11 patients (4.76%), including 7 cases of post-ERCP pancreatitis. The use of ERCP for imaging resulted in surgical procedures in 58 cases. CONCLUSION Endoscopic retrograde cholangiopancreatography was used most commonly for children with pancreatitis and gallstone disease. It was used frequently for infants with a low complication rate. The majority of patients required therapeutic intervention, suggesting an important role for ERCP in the management of pancreaticobiliary disease in infants and children.
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Parsi MA. Peroral cholangioscopy in the new millennium. World J Gastroenterol 2011; 17:1-6. [PMID: 21218076 PMCID: PMC3016668 DOI: 10.3748/wjg.v17.i1.1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 08/27/2010] [Accepted: 09/04/2010] [Indexed: 02/06/2023] Open
Abstract
Peroral cholangioscopy was first described in 1970s and has recently gained popularity. Peroral cholangioscopy is appealing to therapeutic endoscopists because a direct intraluminal view of the biliary duct system offers possibilities for diagnosis and interventions beyond that which other imaging or endoscopic modalities can provide. As the image quality of cholangioscopies improves, so too does their diagnostic capability, and as their durability and maneuverability increases, so too does their potential use for therapeutic applications. This editorial is intended to provide a brief review of recent developments in peroral cholangioscopy and current indications for its use.
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López A, Ferrer I, Villagrasa RA, Ortiz I, Maroto N, Montón C, Hinojosa J, Moreno-Osset E. A new guidewire cannulation technique in ERCP: successful deep biliary access with triple-lumen sphincterotome and guidewire controlled by the endoscopist. Surg Endosc 2010; 25:1876-82. [PMID: 21136105 DOI: 10.1007/s00464-010-1479-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 10/15/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current studies have addressed ways to improve the success of selective biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). The objective of this study was to assess the efficacy of deep bile duct access using a short-wire system with sphincterotome and guidewire controlled only by the endoscopist. METHODS This was a prospective study of 70 patients with biliary diseases subjected to ERCP. Biliary cannulation was performed by the endoscopist without direct cooperation of the assistant in two centers with different experience in ERCP. The RX Biliary System™ was used in all patients. Efficacy (success rate and time to cannulation) of deep bile duct access and procedure-related complications were determined. RESULTS Overall guidewire cannulation was successful in 65 of 70 patients (92.9%). Nonintentional pancreatic duct cannulation with the guidewire was performed in 22 patients (31.4%). Additional techniques were needed in 18 patients (25.7%): guidewire into the pancreatic duct in 11 patients (15.7%); contrast-medium was used in 13 patients (18.6%); and precut was performed in 3 patients (4.3%). Attempts at papilla cannulation numbered<10 in 48 patients (68.6%), and time to biliary cannulation was <10 min in 42 patients (60%). Minor complications occurred in five patients (7.1%). There were no significant differences between patients in both centers. CONCLUSIONS The short-wire system allows the endoscopist to have access to the bile duct with a high success rate--early and safely--without the direct participation of the assistant.
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Affiliation(s)
- Antonio López
- Gastroenterology Department, Manises Hospital, Universidad Católica de Valencia, C/Roses s/n. 46940 Manises, Valencia, Spain.
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Rábago L, Quintanilla E, Delgado M, Castro JL, Cura Gonzalez ID. Is "laparoscopy-first" the final answer to cholecystocholedocholithiasis management? Surg Endosc 2010; 25:975-6. [PMID: 21046165 DOI: 10.1007/s00464-010-1212-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Sphincter of Oddi dysfunction (SOD) is a poorly-understood disorder, typically presenting as postcholecystectomy, "biliary-type," right-sided abdominal and/or chest wall pain. Most patients referred to specialist clinics for work-up of presumed SOD do not, in fact, have anything wrong with their bile ducts or biliary sphincter mechanisms. A careful history and focused physical examination will often identify the true source of the pain syndrome, ranging from chest wall costochondritis and nerve injury at surgical trochar sites, to gastroparesis and visceral hypersensitivity ("irritable bowel"). The Rome III classification of functional gallbladder and biliary disorders defines SOD as episodic (not daily) pain lasting more than 30 min, which is disruptive of normal activities and not associated with bowel upset. It is not relieved by gastric acid suppression or antispasmodics. Other causes of abdominal pain must be excluded. Standard work-up includes endoscopic retrograde cholangiopancreatography (ERCP) with biliary manometry, which risks post-ERCP pancreatitis, especially in young women with normal bile ducts and liver serology. Noninvasive tests for SOD, such as timed ("gated") cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid (HIDA) scans and secretin-stimulated magnetic resonance cholangiopancreatography, are imperfect and still evolving. Although many doubt the very existence of SOD, a multidisciplinary approach to the management of pre- and postcholecystectomy abdominal pain syndromes is long overdue.
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Affiliation(s)
- John Baillie
- Section on Gastroenterology, Hepatobiliary and Pancreatic Disorders Service, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA.
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Durkalski V, Stewart W, MacDougall P, Mauldin P, Romagnuolo J, Brawman-Minzter O, Cotton P. Measuring episodic abdominal pain and disability in suspected sphincter of Oddi dysfunction. World J Gastroenterol 2010; 16:4416-21. [PMID: 20845508 PMCID: PMC2941064 DOI: 10.3748/wjg.v16.i35.4416] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the reliability of an instrument that measures disability arising from episodic abdominal pain in patients with suspected sphincter of Oddi dysfunction (SOD). METHODS Although several treatments have been utilized to reduce pain and associated disability, measurement tools have not been developed to reliably track outcomes. Two pilot studies were conducted to assess test-retest reliability of a newly developed instrument, the recurrent abdominal pain intensity and disability (RAPID) instrument. The RAPID score is a 90-d summation of days where productivity for various daily activities is reduced as a result of abdominal pain episodes, and is modeled after the migraine disability assessment instrument used to measure headache-related disability. RAPID was administered by telephone on 2 consecutive occasions in 2 consenting populations with suspected SOD: a pre-sphincterotomy population (Pilot I, n = 55) and a post-sphincterotomy population (Pilot II, n = 70). RESULTS The average RAPID scores for Pilots I and II were: 82 d (median: 81.5 d, SD: 64 d) and 48 d (median: 0 d, SD: 91 d), respectively. The concordance between the 2 assessments for both populations was very good: 0.81 for the pre-sphincterotomy population and 0.95 for the post-sphincterotomy population. CONCLUSION The described pilot studies suggest that RAPID is a reliable instrument for measuring disability resulting from abdominal pain in suspected SOD patients.
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Woods KE, Willingham FF. Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review. World J Gastrointest Endosc 2010; 2:165-78. [PMID: 21160744 PMCID: PMC2998911 DOI: 10.4253/wjge.v2.i5.165] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/29/2010] [Accepted: 05/06/2010] [Indexed: 02/06/2023] Open
Abstract
The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.
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Affiliation(s)
- Kevin E Woods
- Kevin E Woods, Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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The clinical impact and cost implication of endoscopic ultrasound on use of endoscopic retrograde cholangiopancreatography in a Canadian university hospital. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:138-42. [PMID: 18299731 DOI: 10.1155/2008/498213] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic biliary imaging in choledocholithiasis. Evidence linking a decline in diagnostic ERCP with the introduction of EUS in clinical practice is limited. OBJECTIVE To assess the clinical impact and cost implications of a new EUS program on diagnostic ERCP at a tertiary referral centre. PATIENTS AND METHODS A retrospective review was performed of data collected during the first year of EUS at the University of Alberta Hospital (Edmonton, Alberta). Patients were referred for ERCP because of suspicion of choledocholithiasis based on clinical, biochemical and/or radiological parameters. If they were assessed to have an intermediate probability of choledocholithiasis, EUS was performed first. ERCP was performed if EUS suggested choledocholithiasis, whereas patients were clinically followed for six months if their EUS was normal. Cost data were assessed from a third-party payer perspective, and cost savings were expressed in terms of ERCP procedures avoided. RESULTS Over 12 months, 90 patients (63 female, mean age 58 years) underwent EUS for suspected biliary tract abnormalities. EUS suggested choledocholithiasis in 20 patients (22%), and this was confirmed by ERCP in 17 of the 20 patients. EUS was normal in 69 patients, and none underwent a subsequent ERCP during a six-month follow-up period. One patient had pancreatic cancer and did not undergo ERCP. The sensitivity and specificity of EUS for choledocholithiasis were 100% and 96%, respectively. A total of 440 ERCP procedures were performed over the same 12-month period, suggesting that EUS resulted in a 14% reduction in ERCP procedures (70 of 510). There were no complications of EUS. The cost of 90 EUS procedures was $42,840, compared with $108,854 for 70 ERCP procedures. The cost savings for the first year were $66,014. CONCLUSION EUS appears to be accurate, safe and cost effective in diagnostic biliary imaging for suspected choledocholithiasis. The impact of EUS is the avoidance of ERCP in selected cases, thereby preventing the risk of complications. Diagnostic ERCP should not be performed in centres and regions with physicians trained in EUS.
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Canlas KR, Branch MS. Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis. World J Gastroenterol 2008. [PMID: 18081218 DOI: 10.3748/wjg.13.6314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Affiliation(s)
- Karen R Canlas
- Division of Gastroenterology and Hepatology, Duke University Medical Center, DUMC Box 3662, Durham, NC 27710, United States
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Abstract
Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Varadarajulu S, Eloubeidi MA, Wilcox CM, Hawes RH, Cotton PB. Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography? Surg Endosc 2006; 20:801-5. [PMID: 16544073 DOI: 10.1007/s00464-005-0479-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 12/27/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. METHODS This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP. RESULTS For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001). CONCLUSIONS One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.
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Affiliation(s)
- S Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, 410 Lyons Harrison Research Building, 1530 3rd Avenue South, Birmingham, AL 35294-0007, USA.
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Chak A. A time for change. Gastrointest Endosc 2003; 57:286. [PMID: 12585312 DOI: 10.1067/mge.2003.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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