The clinical importance of different localizations of the papilla associated with juxtapapillary duodenal diverticula

Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto

BACKGROUND

Most of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.

AIM

To compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.

METHODS

Patients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.

RESULTS

A total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.

CONCLUSION

Many clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

The role of periampullary diverticulum on the incidence of pancreaticobiliary diseases and the outcome of endoscopic retrograde cholangiopancreatography

INTRODUCTION

Periampullary diverticulum (PAD), although commonly discovered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), remains controversial regarding its role in pancreaticobiliary diseases and the failure rate of cannulation. The aim of this study was to evaluate the association of PAD with pancreaticobiliary diseases and its impact on the outcome of ERCP.

MATERIAL AND METHODS

A retrospective analysis was carried out on 1455 patients who underwent an ERCP. Patients were divided into a PAD group and a control group without PAD, and propensity score matching was performed to adjust for clinical differences. The comparison was focused on pancreaticobiliary diseases, technical success, and complications of ERCP.

RESULTS

The occurrence of PAD is associated significantly with increasing age (p < 0.001). Incidences of acute pancreatitis (AP), suppurative cholangitis, and pancreatic head cancer were significantly higher in the PAD group (p < 0.05). After propensity score matching, the PAD group exhibited a higher rate of post-ERCP complications including haemorrhage, post-ERCP pancreatitis (PEP), and hyperamylasaemia (p < 0.05). However, the prevalence of perforation and the success rate of ERCP did not differ between groups (p > 0.05).

CONCLUSIONS

Periampullary diverticulum develops with aging and seems to be associated with an increase in pancreaticobiliary diseases and post-ERCP complications except for perforation. Additionally, the presence of PAD does not affect the technical success of ERCP.

Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience

BACKGROUND

Periampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty.

AIM

This study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events.

METHODS

Prospectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models.

RESULTS

Significant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation.

CONCLUSION

The presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1. Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/.

Evaluation of juxtapapillary duodenal diverticula using multiplanar reformation in MDCT: correlation with ERCP findings

OBJECTIVE

To determine the ability of multidetector computed tomography (MPR-MDCT) to identify and classify the juxtapapillary duodenal diverticulum (JPDD), with ERCP findings as the gold standard.

METHODS

We retrospectively reviewed all ERCP examinations (n: 455) performed between January 2010 to December 2018 and selected 105 patients with JPDD as the inclusion criteria. Of those, 28 patients were excluded because of advanced pancreatic carcinoma, incomplete MDCT examinations and biliary catheter insertion. Finally, MDCT examinations of 77 patients with JPDD were assessed for the presence and type of JPDD.

RESULTS

MPR-MDCT was able to identify 71 (92.2%) JPDD in 77 cases with 88.9% accuracy, 83.3% sensitivity, and 91.6% specificity in classifying the type of JPDD. MPR-MDCT performed best in determining type 1 JPDD, with accuracy of 95.4% compared with type 2 (83.3%) and type 3 (87.8%). There was no significant difference between age, gender, incidence of biliary stones and pancreatitis between each type of JPDD. No correlation of sizes with types of JPDD was found.

CONCLUSIONS

MPR-MDCT can accurately identify and classify JPDD. This information will be useful in determining the difficulty of ERCP.

Clinical Efficacy Analysis of the Combination of the Laparoscope and Preoperative or Intraoperative Duodenoscope in the Treatment of Cholecystolithiasis with Choledocholithiasis: A Retrospective Study

Aim: This study aims to analyze the efficacy and safety of the combination of laparoscope and preoperative (PODL) or intraoperative (IODL) duodenoscope in the treatment of cholecystolithiasis with choledocholithiasis.

Materials and Methods: From January 2015 to February 2017, 51 patients with cholecystolithiasis and choledocholithiasis, who were treated with the PODL (n = 29) or IODL (n = 22), were reviewed retrospectively. The efficacy and safety were evaluated and compared between these two groups.

Results: The success rates were 100% in IODL group and 96.6% in PODL group. There was no statistical significance in the difference of stone clearance rate and residual stone rate between two groups (P > .05). There were no significant differences in complications, like aspiration, gastrointestinal perforation, and acute cholangitis between two groups (P > .05). IODL significantly decreased numeric rating scale (NRS) scoring, reduced surgery cost and shortened hospitalization time compared to that of PODL group (P < .05). No cholangitis, reoccurrence of stones or biliary obstruction occurred in all 51 patients.

Conclusion: In this retrospective study, IODL was found superior to PODL. And the IODL can significantly decrease NRS scoring, reduce surgery cost and shorten hospitalization time.

Safety and efficacy of enhanced recovery after surgery in elderly patients after therapeutic endoscopic retrograde cholangiopancreatography

Introduction

The number of elderly patients with biliary and pancreatic diseases has increased significantly. The characteristics of biliary and pancreatic diseases in the elderly increase the risk of treatment.

Aim

To study the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients with biliary and pancreatic diseases with the concept of enhanced recovery after surgery (ERAS).

Material and methods

Patients receiving ERCP under ERAS were grouped into an elderly group (group A, n = 58, aged 75 years or above) and a young and middle-aged group (group B, n = 202, aged less than 60 years). The clinical parameters before, during and after the operation of the two groups were compared.

Results

Before the operation, the incidences of cholangiocarcinoma and complications, nutritional screening score ≥ 3, ASA degree III and Child-Pugh grade A in group A were significantly higher than those in group B (p < 0.05), while the incidences of nausea and vomiting, abdominal pain, nutritional screening < 3 and ASA grade I in group A were significantly lower than those in group B (p < 0.05). Intraoperatively, the incidence of juxta-ampullary duodenal diverticulum (JAD) in internal or bottom papilla in the elder patients with difficult selective biliary cannulation (DSBC) was significantly higher than that in the young and middle-aged group (p < 0.05). In addition, the continuous ECG monitoring duration and the first exhaust time in group A were significantly longer than those in group B (p < 0.05).

Conclusions

Endoscopic retrograde cholangiopancreatography under ERAS in elderly patients is as safe and effective as in young patients.

Is there a link between periampullary diverticula and biliopancreatic disease? An EUS approach to answer the question

BACKGROUND

Many studies, almost all in an Endoscopic Retrograde Cholangiopancreatography (ERCP) setting, have been conducted to establish if a link exists between periampullary diverticula (PADs) and biliopancreatic diseases but the issue is still debated.

AIMS

The objective was to clarify the link between PADs and biliopancreatic disease, for the first time using Endoscopic Ultrasound (EUS).

METHODS

We retrospectively reviewed our database seeking patients scheduled for EUS with an indication that entailed the exploration of the second duodenum. For each patient with a PAD enrolled in the study, 6 controls were randomly selected.

RESULTS

2475 patients met the inclusion criteria. Among them, 185 subjects with a PAD were found (prevalence 7.5%), 1110 subjects served as controls. Patients with a PAD had more frequently a history of cholangitis (8.1 vs 2.2%; OR 3.99, p < 0.001), a higher prevalence of common bile duct (CBD) dilation (44.3 vs 28.2%; OR 2, p < 0.0001) and a higher prevalence of CBD stones (34.1 vs 19.6%; OR 2.1, p < 0.0001). No differences were found about history of jaundice, acute/recurrent pancreatitis or EUS signs of chronic pancreatitis.

CONCLUSION

Whereas PADs were linked with history of cholangitis, CBD stones and dilation, no association was found with pancreatic diseases.

Impact of periampullary diverticula on technical success and complications of endoscopic retrograde cholangiopancreatography

AIM

To investigate the association of periampullary diverticula (PAD) with pancreaticobiliary diseases as well as the impact of PAD on the technical success and complications of endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 1455 consecutive patients who underwent ERCP from January 2016 to December 2016 at The First Affiliated Hospital of Nanchang University were analyzed retrospectively. The patients were divided into a PAD group (n = 293) and a non-PAD group (n = 1162) according to the presence or absence of PAD. The rate of pancreaticobiliary diseases was analyzed and compared between the PAD group and non-PAD group, and the technical success rate of ERCP and the incidence of postoperative complications were also compared.

RESULTS

The rate of PAD increased with age (P < 0.05). The incidence rates of suppurative cholangitis and acute pancreatitis (AP) and carcinoma of the pancreatic head in patients with PAD were significantly higher than those in patients without (P < 0.05). The rates of postoperative complications, such as hemorrhage, perforation, post-ERCP pancreatitis (PEP) and hyperamylasemia, were significantly higher in patients with PAD (P < 0.05). No significant differences was observed in the success rate of ERCP (P > 0.05).

CONCLUSION

PAD is associated with an increased rate of pancreaticobiliary diseases as well as the occurrence of postoperative complications of ERCP. However, the presence of PAD dose not affect the technical success rate of ERCP.

Influence of juxtapapillary duodenal diverticulum on diagnostic and therapeutic performance of endoscopic retrograde cholangiopancreatography

AIM

To assess the effect of juxtapapillary duodenal diverticulum (JDD) on the diagnostic and therapeutic performance of endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 5673 patients underwent ERCP at Linyi People's Hospital from January 2006 to December 2015, including 1267 cases with juxtapapillary duodenal diverticulum. The clinical data for patients with juxtapapillary duodenal diverticulum were analyzed retrospectively. The influence of duodenal diverticulum on the success rate of ERCP and the incidence of associated complications was analyzed.

RESULTS

Of the 1267 patients included, 1242 (98%) had successful intubation, 1206 (81%) were found to have biliary calculi during ERCP examination, 241 (19%) were found not to have biliary calculi. A total of 47 cases suffered from surgery associated complications (3.7%), including 11 cases of intraoperative bleeding, 8 cases of delayed postoperative hemorrhage, 19 cases of pancreatitis after ERCP, 7 cases of biliary tract infection, and 2 cases of gastrointestinal perforation. No death occurred.

CONCLUSION

When ERCP examination is performed in patients with juxtapapillary duodenal diverticulum, endoscopists should be more cautious and have a better understanding that this anatomical variation may have an effect on the location of the distal end of the bile tract. Different methods of operation should be adopted according to the corresponding characteristics of the papilla.

Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center

Aims. We here investigated the association of different types of periampullary diverticula (PAD) with pancreaticobiliary disease and with technical success of endoscopic retrograde cholangiopancreatography (ERCP). Methods. A total of 850 consecutive patients who underwent their first ERCP were entered into a database. Of these patients, 161 patients (18.9%) had PAD and the age- and sex-matched control group comprised 483 patients. Results. PAD was correlated with common bile duct (CBD) stones (59.6% versus 35.0% in controls; P = 0.008) and negatively correlated with periampullary malignancy (6.8% versus 21.5% in controls; P = 0.004). The acute pancreatitis was more frequent (62.5%) in patients with PAD type 1 followed by PAD type 2 (28.9%, P = 0.017) and type 3 (28.0%, P = 0.006). No significant differences were observed in successful cannulation rate and post-ERCP complications among the 3 types of PAD. Type 1 PAD patients had less recurrence of CBD stones than did the patients who had type 2 or type 3 PAD (53.8% versus 85.7%; P = 0.043). Conclusions. PAD, especially type 1 PAD, is associated with an increased acute pancreatitis as well as occurrence and recurrence of CBD stones. PAD during an ERCP should not be considered as an obstacle to a successful cannulation.