EUS and ERCP in the Same Session for Biliary Stones: From Risk Stratification to Treatment Strategy in Different Clinical Conditions

Might be over-evaluated: Predicting choledocholithiasis in patients with acute biliary pancreatitis

BACKGROUND

The increase in liver cholestasis enzyme and bilirubin levels, especially due to pancreatitis, mimics choledocholithiasis. This study aimed to examine the relationship between demographic and laboratory cut-off values and the presence of choledocholithiasis in patients with acute biliary pancreatitis (ABP).

METHODS

Patients diagnosed with ABP in the Department of General Surgery at Istanbul Faculty of Medicine between January 2010 and December 2022 were retrospectively analyzed. The presence of stones in the common bile duct was determined based on the results of magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Demographic and laboratory values of patients with and without bile duct stones were compared. Cut-off values were determined using receiver operating characteristic (ROC) curve analysis, and logistic regression analysis and modeling was performed for each variable.

RESULTS

A total of 1,026 ABP patients were evaluated. Patients whose enzyme levels were not elevated and those who did not undergo MRCP were excluded. A total of 584 patients were included in the study, and choledocholithiasis was detected in 188 (32.2%) patients. In multivariate analysis, age, gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), and direct bilirubin (DB) were found to be statistically associated with choledocholithiasis. The cut-off values were determined as 65 years for age, 394 U/L for GGT, 173 U/L for ALP, and 1.42 mg/dL for direct bilirubin. In the group where all four parameters were below these cut-off values, suggesting a clean common bile duct, it was observed that the negative predictive value was 97%.

CONCLUSION

Based on the demographic and laboratory data of patients with ABP, we were able to predict with more than 97% accuracy that the common bile duct was clean. Considering that our study only included patients who underwent MRCP due to elevated enzyme levels and suspicion of choledocholithiasis, the negative predictive value would be even higher if patients with acute biliary pancreatitis with normal enzyme levels were included. Additionally, no complications were observed in any of the patients during follow-up. This finding suggests that patients whose common bile duct is predicted to be clean can initially be monitored and supported with additional imaging methods if necessary. As a result, unnecessary imaging can be avoided, reducing costs and preventing the mortality and morbidity associated with unnecessary procedures.

Capturing the incidence of patient agitation amongst conscious sedation ERCPs and the impact on therapeutic outcomes

BACKGROUND

Completing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation is challenging. International recommendations favor enhanced sedation (e.g. propofol) for ERCP. Conscious sedation can result in sedation-related failure (SRF) and agitation for some patients, limiting therapeutic efficacy.

AIM

The aim of this study is to establish the risk of SRF and the impact on therapeutic success under conscious sedation practice in a single tertiary referral center.

METHODS

A retrospective review of a prospectively maintained ERCP database, analyzing sedation, procedural success, and complications.

RESULTS

Over 19 months, 807 conscious sedation ERCPs were recorded. Median midazolam dose was 5 mg (range 1-14 mg) and median fentanyl dose was 75 µg (0-200 µg). Sedation reversal was required in 0.1% of cases (1/807). Overall ductal cannulation rate was 92%. Severe agitation was recorded in 11% (86/807) of conscious sedation ERCP reports with SRF present in 3% (22/807). Patient agitation resulted in significantly lower cannulation (81% vs 92%, P = 0.002) and successful clearance rates (49% vs 85%, P = 0.002) versus non-agitated cases. Complication and pancreatitis rates were unaffected. Highest rates of SRF and agitation were identified in female patients, patients aged <50 years old, and post-operative biliary leak indications.

CONCLUSION

Over 10% of conscious sedation ERCPs are compromised by sedation issues, resulting in procedure abandonment or significantly diminished therapeutic success. General anesthetic ERCP is beneficial in facilitating biliary access, removing the risk of agitation and providing stability to aid cannulation. Female patients, patients aged <50 years, and post-operative biliary leak ERCPs appear as the priority cases for enhanced sedation support.

Endoscopic retrograde cholangiopancreatography: A comprehensive review as a single diagnostic tool

Endoscopic retrograde cholangiopancreatography (ERCP) was initially introduced in clinical practice as diagnostic tool. However, the presence of adverse events and the development of non-invasive techniques, such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS), limited its role as a stand-alone diagnostic choice, modifying its role to the leader of therapeutic pancreatobiliary endoscopy. Despite technological advances, there are still conditions where non-invasive diagnostic modalities are inconclusive, such as indeterminate biliary and pancreatic duct strictures, primary sclerosing cholangitis functional stenoses, intraductal papillary mucinous neoplasms (IPMNs) and paediatric indications, such as congenital anatomical abnormalities. This narrative review aimed to identify and analyse indications of diagnostic ERCP, without the need for therapeutic manipulations.

Application of EUS or MRCP prior to ERCP in patients with suspected choledocholithiasis in clinical practice

Background and study aims Patients with symptomatic cholelithiasis can be stratified according to the 2019 European Society for Gastrointestinal Endoscopy (ESGE) guideline into low-, intermediate- and high-likelihood groups for presence of choledocholithiasis. For the intermediate group, endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is recommended to assess whether an endoscopic retrograde cholangiopancreatography (ERCP) is necessary prior to cholecystectomy. The aim of the study was to investigate adherence to the guideline for diagnostic and treatment strategy for cholelithiasis in daily clinical practice. Patients and methods A multicenter, retrospective cross-sectional observational study of the diagnostic pathway of patients with suspicion of choledocholithiasis was conducted between 2019 and 2021. Patients were stratified according to the ESGE guideline "Endoscopic management of common bile duct stones". Results A total of 305 patients were included in the analysis and stratified into low- (17%), intermediate- (40%) and high- (43%) likelihood of choledocholithiasis. In these three categories, 182 patients (60%) underwent ERCP. Adherence to the ESGE guideline recommendation was 59.7% overall and was the highest in the intermediate-likelihood group (83.6%), compared with 45.1% in the low- and 43.2% in the high-likelihood group, respectively ( P < 0.001). In the high-likelihood group, 49% underwent additional imaging. In 195 patients who underwent additional imaging, 55 ERCPs (28.2%) could be avoided. Conclusions This study shows that stratification according to the ESGE guideline is useful to reduce the number of unnecessary additional imaging procedures and ERCPs in patients with a suspicion of choledocholithiasis. It seems worthwhile to perform EUS prior to ERCP in the same session.

The Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound Connection: Unity Is Strength, or the Endoscopic Ultrasonography Retrograde Cholangiopancreatography Concept

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the "Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept", has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain.

Acute lithiasis cholangitis in pregnant women: About three cases

Acute lithiasis cholangitis is a rare non-obstetric emergency during pregnancy, which may threaten fetus and mother's life. It requires a codified management in order to avoid complications. In this current study, we aimed to report our center experience in the management of acute lithiasis cholangitis occurring in three pregnant women.

Evaluation of the American Society of Gastrointestinal Endoscopy 2019 and the European Society of Gastrointestinal Endoscopy guidelines' performances for choledocholithiasis prediction in clinically suspected patients: A retrospective cohort study

Background and Aim

The American Society of Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have published guidelines for choledocholithiasis. However, the guidelines were formulated using data from a large number of patients with no to low risk of common bile duct (CBD) stones. This study aimed to assess the guidelines' predictive performance in a population with a high frequency of stones.

Methods

Data for three choledocholithiasis standard reference tests were retrospectively reviewed from January 2019 to June 2021. Clinical parameters were used to categorize patients into risk groups according to the guidelines, and then the guidelines' predictive abilities were calculated.

Results

Among 1185 patients, 521 were included. The stone prevalence was 61.0% (n = 318). Twelve (2.3%), 146 (28.0%), and 363 (69.7%) patients were classified into low‐, intermediate‐, and high‐risk groups according to the ASGE guidelines, and 30 (5.8%), 149 (28.6%), and 342 (65.6%) according to the ESGE guidelines. Focusing on the high‐risk group, the ASGE guidelines had a positive predictive value of 73.6 and a positive likelihood ratio of 1.78. The ESGE guidelines had a positive predictive value of 73.7 and positive likelihood ratio of 1.79. Both guidelines had equivalent areas under the receiver operating characteristic curve of 0.69 (95% confidence interval [CI]: 0.65–0.73) and 0.68 (95% CI: 0.64–0.72), respectively.

Conclusion

In the high‐risk group, the guidelines increased the chance of detecting choledocholithiasis by approximately 10% (61.0% prevalence to 73.6 and 73.7% positive predictive value). However, statistically, the guidelines had marginal discriminative performance in a population with high stone prevalence.

Effect of Programmed Nursing Plan Based on Thinking Map Guidance Mode on Hemodynamics and Intestinal Function Recovery of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography

ERCP is an effective method for the diagnosis and treatment of pancreatic and biliary diseases. With the improvement of endoscopes by researchers and the intubation and angiography technologies of medical workers, the role of ERCP in the diagnosis and treatment of pancreatic and biliary diseases has become increasingly important. Although ERCP is a minimally invasive diagnostic technique, it still falls into the category of surgery, and thus the physical and psychological dysfunction of patients undergoing ERCP caused by various factors such as surgery cannot be ignored. This study explored the effects of the procedural nursing plan based on the thinking map guidance mode on hemodynamics and intestinal function recovery of ERCP patients. The results showed that this plan could reduce the effects of ERCP on hemodynamics of patients, promote intestinal function recovery, relieve their bad psychology, reduce postoperative complications, and help to improve patients’ satisfaction with the nursing work, and it was worthy of promotion.