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Sadek A, Hara K, Okuno N. Endoscopic ultrasonography-guided trans-afferent loop drainage of liver abscess using forward-viewing echoendoscope. Dig Endosc 2023; 35:e136-e137. [PMID: 37641560 DOI: 10.1111/den.14655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023]
Abstract
Watch a video of this article.
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Affiliation(s)
- Ahmed Sadek
- Internal Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
- Department of Gastroenterology, Aichi Cancer Center, Aichi, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center, Aichi, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center, Aichi, Japan
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Chiu HC, Liu CA, Tseng HS, Ling K, Tsai YC, Huang HE, Wu PS, Lee RC. Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size? Eur Radiol 2023; 33:6872-6882. [PMID: 37081299 DOI: 10.1007/s00330-023-09631-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones. METHODS We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram. RESULTS The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success. CONCLUSIONS PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate. KEY POINTS • PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.
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Affiliation(s)
- Hsun-Chieh Chiu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Chien-An Liu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China.
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China.
| | - Hsiuo-Shan Tseng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
- Department of Medical Imaging, Cheng Hsin General Hospital, Taipei, 201, Section 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China
| | - Kan Ling
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Yin-Chen Tsai
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Hsuen-En Huang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Pei-Shan Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Rheun-Chuan Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
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Ebrahimi B, Hosseini SV, Haghighat N, Moeinvaziri N, Amini M, Sobhani Z, Hosseini B. Presence of Parasite in the Gastrointestinal Tract of a Patient Undergoing Single Anastomosis Sleeve Ileal Bypass (SASI) Surgery: Case Report. Obes Surg 2021; 31:4640-4642. [PMID: 34081273 DOI: 10.1007/s11695-021-05504-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Bahareh Ebrahimi
- Shiraz Geriatric Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Neda Haghighat
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nader Moeinvaziri
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Surgery, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, 32279711-071, Iran
| | - Masoud Amini
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Surgery, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, 32279711-071, Iran
| | - Zahra Sobhani
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Babak Hosseini
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Surgery, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, 32279711-071, Iran.
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Ichkhanian Y, Runge T, Jovani M, Vosoughi K, Brewer Gutierrez OI, Khashab MA. Management of adverse events of EUS-directed transgastric ERCP procedure. VideoGIE 2020; 5:260-263. [PMID: 32529164 PMCID: PMC7276935 DOI: 10.1016/j.vgie.2020.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Accessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period. Methods This was a retrospective review of 4 patients with RYGB anatomy who underwent EDGE for the management of pancreaticobiliary disease and experienced LAMS-related adverse events. Techniques for managing and avoiding these events are discussed. Results Four patients underwent EDGE with both technical and clinical success. Slight LAMS migration with partial mucosal overgrowth was encountered in 1 case and was managed by LAMS removal. A large, bleeding, distal marginal ulcer after the EDGE procedure was encountered in the second case and was managed with proton pump inhibitor and removal of the LAMS, with fistula treatment with argon plasma coagulation used to enhance closure. The third case was complicated by moderate intraprocedural bleeding after LAMS dilation, which was managed by applying balloon tamponade and placing a through-the-scope esophageal stent across the LAMS. Last, preferential food passage to the excluded stomach was noted in the fourth case and resulted in symptomatic distention. The symptomatic distention was managed by another de novo jejunogastrostomy using a LAMS for drainage. Conclusions Despite its feasibility and acceptable safety profile, the use of LAMSs during EDGE could be associated with several procedure-specific adverse events, which can be avoided or managed endoscopically with no further consequence.
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Affiliation(s)
- Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Thomas Runge
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
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5
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Jovani M, Ichkhanian Y, Vosoughi K, Khashab MA. EUS-guided biliary drainage for postsurgical anatomy. Endosc Ultrasound 2019; 8:S57-S66. [PMID: 31897381 PMCID: PMC6896432 DOI: 10.4103/eus.eus_53_19] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/15/2019] [Indexed: 12/19/2022] Open
Abstract
ERCP is the mainstay of therapy for pancreatobiliary diseases in patients with native upper gastrointestinal (UGI) anatomy. However, when UGI anatomy is surgically altered, standard ERCP becomes technically challenging or not possible. In such instances, EUS-guided biliary drainage (EUS-BD) has been increasingly employed by advanced endoscopists as a safe and effective method of access to the biliary tree. In this study, we review the technical aspects and outcomes of EUS-BD in patients with surgical UGI anatomy.
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Affiliation(s)
- Manol Jovani
- Clinical and Translational Epidemiology Unit, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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6
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Mukai S, Tsuchiya T, Itoi T. Interventional endoscopic ultrasonography for benign biliary diseases in patients with surgically altered anatomy. Curr Opin Gastroenterol 2019; 35:408-415. [PMID: 31343415 DOI: 10.1097/mog.0000000000000565] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW At present, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of therapy for benign biliary diseases in patients with surgically altered anatomy (SAA). Recently interventional endoscopic ultrasonography (EUS) techniques have been used for not only drainage procedure but also treatment procedure in such patients. This review aims to discuss details about interventional EUS techniques in such patients and published clinical data. RECENT FINDINGS Antegrade treatment such as antegrade stone removal for bile duct stones or guidewire manipulation across the anastomotic stricture following antegrade balloon dilation and antegrade stenting for the stricture via the approach route created by EUS-bilioenterostomy, so-called EUS-guided antegrade intervention, have been developed. In difficult cases, per-oral cholangioscopy-assisted antegrade intervention has been reported as a useful technique. In addition, other novel alternative interventional EUS techniques have been also reported such as EUS-directed transgastric ERCP in patients with Roux-en-Y gastric bypass. SUMMARY Interventional EUS techniques appear to be feasible and safe alternative procedures for benign biliary diseases in patients with SAA after balloon enteroscopy-assisted ERCP failure.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Ivano FH, Ponte BJ, Dubik TC, Ivano VK, Winkeler VLL, Kay AK. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP): ANALYSIS OF THE EFFECTIVENESS AND SAFETY OF THE PROCEDURE IN THE PATIENT WITH ROUX-EN-Y GASTRIC BYPASS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2019; 32:e1432. [PMID: 31038557 PMCID: PMC6488270 DOI: 10.1590/0102-672020190001e1432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/16/2019] [Indexed: 01/22/2023]
Abstract
Background: Obesity can be treated with bariatric surgery; but, excessive weight loss
may lead to diseases of the bile duct such as cholelithiasis and
choledocholithiasis. Endoscopic retrograde cholangiopancreatography is a
diagnostic and therapeutic procedure for these conditions, and may be
hampered by the anatomical changes after surgery. Aim: Report the efficacy and the safety of videolaparoscopy-assisted endoscopic
retrograde cholangiopancreatography technique in patients after bariatric
surgery with Roux-en-Y gastric bypass. Method: Retrospective study performed between 2007 and 2017. Data collected were:
age, gender, surgical indication, length of hospital stay, etiological
diagnosis, rate of therapeutic success, intra and postoperative
complications. Results: Seven patients had choledocholithiasis confirmed by image exam, mainly in
women. The interval between gastric bypass and endoscopic procedure ranged
from 1 to 144 months. There were no intraoperative complications. The rate
of duodenal papillary cannulation was 100%. Regarding complications, the
majority of cases were related to gastrostomy, and rarely to endoscopic
procedure. There were two postoperative complications, a case of
chest-abdominal pain refractory to high doses of morphine on the same day of
the procedure, and a laboratory diagnosis of acute pancreatitis after the
procedure in an asymptomatic patient. The maximum hospital stay was four
days. Conclusion: The experience with endoscopic retrograde cholangiopancreatography through
laparoscopic gastrostomy is a safe and effective procedure, since most
complications are related to the it and did not altered the sequence to
perform the conventional cholangiopancreatography.
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Affiliation(s)
- Flávio Heuta Ivano
- Pontificate Catholic University of Paraná, Medicine.,Service of Digestive Endoscopy, Sugisawa Hospital, Curitiba, PR, Brasil
| | | | | | | | | | - Antônio Katsumi Kay
- Pontificate Catholic University of Paraná, Medicine.,Service of Digestive Endoscopy, Sugisawa Hospital, Curitiba, PR, Brasil
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Alabraba E, Travis S, Beckingham I. Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.299] [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: 02/06/2023] Open
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Alabraba E, Travis S, Beckingham I. Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports. World J Gastrointest Endosc 2019; 11:298-307. [PMID: 31040891 PMCID: PMC6475703 DOI: 10.4253/wjge.v11.i4.298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/15/2019] [Accepted: 03/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.
CASE SUMMARY We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.
CONCLUSION PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.
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Affiliation(s)
- Edward Alabraba
- Department of Hepato-Pancreato-Biliary Surgery, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Simon Travis
- Department of Radiology, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Ian Beckingham
- Department of Hepato-Pancreato-Biliary Surgery, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
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Nakai Y, Kogure H, Isayama H, Koike K. Endoscopic Ultrasound-Guided Biliary Drainage for Benign Biliary Diseases. Clin Endosc 2019; 52:212-219. [PMID: 30866611 PMCID: PMC6547351 DOI: 10.5946/ce.2018.188] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/05/2018] [Indexed: 12/15/2022] Open
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Shah RM, Tarnasky P, Kedia P. A review of endoscopic ultrasound guided endoscopic retrograde cholangiopancreatography techniques in patients with surgically altered anatomy. Transl Gastroenterol Hepatol 2018; 3:90. [PMID: 30603726 DOI: 10.21037/tgh.2018.10.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/22/2018] [Indexed: 12/28/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic intervention for pancreaticobiliary duct diseases. Surgically altered anatomy (SAA) makes performing successful ERCP challenging. In this review article the concept of endoscopic ultrasound guided pancreaticobiliary drainage (EUS-PBD) in cases of SAA where conventional ERCP fails or is not possible will be reviewed. EUS-PBD serves as an emerging and promising alternative for pancreaticobiliary therapy in the hands of skilled endoscopists compared to conventional therapies such as device-assisted ERCP, laparoscopic-assisted ERCP, or percutaneous drainage. The purpose of this review is to discuss the rationale, technique and current published outcomes on EUS-PBD for SAA.
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Affiliation(s)
- Rucha Mehta Shah
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Paul Tarnasky
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
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Togliani T, Pilati S, Lisotti A, Caletti G, Fusaroli P. Catheter probe extraductal ultrasound (EDUS) exploration of the common bile duct is safe in elderly patients with suspicion of choledocholithiasis after distal gastrectomy. Abdom Radiol (NY) 2018; 43:2987-2990. [PMID: 29600432 DOI: 10.1007/s00261-018-1580-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Post-surgical upper gastrointestinal anatomy may hamper a complete bilio-pancreatic evaluation with a standard echoendoscope. The aim of this study was to assess the role of catheter probe extraductal ultrasound (EDUS) for the evaluation of the common bile duct (CBD) in patients who are status post-gastric surgery and who are suspected of having choledocholithiasis. METHODS We retrospectively analyzed patients with a prior history of gastric surgery, who underwent EDUS for a suspicion of CBD obstruction. For each patient, technical success, accuracy, and safety were recorded. In case of a positive finding of CBD stones, endoscopic retrograde cholangiopancreatography (ERCP) was performed. In case of other findings or a negative EDUS, computed tomography or magnetic resonance cholangiopancreatography (MRCP) was performed as appropriate. RESULTS EDUS was technically successful in all the 11 patients with a Billroth II gastrectomy, while it failed in all the 5 patients with Roux-en-Y gastric surgery. EDUS accuracy was 100% (3 true-positive and 8 true-negative cases). CBD stones, confirmed and successfully extracted at ERCP, were found in two patients, while in one patient EDUS showed a CBD stenosis that was treated with a plastic stent during ERCP; computed tomography at follow-up was negative for cancer. EDUS was correctly negative in 8 patients, as confirmed by MRCP. CONCLUSIONS EDUS may represent an accurate and safe alternative to standard endoscopic ultrasonography and MRCP for the detection of CBD stones in elderly patients who are status post-Billroth II gastric surgery.
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13
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Navaratne L, Al-Musawi J, Mérida AA, Vilaça J, Isla AM. Trans-infundibular choledochoscopy: a method for accessing the common bile duct in complex cases. Langenbecks Arch Surg 2018; 403:777-783. [PMID: 30058037 DOI: 10.1007/s00423-018-1698-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/23/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE During laparoscopic common bile duct exploration (LCBDE) where Calot's triangle cannot be safely dissected due to a 'frozen' hepatic hilum secondary to severe inflammation or fibrosis, the preferred transcystic approach to the common bile duct (CBD) is precluded. The aim of this paper is to describe a safe method of accessing the CBD via a trans-infundibular approach (TIA) in complex cases where conventional access to the cystic duct or CBD is denied. METHODS A retrospective review of 154 consecutive patients who underwent LCBDE at a single centre between 2014 and 2018 was performed. Outcomes of this study were successful access to the CBD to achieve choledochoscopy, successful stone clearance (when required), conversion to open surgery, total or subtotal cholecystectomy, post-operative complications, and length of hospital stay. RESULTS Nine (5.8%) patients underwent access to the CBD via TIA choledochoscopy. TIA-LCBDE resulted in a stone extraction rate of 86% with one patient requiring choledochotomy. There were zero conversions to open surgery, and total/near total cholecystectomy was achieved in all patients. One patient suffered a post-operative complication for bilateral atelectasis and lower respiratory tract infection. Median length of hospital stay was 3 days. CONCLUSIONS The use of a trans-infundibular approach to the CBD is indicated when the hepatic hilum is 'frozen' with severe inflammation and/or fibrosis precluding safe dissection of the critical structures within Calot's triangle. This strategy enables exploration of the CBD via the transcystic route without the need for critical view dissection or choledochotomy.
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Affiliation(s)
- Lalin Navaratne
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK.
| | - Jasim Al-Musawi
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK
| | - Asuncion Acosta Mérida
- Department of General Surgery, The Doctor Negrin University Hospital of Gran Canaria, Las Palmas, Spain
| | - Jaime Vilaça
- Department of Surgery, Hospital da Luz Oporto, Oporto, Portugal
| | - Alberto Martinez Isla
- Department of Upper GI Surgery, Northwick Park Hospital and St Marks Hospitals, Watford Road, London, HA1 3UJ, UK
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14
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Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 2018; 87:1241-1247. [PMID: 29317267 DOI: 10.1016/j.gie.2017.12.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. METHODS This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. RESULTS Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. CONCLUSION With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.
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Affiliation(s)
- Mohammad F Ali
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Krishna C Gurram
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | | | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
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15
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Hosmer A, Abdelfatah MM, Law R, Baron TH. Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy. Endosc Int Open 2018; 6:E127-E130. [PMID: 29399608 PMCID: PMC5794438 DOI: 10.1055/s-0043-123188] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/07/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiography (ERC) in patients with complex surgically-altered anatomy (SAA) is technically demanding and has limitations. Developments in EUS-guided procedures allow alternative approaches for patients with altered gastrointestinal anatomy and biliary lithiasis. PATIENTS AND METHODS Single-center, retrospective review of prospectively entered patients with SAA who underwent EUS-guided hepaticogastrostomy (HGS) followed by an interval antegrade endoscopic clearance of biliary lithiasis. RESULTS 9 patients with Roux-en-Y anatomy underwent HGS to allow clearance of biliary lithiasis after a mean of 2.5 procedures. Technical success was achieved in 100 % of patients utilizing subsequent antegrade endoscopic techniques after HGS including: balloon sweep (9), transpapillary balloon dilation (8), cholangioscopy with electrohydraulic lithotripsy (4), and mechanical lithotripsy (1). HGS stents were removed in all patients. 1 adverse event (cholangitis) occurred after cholangioscopy and prolonged intraductal electrohydraulic lithotripsy. CONCLUSION EUS-guided antegrade therapy for the management of biliary lithiasis in patients with altered gastrointestinal anatomy appears efficacious with a low risk of adverse events. These preliminary results suggest this approach should be considered at centers with available expertise.
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Affiliation(s)
- Amy Hosmer
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, United States
| | - Mohamed M Abdelfatah
- Division of Gastroenterology and Hepatology, East Carolina University, Greenville, North Carolina, United States
| | - Ryan Law
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, United States
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, United States,Corresponding author Todd H. Baron, MD 130 Mason Farm Road, CB 7080Chapel Hill, NC 27599984-974-0744
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16
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Endoscopic ultrasound–guided biliary and pancreatic duct access and intervention. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Abstract
PURPOSE OF REVIEW This review highlights the current status of endoscopic retrograde cholangiopancreatography (ERCP) techniques in patients with altered anatomy. Endoscopic treatment of biliopancreatic disorders is particularly challenging in patients with altered anatomy. RECENT FINDINGS There are two main approaches to perform ERCP in patients with altered anatomy: the transluminal access and the transmural access. The transluminal access uses device-assisted enteroscopy (DAE) to reach and cannulate the biliopancreatic system. The transmural access is created using therapeutic endoscopic ultrasound (EUS) or surgery to reach the biliopancreatic system. Both techniques are under continuous development and optimization. SUMMARY Based on the currently available data in the literature, the transluminal access is the preferred first-line approach because of an acceptable success rate and an excellent safety profile, whereas the transmural approach may be more efficacious but with a higher complication rate, even in experienced hands. Due to the complexity of both techniques and the relative low number of procedures, patients with altered anatomy are best referred to high-volume centres where both techniques are available for optimal treatment.
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18
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Paik WH, Park DH. Endoscopic Ultrasound-Guided Biliary Access, with Focus on Technique and Practical Tips. Clin Endosc 2017; 50:104-111. [PMID: 28391670 PMCID: PMC5398369 DOI: 10.5946/ce.2017.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 03/12/2017] [Indexed: 12/11/2022] Open
Abstract
In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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