Endoscopic Cannulation Research Articles

Endoscopic retrograde cholangiopancreatography using a pediatric colonoscope in patients with Roux‑en‑Y gastrectomy and an intact major duodenal papilla.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastrectomy and an intact major duodenal papilla is challenging and difficult, with unsatisfactory outcomes using various endoscopes. Limited data are available regarding the outcomes of ERCP using a pediatric colonoscope in such patients. To evaluate the efficacy of a pediatric colonoscope in patients with Roux-en-Y gastrectomy and an major duodenal intact papilla, 93 consecutive patients with Roux-en-Y gastrectomy and an intact major duodenal papilla who underwent ERCP using a pediatric colonoscope at the Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, (Nanjing, China) between January 2018 and December 2022 were retrospectively reviewed. Following the failure of bile duct cannulation, a double-guidewire or precut technique was utilized for advanced cannulation. Interventions were performed using standard ERCP therapeutic accessories. The results indicated that distal gastrectomy with Roux-en-Y reconstruction was performed in 38 out of 93 patients, while 55 patients underwent total gastrectomy with Roux-en-Y reconstruction. The success rates associated with endoscope insertion, endoscopic cannulation and therapeutic ERCP were 88.17% (82/93), 85.37% (70/82) and 95.71% (67/70), respectively, while the clinical intervention success and complication rates were 72.04% (67/93) and 7.53% (7/93), respectively. The endoscope insertion time was 40.78±10.04 min, and the ERCP procedure time was 88.55±16.38 min. Student's t-test showed that the endoscope insertion time and the ERCP procedure time in patients undergoing distal gastrectomy were longer than those in patients undergoing total gastrectomy (P<0.05). Binary logistic regression analysis showed that age and number of previous abdominal surgeries were independent risk factors associated with endoscope insertion failure. In conclusion, the present study demonstrated that the use of a pediatric colonoscope is efficacious and safe for patients with Roux-en-Y gastrectomy and an intact major duodenal papilla undergoing ERCP.

Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

Bouncing Off the Balloon: A New Trick for Selective Cystic Duct Cannulation

Introduction: Management of acute cholecystitis in non-surgical or high-risk candidates includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). Endoscopic cannulation of the cystic duct (CD) for transpapillary GB drainage in such cases can be technically challenging and difficult, given narrowing of cystic duct orifice from edema, stones and valves in the cystic duct, and angulation of the cystic duct takeoff. Here we describe a novel technique, using no special equipment that can be utilized in cases of angulated CD takeoff. Case Description: A 47-year-old woman was admitted with acute cholecystitis and choledocholithiasis. Her vitals were stable with no signs of sepsis. Her WBC was 7.7 X 103/dl, AST 78 unit/L, ALT 267 unit/L, ALP 207 unit/L, total bilirubin was 1.2 mg/dl. Given her morbid obesity (BMI 53) and multiple comorbidities (history of recent uterine infection with perforation, multiple intra-abdominal abscesses, and a diversion colostomy) she was deemed not a surgical candidate for cholecystectomy. Subsequently, she underwent an endoscopic retrograde cholangiography (ERC) with successful mechanical lithotripsy and balloon extraction of multiple common bile duct (CBD) stones. Selective CD cannulation was then attempted; however, was unsuccessful despite multiple attempts using different guidewires and catheters given the downward angulation (Image 1) of the CD takeoff that made it technically challenging. A 15 mm extraction balloon was inflated in the distal common hepatic duct (1 cm proximal to the CD orifice) and a 0.035-inch guidewire was inserted into the CBD alongside the extraction balloon catheter. The guidewire was further advanced into the bile duct allowing the guidewire to recoil (bounce) off the balloon, and was carefully manipulated into the angulated CD takeoff (Image 2). Contrast injection showed filling defect in the neck of the gallbladder. Pus was seen draining from the major ampulla after CD cannulation. A transpapillary 7 Fr x 22 cm double-pigtail plastic stent was successfully placed across the CD with the internal pigtail in the gallbladder lumen (Image 3).1323_A.tif Figure 1: No Caption available.1323_B.tif Figure 2: No Caption available.1323_C.tif Figure 3: No Caption available.Discussion: There is a paucity of techniques describing CD cannulation. These include using intraductal ultrasound or cholangioscopy for guidance, however, such devices may not be readily available. We believe our novel and simple method can be utilized for selective CD cannulation in such difficult cases.

Synchronous laparoscopic cholecystectomy and intra-operative endoscopic retrograde cholangio-pancreatography: should it be the standard of care?

Introduction: Up to 20 % of patients diagnosed with chronic calcular cholecystitis have concomitant CBD stones. Management included open and laparoscopic CBD exploration, endoscopic approach; pre-operative or intra-operative ERCP. Methods: This is a retrospective analysis of 120 patients who underwent laparoscopic cholecystectomy (LC) and intra-operative ERCP at Gastrointestinal surgery center, Mansoura university between 2012 and 2017. LC was done first. Intra-operative cholangiography (IOC) was attempted in all cases. Results: Median age was 32 years. Median CBD stone size was 8 mm. Median number of stones was 1 (1–3). The median operative time for both LC and ERCP was 75 minutes. Transcystic IOC was successful in 97.5% of cases where passed CBD stone was confirmed in 9 patients therefore avoiding unnecessary ERCP. We had 4 cases of failed endoscopic cannulation (3.6%), 2 of them underwent laparoscopic CBD exploration and the other 2 underwent open CBD exploration. We failed to completely clear the CBD endoscopically in 3 cases. Conclusion: LC with intra-operative ERCP is safe and feasible where combining laparoscopy and endoscopy enhances the outcomes of both.

Clinical efficacy of primary closure in laparoscopic common bile duct exploration (A report of 2 429 cases)

Objective To investigate the clinical efficacy of primary closure in laparoscopic common bile duct exploration (LCBDE). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 2 429 patients who underwent primary closure in LCBDE in the Second Hospital of Chengdu City from March 1992 to December 2017 were collected. Patients underwent laparoscopic cholecystectomy (LC) + stone extraction using LCBDE or extracorporeal shock wave lithotripsy (ESWL), laparoscopic endoscopic sphincteropapillotomy (LEST) was performed selectively, then underwent laparoscopic endoscopic nasobiliary drainage (LENBD) or laparoscopic transabdominal antegrade-guide common bile duct stent implantation, finally underwent primary closure of common bile duct. Observation indicators: (1) surgical situations; (2) postoperative recovery; (3) postoperative short-term complications; (4) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to observe long-term surgical complications once every 3 months up to 1 year postoperatively. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical situations: of 2 429 patients, 2 251 underwent successful stone extraction using LCBDE, relief of the obstruction and primary closure of common bile duct, with depletion of stones; 15 underwent stone extraction using conversion to open surgery, with depletion of stones; 163 had residual stones or surgery-related complications. Of 2 429 patients, 1 144, 898, 223, 110 and 54 were respectively detected in grade N or 0, 1, 2, 3 and 4 of laparoscopic distal of the common bile duct smooth classification (LDSC); 599 underwent LEST, 367 underwent LENBD, 207 indwelled urinary catheter through cystic duct stump, 125 underwent laparoscopic transabdominal antegrade-guide common bile duct stent implantation and 1 131 underwent primary closure in LCBDE only. Number of removing the stones, diameter of common bile duct, volume of intraoperative blood loss and operation time was (2.5±0.2)per case, (0.7±0.4)cm, (22.4±2.6)mL and (100±12)minutes, respectively. (2) Postoperative recovery: time of postoperative gastrointestinal function recovery, duration of hospital stay and treatment expenses were respectively (2.5±0.5)days, (7.3±1.2)days and (2.7±0.3)×104 yuan. Of 2 429 patients, 367 removed nasobiliary catheter at 3-7 days postoperatively, 207 removed urinary catheter at 3-6 weeks postoperatively, and 125 removed common bile duct stent through duodenoscope port at 1-4 months postoperatively. (3) Postoperative short-term complications: incidence of postoperative short-term complications in 2 429 patients was 6.711%(163/2 429). ① Ninety-four patients with bile leakage were cured after drainage and symptomatic and supportive treatment. ② Of 29 patients with residual stones: 25 with residual stones of common bile duct were cured by stone extraction using endoscopic sphincterotomy of duodenal papilla, and 4 with residual stones of intrahepatic bile duct didn′t receive treatment. ③ One patient died at 15 days after surgery for pancreatic cancer. ④ Of 39 with postoperative other complications: 2 with postoperative hemorrhage were cured by laparoscopic reoperation; 12, 19 and 3 were respectively complicated with postoperative inflammatory stenosis of duodenal papilla induced to short-term obstructive jaundice, mild acute pancreatitis and stress ulcer bleeding of upper digestive tract, and they were improved by endoscopy or non-operation treatment; 2 with stenosis of bile duct didn′t receive treatment; 1 had a miss ligation at bending section of front zone of nasobiliary catheter, and ligation was removed by endoscopic retrograde cannulation of the pancreatic at 19 days postoperatively. (4) Follow-up situation: of 2 429 patients, 1 749 were followed up for 3-12 months, with a median time of 6 months. During the follow-up, of 1 749 patients, 2 had mild stenosis in the primary closure area of common bile duct incision and 1 had stenosis of duodenal papilla, they were not treated, and other patients didn′t have related complications. Conclusion Controlling strictly the operative indication, primary closure of common bile duct in LCBDE is safe and feasible, with satisfactory clinical outcomes. Key words: Hepatolithiasis; Cholelithiasis; Obstruction of biliary tract; Common bile duct exploration; Primary closure; Laparoscopy

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

新生児・乳児梨状窩瘻に対する内視鏡的 cannulation を利用した瘻管完全摘出法

新生児・乳児梨状窩瘻に対する内視鏡的 cannulation を利用した瘻管完全摘出法

Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: One single center's experience.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Results of ERCP in those patients varied.The aim of our study was to evaluate the safety and effectiveness of various endoscopes-assisted ERCP in patients with surgically altered anatomy.Fifty-two patients with Billroth II reconstruction (group A), 20 patients with subtotal or total gastrectomy with Roux-en-Y anastomosis (group B), 25 patients with pancreatoduodenectomy or Roux-en-Y hepaticojejunostomy reconstruction (group C) were included. Gastroscope, duodenoscope, colonoscope, and double-balloon enteroscope were used.The endoscope insertion success rate of groups A, B, C was 96.2% (50/52), 85.0% (17/20), 80% (20/25), respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.068). The mean insertion time was 36.7, 68.4, and 84.0 minutes, respectively. One-way ANOVA showed that the insertion time of group C was significantly longer than that of groups B and C (both P <0.001). The endoscopic cannulation success rates of groups A, B, C were 90%, 82.4%, and 100%, respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.144). The mean cannulation time was 19.4, 28.1, and 20.4 minutes, respectively. One-way ANOVA showed that the cannulation time of group B was longer than that of groups A and C (P <0.001, P = 0.001, respectively). In total, 74 patients with successful biliary cannulation achieved the therapeutic goal; thus, the clinical success rate was 76.3% (74/97).Our study showed that ERCP in patients with surgically altered anatomy was safe and feasible.

Gastrostomy tube replacement by endoscopic cannulation of a narrowed previous tube site.

Percutaneous endoscopic gastrostomy is warranted when oral feeding is not feasible. Indications include central nervous system disorders, head trauma and occasionally malignancies of upper gastrointestinal tract. If tube replacement after accidental dislodgement is delayed, the track may become narrowed. This may compromise routine replacement and may require repeated procedures. Occasionally no further external dilation is possible. We describe the endoscopic cannulation of the previously used track after its internal cannulation and subsequent external dilation and the successful replacement of a gastrostomy tube.

Comparison between loop-tip guidewire-assisted and conventional endoscopic cannulation in high risk patients.

Background: The guidewire biliary cannulation (GWC) technique may increase the cannulation rate and decrease the risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of our multicenter prospective randomized controlled trial was to determine if the use of an atraumatic loop-tip guidewire reduces the rate of post-ERCP pancreatitis (PEP) compared with the standard contrast-assisted cannulation (CC) technique. Methods: From June 2012 to December 2013, a total of 320 patients who had a naïve papilla and were referred for ERCP were randomly assigned to the GWC group (n = 160) or the CC group (n = 160). GWC or CC was randomly used. In cases of failed cannulation in both arms after crossover, biliary access was attempted with alternative techniques (e. g., dual-wire technique, pancreatic duct stenting, precut). Results: The biliary cannulation rates were 81 % in the GWC group and 73 % in the CC group (P = n. s.). Following crossover, cannulation was successful in 8 % and 11 % of patients in the GWC and CC groups, respectively. With use of an alternative technique, the cannulation rates were 98 % in the GWC group and 96 % in the CC group, respectively. The rates of PEP were 5 % in the GWC group and 12 % in the CC group (P = 0.027). The post-interventional complication rates did not differ between the two groups. Conclusion: GWC with the new wire guide is associated with a lower rate of PEP in comparison with the CC technique.Clinical trial reference number: NCT01771419

‘Double guidewire in one catheter’ method for a difficult endoscopic retrograde cholangiopancreatography cannulation (with video)

‘Double guidewire in one catheter’ method for a difficult endoscopic retrograde cholangiopancreatography cannulation (with video)

Complications of ERCP

Complications of ERCP

Pancreatic duct stenting for acute biliary pancreatitis with difficult endoscopic cannulatio

Objective To evaluate pancreatic duct stenting for acute biliary pancreatitis with difficult endoscopic cannulation. Methods From January 2005 to December 2009, in patients with acute biliary pancreatitis who needed intervention of emergency ERCP, a total of 81 cases were found to be with difficult cannulation and were randomly divided into either treatment group （ n = 35 ） to receive pancreatic duct stenting, or control group （ n = 46 ） to receive the procedure without pancreatic duct stenting. All patients were treated with same medication, and the pancreatic stents were removed after stabilization at a mean time of 11 days after ERCP. All patients were followed up for 3 months after discharging from the hospital. Results There was no significant difference between two groups in regarding of mean age, the time from onset to endoscopy, Glasgow scores and relevant biochemical parameters, but the occurrence of postoperative complications was significantly higher in control group than that of the treatment group （ 17. 39% vs. 5. 71%, P 〈 0. 01 ）. Conclusion Pancreatic duct stenting is a safe and bridging procedure for patients with acute billiary pancreatitis, which can also reduce complications. Key words: Pancreatitis ; Stents ; Cholangiopancreatography, endoscopic retrograde

Strategies for difficult endoscopic cannulation of major duodenal papilla

Objective To improve the success rate of selective cannulation of major papilla during endoscopic retrograde cholangiopancreatography （ERCP）. Methods When cannulation failed with conven- tional methods, ultra-fine guide wire combined with taped cannulation, precut papillotomy, guide wire pancreatic occupation technique, and percutaneous transhepatic eholangial drainage （PTCD） assisted rendezvous technique was applied to improve the success rate of eannulation of major papilla. Results A total of 5743 patients received ERCP in our hospital during last 5 years, with a success rate of cannulation of major papilla at 98.6% （5664/5743）. For 396 patients with difficult cannulation under conventional methods, ultra fine guide-wire technique was applied in 20, pancreatic occupation technique in 67, precut technique in 294 and PTCD assisted rendezvous technique in 15, which achieved a success rate of 80. 0% （317/396）. Conclusion Application of combined techniques according to the features of papilla can increase success rate of difficult cannulation. Key words: Cholangiopancreatography, endoscopic retrograde ; Intubation ; Bile ducts ; Duodenal papilla

Biliary cannulation facilitated by endoscopic clip assistance in the setting of intradiverticular papilla

Endoscopic cannulation of the biliary tract may be challenging in cases with juxtapapillary, duodenal diverticula. A 70-year old woman admitted to the hospital with the diagnosis of choledocholithiasis and acute cholangitis. She was placed on antibiotic treatment and parenteral fluid resuscitation. On endoscopic retrograde cholangiopancreatography, the papilla could not be cannulated because of the duodenal diverticulum. Various attempts at biliary cannulation failed. Endoscopic clips were used for evertion and fixation of a partially everted papilla from the diverticulum and for securing it in an orientation that allowed direct cannulation of the biliary tree. Cholangiography demonstrated multiple calculi within the choledochus. She was discharged from the hospital on the 9th day following endoscopic retrograde cholangiopancreatography in good condition. With this report, we aimed to remind physicians that the clip assisted method is a safe and effective technique for pancreatic and/or biliary cannulation, and should be preferred in patients in whom cannulation is extremely difficult due to large periampullary diverticula..

Significance of cytomorphological and microbiological examination of bile collected by endoscopic cannulation of the papilla of vater

Bile analysis yields important information such as "biliary microlithiasis" and biliary tract colonization by microorganisms like Salmonella typhi or paratyphi, Escherichia coli, etc., which may progresses to cholelithiasis and have been found to have a role in the development of gallbladder cancer in India. To perform microscopic, cytomorphological and microbiological examination of bile collected during endoscopic retrograde cholangiopancreatography in patients with benign and malignant lesions of the gallbladder. Bile was collected from 48 patients by a catheter inserted through the cystic duct during endoscopic retrograde cholangiopancreatography. Direct microscopy and grading of crystals was performed. Smears prepared from centrifuged deposits were stained with Giemsa, Papanicolaou stain and Gram's stain for cytological and microbiological examination. Special staining for Helicobacter pylori was performed using Loeffler's Methylene blue and Warthin Starry stain. The rest of the sample was used for culture and complete microbiological examination. Thirty-six patients had inflammatory lesions while 12 had malignant lesions. Crystals were observed in 93% of the cases, 13 (28.8%) had only cholesterol crystals, three (6.6%) had bilirubinate and 29 (64.4%) had both cholesterol and bilirubinate crystals. Smears from the centrifuged deposit mainly showed coccoid or cocobacillary bacteria on Gram's staining (81.3%). Five of 12 (41.6%) malignant cases showed epithelial atypia while none of the benign or inflammatory lesions showed such a change in hematoxylin and eosin and Pap-stained smears. Microbiologic analysis showed Staphylococcus aureus (14%), S. saprophyticus (5.5%), Peptococcus (5.5%), Peptostreptococcus (5.5%), Proteus mirabilis (5.5%), E. coli (17%), Enteorbacter cloacae (5.5%) and H. pylori (2.8%). Complete microscopic and microbiological examination of bile directly obtained from the common bile duct during endoscopic retrograde cholangiopancreatography yielded good results as fresh samples could be analyzed. It may help in diagnosis of many gallbladder lesions in early stages, thereby reducing the morbidity and mortality.

Laparoscopic resection of pancreatic islet cell tumors

To summarize the surgical technique and clinical experience of total laparoscopic resection of the pancreatic islet cell tumors. From July 2002 to December 2007, 30 cases including 12 males and 18 females were diagnosed as pancreatic islet cell tumor. There were at least one positive imaging examination of each patient preoperatively. The location of the tumors included 4 in proximal pancreas and 26 in distal pancreas. The tumors were successfully found and removed in 28 cases and unsuccessfully located in the other 2 cases. The procedures included local resections in 13 cases and distal pancreatectomies in 15 cases (spleen reserved in 7 cases). The mean operation time was 165 min (range, 65 - 465 min). The mean blood loss was 145 ml (range, 50 - 800 ml). Pancreatic leakage occurred in 3 cases, 2 of which were cured conservatively. And the other one were cured by endoscopic retrograde cannulation of the pancreatic duct. The mean postoperative hospital stay was 5.6 days (range, 2 - 17 d). There were no conversions and death. After follow up of (14.3 +/- 16.7) months (range, 4 - 62 months), there were no recurrences. Total laparoscopic resection is a safe and effective method for pancreatic islet cell tumors.

Endoscopic biliopancreatic investigations and therapy

The management of most biliopancreatic diseases benefits from endoscopic treatment. Forty years after the first endoscopic cannulation of the ampulla of Vater, the overall effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated using the quality assurance programs that have recently been developed for gastrointestinal endoscopy, including ERCP. Such evaluation does not mean simply reporting therapeutic success and complication rates; rather, it involves a complex analysis of the entire gastrointestinal unit, of the medical practises, and of patient satisfaction. The overall quality of ERCP has been analysed and many quality deficits identified, even in referral centres. Training for such a specialised procedure is difficult and expensive. Competence in ERCP requires as many as 200 ERCP procedures. Quality assurance programs can help to improve the overall quality of endoscopic practise, including training of young endoscopists.

Bile leak following living donor liver transplantation: Clinical efficacy of percutaneous transhepatic treatment

Percutaneous transhepatic treatment may be effective in patients with bile leaks after living donor liver transplantation (LDLT). We therefore evaluated the clinical efficacy of percutaneous transhepatic treatment for biliary leaks in adult-to-adult LDLT recipients. Twenty-three LDLT recipients underwent percutaneous transhepatic treatment to manage bile leaks. The treatment included percutaneous transhepatic biliary drainage (PTBD) and drainage of perihepatic biloma. In patients with combined biliary strictures, balloon dilation was usually performed. Indications for PTBD included patients who had a Roux-en-Y hepaticojejunostomy (n = 9), failed endoscopic cannulation of bile ducts (n = 6), a bile leak refractory to endoscopic management (n = 5), and a poor general condition for endoscopic management (n = 3). Clinical success was achieved in 16 of 23 (70%) patients. PTBD catheters were removed from 14 of the 16 patients with clinical success at a median of 8 months (range, 3-42 months) after initial PTBD. Aside from 1 patient with intrahepatic pseudoaneurysms, there were no major complications. During a median follow-up period of 42 months (range, 3.0-84 months), 6 (43%) of the 14 patients who underwent PTBD catheter removal experienced jaundice or cholangitis due to biliary anastomotic stricture at a median of 26 months (range, 22-49 months) after PTBD catheter removal. In conclusion, percutaneous transhepatic treatment for biliary leaks in adult-to-adult LDLT recipients is clinically effective. This approach is a valuable alternative for treating bile leaks resistant to or inaccessible by endoscopic methods. However, further investigations are needed to minimize the duration of treatment and biliary strictures following PTBD catheter removal.

Pharmacological prevention of post-ERCP pancreatitis—An everlasting dream?

In 1965 two radiologists, Rabinov and Simon [1], reported the first successful per oral cannulation of the papilla of Vater using a fluoroscopically guided catheter, rendering a non-operative pancreatography possible. At that time the surgical procedure of pancreatography was dangerous and difficult requiring not only a laparotomy but also duodenotomy and the radiological technique was clumsy, blind and time-consuming. Due to the improved flexibility of instruments, William S. McCune of George Washington University reported his experience with successful endoscopic cannulation of the papilla of Vater in 1968 [2].