Endoscopic Retrograde Cholangiopancreatograpy Research Articles

Diagnosis and minimally invasive treatment of type III choledochal cysts

BackgroundType III choledochal cysts (CCs) are the rarest and least well-characterized of the five variants of biliary cysts. Only a few relevant studies have been conducted and a gold standard treatment for type III CCs is still lacking because of their scarcity. An unusual case of type III CC with choledochocele at the end of the distal common bile duct (CBD) with no bulging of the duodenum is presented here.Case presentationA 61-year-old woman presented to our department with repeated upper abdominal pain for one year. Laboratory examination revealed abnormal liver function and a slight increase in the white blood cell (WBC) count and proportion of neutrophils. In an MRCP of the patient, the distal CBD was found to have a cystic structure indicative of a type III CC. Endoscopic retrograde cholangiopancreatograpy (ERCP) revealed cystic findings compatible with Todani type III CCs. However, duodenoscopy did not show a bulge in the duodenum so laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy were performed. In her 6-month follow-up, the patient reported that recovery from the operation was uneventful.ConclusionsERCP has become the gold standard for diagnosing type III CCs. Type III CCs can be treated minimally invasively with laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy.

Duodenoscope-Acquired Infections: Risk Factors to Consider

AbstractIn the wake of highly publicized duodenoscope-associated outbreaks caused by multidrug-resistant organisms (MDRO), a herculean effort was made to understand the conditions that led to these transmission events. Although there is now a clearer picture on how these outbreaks happened, there are still significant data gaps when it comes to understanding the rate of duodenoscope-acquired infections (DAIs), especially in nonoutbreak situations. Recent publications indicate that DAIs are still occurring and suggest that infection rates are higher than currently believed. Given this data gap, it is important to identify those patient populations that are most at risk of postprocedure infection, so that appropriate infection control measures may be implemented. Although those patients receiving antibiotic prophylaxis are most at risk for infection, there are additional risk factors that should be considered. For the purposes of this review, risk factors for infection were divided into three broad categories as follows: (1) those that increase patient susceptibility to infection, (2) those related to the endoscopic procedure, and (3) those factors that put reusable duodenoscope inventories at risk of contamination. Infection risk is a complex interaction between the immune status of the patient, the characteristics of the infectious agent (antibiotic sensitivity, virulence factors, and epidemiology), and the environment of care. Because of this complexity, any assessment of the risk of infection should be performed on a case-by-case basis. There is a dearth of information on infection risk for those patients undergoing endoscopic retrograde cholangiopancreatograpy (ERCP), especially in the context of the development and implementation of new device technology, and new endoscopic procedures that are increasing in complexity. This narrative review was developed using the Medical Subject Heading (MeSH) terms to perform an electronic search in PubMed with the goal of generating a summary of the patient, procedural, and duodenoscope-associated factors that increase the risk of infection in patients undergoing ERCP. This review provides practical information regarding the segmentation of ERCP patients by infection risk, so that endoscopists can make informed decisions about the risk benefits of using enhanced duodenoscope technologies in the care of their patients.

Initial Experience of ERCP-Guided Radiofrequency Ablation as the Primary Therapy for Inoperable Ampullary Carcinomas

Endoscopic ablation of duodenal ampullary malignancy has not been fully assessed. The study aimed to evaluate the efficacy and safety of Endoscopic retrogradecholangiopancreatograpy (ERCP)-guided radiofrequency ablation (RFA) for inoperable ampullary cancer. Patients with inoperable ampullary cancer underwent ERCP-guided RFA from January 2012 to August 2017. RF energy (7-10W) was delivered using bipolar RFA electrodes under endoscopic guidance. RFAs were repeated every 1-3months until visible tumor was eliminated. All patients were followed up till June 2018, during which any biliary event was noted and managed endoscopically. Twenty-three patients underwent a median of two RFA sessions (range 1-6) at a median interval of 56 (range 35-90) days. Among 18 (78.3%) patients who received endoscopic re-evaluations, nine patients showed no remaining lesion and nine showed more than 50% tumor size reduction. During a median follow-up duration of 517days (range 60-1836days), eight (34.8%) patients required endoscopic re-interventions. The re-intervention rate at 6months after RFA was 36.8%. Twelve patients were alive, among whom six required no biliary stenting. The accumulative mean survival was 1081 (95% CI 757.8-1404.0) days. RFA-related adverse events occurred in four cases (7.7%) including mild pancreatitis (1), bleeding (1), and late distal biliary stenosis (2). This pilot study shows that ERCP-guided RFA is safe to use and able to reduce tumor volume and re-interventions in patients with inoperable ampullary cancer.

Impact of Introduction of Endoscopic Ultrasound on the Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatograpy in a Community Hospital

Impact of Introduction of Endoscopic Ultrasound on the Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatograpy in a Community Hospital

Management of a massive choledochal cyst in a 12 year-old girl: Which imaging modalities should be performed preoperatively?

Abstract A previously well 12 year-old girl presented to the emergency department with a three-day history of fatigue, pruritus, and epigastric discomfort. Abdominal ultrasound revealed a cystic mass in the right upper quadrant measuring 17.0 × 13.2 × 11.7 cm. Magnetic resonance imaging (MRI) confirmed the diagnosis of a choledochal cyst and hepatobiliary iminodiacetic acid (HIDA) scintigraphy demonstrated a communication between the cyst and biliary tree. Percutaneous cholangiography was also performed but did not provide additional diagnostic information. The patient was brought to the operating room a few days later for open resection of the choledochal cyst, cholecystectomy, and Roux-en-Y hepaticojejunostomy. Frozen sections were obtained to ensure complete excision of cyst mucosa. The patient continues to do well more than 18 months post-operatively with no signs of recurrent inflammation or malignancy. Multiple imaging modalities may be used preoperatively to assess the anatomy and subtype of choledochal cysts. The role of invasive options, such as percutaneous cholangiography or endoscopic retrograde cholangiopancreatograpy (ERCP), remains limited and unclear. Here, we present a potential imaging algorithm to assist with preoperative workup and avoid invasive diagnostic procedures whenever possible.

PTH-007 Fully-covered metal stents in the endoscopic treatment of malignant distal biliary obstruction – review of outcome in a large acute hospital: Abstract PTH-007 Table 1

Introduction Endoscopic Retrograde Cholangiopancreatograpy (ERCP) and stent insertion is a mainstay of treatment for malignant distal biliary obstruction. Choice of stent remains controversial with plastic, uncovered and more recently introduced fully-covered self-expanding metal stents (SEMS) in use. Our aim was to examine the outcome of ERCP stent insertion using different stent types, in a large acute hospital. Method We performed retrospective review of all cases of ERCP stent insertion in our unit for malignant distal biliary obstruction over a 5 year period to September 2013. Outcome data were collected for each case at 3, 6 and 12 months following stent insertion and statistical analysis performed using Fisher’s exact test. Results 301 stents were placed for confirmed malignant obstruction in 237 patients; median age 73 years (range 35–98). Cumulative stent occlusion rates were significantly higher with plastic stents versus fully-covered SEMS at 3 months (15% vs 4%, p = 0.006), 6 months (30% vs 8%, p = 0.001) and 12 months (37% vs 12%, p = 0.001). Ascending cholangitis was significantly more frequent following plastic stent insertion than fully-covered SEMS at 6 months (20% vs 9%, p = 0.027) and 12 months (23% vs 12%, p = 0.017). There were no significant differences in rates of stent migration or cholecystitis between the stent types (Table 1), or in survival at 12 months. Compared with covered SEMS, unplanned repeat ERCP was significantly more likely following insertion of a plastic stent (32% vs 6%, p Conclusion In this case series plastic stents were associated with significantly greater rates of stent occlusion and ascending cholangitis than fully-covered SEMS. There were no significant differences in rates of stent migration or gallbladder complications. Overall need for repeat unplanned ERCP was markedly reduced by fully-covered SEMS placement. Disclosure of interest None Declared.

Safety and efficacy of endoscopic retrograde cholangiopancreatography for common bile duct stones in liver cirrhotic patients.

In order to investigate the safety and efficacy of endoscopic retrograde cholangiopancreatograpy (ERCP) in liver cirrhosis patients with common bile duct stones, we retrospectively analyzed data of 46 common bile duct stones patients with liver cirrhosis who underwent ERCP between 2000 and 2008. There were 12 cases of Child-Pugh A, 26 cases of Child-Pugh B, and 8 cases of Child-Pugh C. 100 common bile duct stones patients without liver cirrhosis were randomly selected. All the patients were subjected to ERCP for biliary stones extraction. The rates of bile duct clearance and complications were compared between cirrhotic and non-cirrhotic patients. The success rate of selective biliary cannulation was 95.6% in liver cirrhotic patients versus 97% in non-cirrhotic patients (P>0.05). The bile duct clearance rate was 87% in cirrhotic patients versus 96% in non-cirrhotic patients, but the difference was not statistically significant. Two liver cirrhotic patients (4.35%, 2/46) who were scored Child-Pugh C had hematemesis and melena 24 h after ERCP. The hemorrhage rate after ERCP in non-cirrhotic patients was 3%. The hemorrhage rate associated with ERCP in Child-Pugh C patients was significantly higher (25%, 2/8) than that (3%, 3/100) in non-cirrhotic patients (P<0.01%). There was no significant difference between these two groups in the rate of post-ERCP pancreatitis (PEP) and cholangitis. ERCP is safe and effective for Child-Pugh A and B cirrhotic patients with common bile duct stones. Hemorrhage risk in ERCP is higher in Child-Pugh C patients.

Unexpected anomaly of the common bile duct and pancreatic duct

Variations in the bile duct and pancreatic duct opening are related to the process of rotation and recanalization during embryologic development. Complete non-union of distal common bile duct and pancreatic duct gives rise to double papillae of Vater. The separation of the drainage of the main pancreatic duct and bile duct can be appreciated by careful assessment at the time of endoscopic retrograde cholangiopancreatograpy. The cranial orifice is a bile duct opening, whereas the caudal orifice is a pancreatic duct opening. The separate orifice finding can be confirmed by cholangiogram and pancreatogram with no communication between the two orifices. Endoscopists should be aware of this rare variant because late recognition can result in unnecessary manipulation and contrast injections of the main pancreatic duct and biliary cannulation failure.

Extrahepatic ducts neoplasms are correlating with higher incidence of post endoscopic retrograde cholangiopancreatograpy pancreatitis

Post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Causes of PEP are not completely established but there are several risk factors.

Safety and efficacy of endoscopic retrograde cholangiopancreatograpy in very elderly patients

Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; <65, 65-79 and >or=80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients

Percutaneous Transhepatic Lithotripsy With the Holmium

Fourteen patients who failed at least 1 endoscopic retrograde cholangiopancreatograpy attempt underwent Holmium laser biliary lithotripsy between 2003 and 2007. Ten had prior biliary surgeries, 7 harbored multiple stones, and 6 had common bile duct strictures. Mean age at surgery was 63.6 years (50 to 80 y), biggest stone burden 30 mm, mean operative time 58.4 minutes (24 to 105), and stone free rate 85.7%. One patient had postoperative bleeding from the choledochostomy tube that eventually resolved spontaneously and 3 patients had postoperative cholangitis managed conservatively. Neither conversions to open surgery nor mortality was recorded. Two patients were diagnosed with cholangiocarcinoma missed by previous endoscopic retrograde cholangiopancreatograpy. After a mean follow-up of 18.9 months (2 to 43) no de novo strictures were recorded. Percutaneous choledochoscopy with holmium laser lithotripsy is a safe and effective minimally invasive technique to treat complex biliary stone disease and may preclude high-risk open biliary tract surgery.

The effects of contrast agent and intraductal pressure changes on the development of pancreatitis in an ERCP model in rats

Although there are various experimental pancreatic models in animals, only a few studies have evaluated how intraductal pressure and contrast agent affect the development of pancreatitis after endoscopic retrograde cholangiopancreatograpy (ERCP). The rats were randomly divided into seven groups (n = 8/group). The rats in all groups underwent laparotomy and their biliopancreatic ducts were cannulated transduodenally using a 24G catheter. In the control group, group 1, the biliopancreatic ducts of the rats were not infused with any fluid. The biliopancreatic ducts of the rats in groups 2, 3, and 4 were infused with 0.5 ml isotonic NaCl solution at 10, 2, and 50 mmHg, respectively. Groups 5, 6, and 7 were given 0.5 ml of 50% diluted contrast agent at 10, 25, and 50 mmHg, respectively. The serum amylase, aspartate aminotransferase (AST), lactic dehydrogenase (LDH), and C-reactive protein (CRP) were measured 24 h after the procedure. Pancreatic tissue was also evaluated histopathologically. Pancreatitis due to the contrast agent was noted when comparing the low pressure isotonic NaCl group and the low pressure contrast group (p < 0.05). Based on serum amylase and CRP values, there was a positive correlation between the severity and frequency of acute pancreatitis and pressure (p < 0.01). AST and LDH levels increased in all of the groups that underwent the procedure; however, no correlation was detected with increasing pressure or with the use of contrast agent (p > 0.05). Both pancreatic edema and the inflammatory cell infiltration score were elevated in isotonic NaCl and contrast group (p < 0.05); however, necrosis was not significantly changed (p > 0.05). The results of this study suggest that the main mechanism for preventing pancreatitis after ERCP is to minimize trauma to the pancreatic canal, to cannulate the pancreas only when it is necessary, and to give contrast agent under low pressure when it is needed.

Endoscopic Retrograde Cholangiopancreatograpy (ERCP) in the Evaluation and Management of Abdominal Pain in Children: Experience From a Tertiary Care Center

Introduction: Previous studies have shown ERCP to be feasible and safe in the pediatric population. Aim: To determine the utility of ERCP in the diagnosis and management of abdominal pain in children. Methods: Children (≤18 years) undergoing ERCP for evaluation of abdominal pain at one tertiary care center (1996-2003) were identified using an endoscopy database and retrospectively studied. Abdominal pain suggestive of pancreatobiliary origin was classified as Type I if associated with abnormal liver tests and/or abnormal pancreatic enzymes.