Endoscopic Sphincterotomy In Patients Research Articles

The efficacy and safety of endoscopic sphincterotomy in patients with Sphincter of Oddi dysfunction: a systematic review and meta-analysis.

Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.

Comprehensive review on small common bile duct stones.

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

A novel sphincterotome facilitates endoscopic sphincterotomy in patients with Roux-en-Y gastrectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) using a short-type single-balloon enteroscope (short SBE) (SIF-H290; Olympus Medical Systems, Tokyo, Japan), with a working length of 152 cm and a working channel diameter of 3.2 mm, has been reported to be effective in patients with surgically altered anatomy (SAA) [1] [2] [3]. However, endoscopic sphincterotomy (ES) in such patients is challenging, as the appearance of the papilla is inverted and the position is frequently tangential, which makes visualizing the correct incision direction difficult. Despite the effectiveness of reported devices, they do not always achieve the correct incision direction [4] [5].

Direct oral anticoagulants increase bleeding risk after endoscopic sphincterotomy: a retrospective study

BackgroundBleeding can be a serious adverse event of endoscopic sphincterotomy (EST). However, the risk of EST bleeding between direct oral anticoagulant (DOAC) users and those who received no antithrombotic agents has not been clarified. This study analyzed the risk factors for bleeding after EST in patients on DOAC and evaluated the Japan Gastroenterological Endoscopy Society (JGES) guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment.MethodsWe retrospectively analyzed 524 patients treated with EST who received DOAC or no antithrombotic drug from May 2016 to August 2019. We investigated the risk factors for bleeding. DOAC was typically discontinued for ≤ 1-day based on the JGES guideline. Although DOAC therapy recommenced the next morning after EST in principle, the duration of DOAC cessation and heparin replacement were determined by the attending physician based on each patient’s status.ResultsThe number of patients on DOAC (DOAC group) and those not on antithrombotic drug (no-drug group) was 42 (8.0%) and 482 (92.0%), respectively. DOAC was discontinued for ≤ 1-day in 17 (40.0%) patients and for > 1-day in 25 (60.0%). Of the 524 patients, 21 (4.0%) had EST bleeding. The bleeding rate was higher in the DOAC group (14.0%) (p = 0.004). Multivariate analysis showed that bleeding occurred more frequently in patients on DOAC (odds ratio [OR] 3.95, 95% confidence interval [CI] 1.37–11.4, p = 0.011), patients with low platelet counts (< 100,000/µl) (OR 6.74, 95% CI 2.1–21.6, p = 0.001), and elderly patients (> 80 years old) (OR 3.36, 95%CI 1.17–9.65, p = 0.024).ConclusionsDOAC treatment, low platelet count, and old age (> 80 years old) are risk factors for EST bleeding. Although the bleeding incidence increased in patients on DOAC who received antithrombotic therapy according to the JGES guidelines, successful hemostasis was achieved with endoscopy in all cases, and no thrombotic events occurred after cessation of DOAC. Thus, the JGES guidelines are acceptable.

Biliary stent placement without endoscopic sphincterotomy in patients with common bile duct stones

Biliary stent placement without endoscopic sphincterotomy in patients with common bile duct stones

The Place of Early Period ERCP in Acute Biliary Pancreatitis?

Objective: Acute pancreatitis; It can be defined as a clinical picture that occurs as a result of non_bacterial inflammation of the pancreas and may progress with pathological findings. For years, various studies have been conducted on the use of Endoscopic Retrograde Pancreatic Cholangiography and Endoscopic Sphincterotomy for therapeutic purposes in Acute Pancreatitis. For years, various studies have been conducted on the use of Endoscopic Retrograde Pancreatic Cholangiography and Endoscopic Sphincterotomy for therapeutic purposes in Acute Pancreatitis.&#x0D; In our study, we aimed to examine either the effectiveness of Endoscopic Retrograde Pancreatic Cholangiography and Endoscopic Sphincterotomy in patients with mild severity and how the endoscopic procedure affects the course of the disease.&#x0D; &#x0D; Material and Method: In this study, patients with mild pancreatitis were selected among the patients who applied to the Department of General Surgery, of Atatürk University Faculty of Medicine and diagnosed with acute biliary pancreatitis (ABP).&#x0D; After the patients were separated according to the mild pancreatitis table, early (within 72 hours) and late period, they were randomly selected to be performed Endoscopic Retrograde Pancreatic cholangiography and Endoscopic Sphincterotomy. 59 patients were detected in this way.&#x0D; &#x0D; Results: Twelve (20.3%) of the patients included in our study were male, and 47 (79.7%) were female, and their ages were between 25-75 years (mean 64.3 years). Two groups were created in order to perform ERCP/ES in the early and late periods. All patients had acute onset abdominal pain and serum amylase levels have been ranging between (1012-7660 UI/L). &#x0D; &#x0D; Conclusion: Consequently, we can say that; in patients with mild acute biliary pancreatitis, there is no significant difference in the early (first 72 hours) ERCP/ES results compared to the results of patients with ERCP/ES in the late period.

Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

BackgroundEndoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.MethodsWe analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990–2019), Embase (1990–2019), and Cochrane (1990–2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.ResultsWe retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27–0.53; P < 0.00001; I2 = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26–0.38; P < 0.00001; I2 = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52–1.02; P = 0.07; I2 = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24–0.32; P < 0.00001; I2 = 17%).ConclusionEarly cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

Self-expandable metallic stent placement above the papilla without endoscopic sphincterotomy in patients with distal malignant biliary obstruction.

Background and study aims The best method for endoscopic placement of self-expandable metallic stents (SEMS) for distal malignant biliary obstruction (MBO) has not yet been determined. The aim of this study was to evaluate how SEMS placement above the papilla and without endoscopic sphincterotomy (EST) impacts the time to recurrent biliary obstruction (RBO) in patients with distal MBO. Patients and methods We retrospectively reviewed data for 73 consecutive patients with unresectable distal MBO who underwent endoscopic SEMS placement for the first time at our institution between April 2014 and March 2016. We compared time to RBO of SEMS placement above the papilla (intraductal placement) with SEMS placement across the papilla (transpapillary placement). In the intraductal placement group, we also compared time to RBO of placement without EST with placement with EST. Results Endoscopic SEMS placement was performed in 30 patients with intraductal placement and in 43 patients with transpapillary placement. The median time to RBO was significantly longer with intraductal placement (307 days) than with transpapillary placement (161 days) ( P = 0.022). Complication rates did not differ between the two groups. In both univariate and multivariate analysis, intraductal placement was an independent factor contributing to prolonged time to RBO. In intraductal placement, time to RBO was significantly longer in SEMS placement without EST than with EST (363 days vs. 227 days, respectively; P = 0.026). Conclusions Intraductal SEMS placement, especially without EST for distal MBO contributed to longer time to RBO.

906 To Cut or Not to Cut – Clinical Efficacy of Endoscopic Sphincterotomy in Recurrent Acute Pancreatitis From Functional Biliary Sphincter of Oddi Disorder: A Systematic Review and Meta-Analysis

INTRODUCTION: Functional biliary Sphincter of Oddi disorder, previously referred to as Sphincter of Oddi Dysfunction, is an established cause of recurrent acute pancreatitis which is defined as two or more episodes of documented acute pancreatitis per year. Data on the efficacy of endoscopic sphincterotomy in preventing future episodes of pancreatitis is limited. We performed a systematic review and meta-analysis to evaluate the clinical efficacy of index endoscopic sphincterotomy in patients with Recurrent Acute Pancreatitis secondary to manometrically proven functional biliary Sphincter of Oddi disorder. Our goal was to assess reduction in episodes of pancreatitis following sphincterotomy, and not to assess chronic pain in these patients. METHODS: We conducted a search of several databases including PubMed, EMBASE, Google-Scholar, Scopus and Cochrane Review (from 1960 to October 2018). Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using Cochran Q statistical test, 95% confidence interval (CI) and I2 statistics. Publication bias was ascertained, qualitatively, by visual inspection of funnel plot and quantitatively, by the Egger test. RESULTS: Our initial search yielded 3201 results. Of 1936 studies screened, 12 met inclusion criteria. A total of 396 patients with recurrent acute pancreatitis and abnormal manometry findings were included from these studies in the final analysis. The interventions performed were as follows: Endoscopic biliary sphincterotomy in 212 (53.5%), endoscopic pancreatic sphincterotomy in 19 (4.8%) and dual biliary and pancreatic sphincterotomy in 165 (41.6%) patients. Technical success ranged from 99 to 100%.The pooled estimate for clinical success following index sphincterotomy was 68.4% (95% CI 57.6-77.4; I2 = 71.4%). Lone endoscopic biliary sphincterotomy was successful in 43/60 (71.6%) patients. The pooled estimate for proportion of patients with post-ERCP pancreatitis was 23.2% (95% CI 16.6-31.4; I2 = 44.4%). The follow up duration ranged from 6 to 120 months. There was no evidence of publication bias, based on funnel plot analysis and Egger’s test. CONCLUSION: Our study highlights the utility and clinical efficacy of endoscopic sphincterotomy in patients with recurrent acute pancreatitis secondary to Functional biliary Sphincter of Oddi disorder. We conclude that 68.4% of patients improved after endoscopic sphincterotomy and that it can be considered in patients with recurrent acute pancreatitis.

44 Trends in ERCP Utilization for Sphincter of Oddi Dysfunction: The Real World Impact of EPISOD and Rome IV

INTRODUCTION: The widespread clinical adaptation of landmark clinical trials and practice guidelines is often unclear. The EPISOD trial, a randomized, sham-controlled trial, demonstrated that endoscopic sphincterotomy in patients with Type III Sphincter of Oddi dysfunction (SOD) did not result in clinical improvement. The results of this study were presented at the 2013 National Meeting of the American College of Gastroenterology and published in May 2014. Subsequently, the updated 2016 Rome IV criteria removed Type III SOD from the functional biliary disorder classification. Though patients with Type III SOD make up a minority of all SOD patients, we aimed to assess the utilization of ERCP for patients with SOD in a large population database from 2012–2017. METHODS: We searched electronic health record (EHR)-based disparate data from a cloud-based dataset which incorporates over 300 individual hospitals in the United States (Explorys Inc, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a first-ever diagnosis of “disorder of Sphincter of Oddi” or “spasm of Sphincter of Oddi” annually from 2012–2017. Because the dataset uses SNOMED codes, it was not feasible to sub-classify the types of SOD. Stratified by year, we identified the proportion of patients undergoing ERCP with sphincterotomy and those receiving tricyclic antidepressants (TCA). A Mantel-Haenszel test was used. RESULTS: The number of index cases of SOD and rates of ERCP utilization are outlined in Table 1. From 2013 (the presentation of EPISOD data) to 2016, there was a significant trend demonstrating lower rates of ERCP for newly-diagnosed SOD (P = 0.018). A divergent increase in TCA utilization was concomitantly seen from 2013–2015, but the trend was not statistically significant (P = 0.29). Following the publication of the ROME IV criteria, rates of ERCP utilization for newly-diagnosed SOD significantly increased (P = 0.048) (Figure 1). CONCLUSION: Following the presentation of the EPISOD data, there was a significant 3-year linear decrease in ERCP utilization for all-comers newly-diagnosed with SOD. Concomitantly, a divergent yet insignificant increase in TCA usage was observed. In 2016, after the Rome IV criteria narrowed the diagnosis of SOD, an expected increase in ERCP utilization was observed. These findings call for ongoing observation to see if these trends are durable.

Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis.

AimTo compare endoscopic papillary large balloon dilation (EPLBD) alone with EPLBD following endoscopic sphincterotomy (EST) in patients with large and/or multiple common bile duct stones.MethodsWe conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles until July 19, 2018. Complete common bile duct stone (CBDS) removal rate, frequency of mechanical lithotripsy (ML) usage, total procedure time and intra- and postoperative adverse events were analyzed. We used RevMan 5.3 to perform the pooled analyses.ResultsSeven RCTs matched the selection criteria. A total of 369 patients underwent EPLBD alone, and 367 patients underwent EPLBD following EST. Our meta-analysis revealed that there were no significant differences in terms of initial success rate (OR =0.69, 95% CI=0.44–1.09, P=0.11), frequency of ML usage (OR =1.18, 95% CI=0.68–2.05, P=0.55), rate of post-endoscopy pancreatitis (PEP) (OR =0.88, 95% CI=0.43–1.78, P=0.72), total procedure time (MD =1.52, 95% CI=-0.13–3.17, P=0.07), or other intra- and postoperative adverse events between the groups for patients with large and/or multiple CBDSs.ConclusionsEPLBD alone was comparable to EPLBD with prior EST in patients with large and/or multiple CBDSs. Further studies are required to confirm the mechanisms of PEP in patients who accept EPLBD during endoscopic retrograde cholangiopancreatography (ERCP).

Safety of endoscopic sphincterotomy in patients undergoing antithrombotic treatment: a retrospective study

Background:This study investigated the safety of endoscopic sphincterotomy in patients undergoing antithrombotic treatment.Methods:From January 2014 to December 2016, a single-center retrospective study was conducted. Of the 80 patients with naïve papilla receiving antithrombotic treatment who underwent endoscopic sphincterotomy, 76 patients were retrospectively analyzed. We divided the participants into two groups as follows: 45 patients who discontinued antithrombotic treatment (discontinuation group) and 31 patients who continued antithrombotic treatment (continuation group). We evaluated the safety of endoscopic sphincterotomy in patients with naïve papilla who received antithrombotic treatment.Results:The percentage of patients requiring emergency endoscopic retrograde cholangiopancreatography in the continuation group was significantly higher than that in the discontinuation group (55% vs 11%; p = 0.001). The incidence of adverse events did not differ significantly between the two groups. Neither bleeding nor perforation occurred in either group. The length of hospital stay did not differ significantly between the two groups.Conclusions:Endoscopic sphincterotomy in patients undergoing antithrombotic treatment may be safe if the guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment are followed.

Optimal time of resuming anticoagulant after endoscopic sphincterotomy in patients at risk for thromboembolism: a retrospective cohort study.

One major adverse event of endoscopic sphincterotomy (EST) is bleeding, which could be more common and severe in patients receiving anticoagulant therapy. However, the cessation of anticoagulants for long periods could lead to thromboembolic events. We aimed to evaluate the optimal timing of resumption of anticoagulants after EST in patients at risk for thromboembolism. From January 2010 through October 2017, a retrospective cohort at risk for thromboembolism who had taken warfarin and bridging therapy with heparin around EST from three tertiary hospitals in South Korea was investigated. The primary outcome was to compare the incidence of post-EST delayed bleeding according to the resumption time of anticoagulant. The secondary outcome was to investigate any thromboembolic adverse events related to interruption of the anticoagulant. A total of 96 patients (46 males and 50 females; median age 75years [range, 24-91years]) were enrolled. Overall, the patient numbers of very early (< 24h), early (24-48h), and late resumption (> 48h) of anticoagulant after EST were 56, 23, and 17, respectively. The baseline characteristics were similar between groups except resumption time of anticoagulant. There was no significant difference in the rate of post-EST delayed bleeding (5% in very early group vs. 9% in early group vs. 0 in late group, p = 0.47). The rate of thromboembolic adverse events was significantly higher in the late resumption of anticoagulant group (0 vs. 0 vs. 24%, p < 0.001). There was no significant difference in the incidence of post-EST delayed bleeding according to the resuming time of anticoagulant. Since long cessation of anticoagulant could increase the risk of thrombotic adverse events, the early resumption of anticoagulant seems to be preferred.

Long-term consequences of young patients undergoing endoscopic sphincterotomy: a cohort study

BackgroundAn estimated 15% of the UK population has gallstones. Gallstones in the biliary tree can result in complications such as cholangitis and pancreatitis, which have high morbidity and mortality rates. To prevent such complications, patients can undergo endoscopic sphincterotomy. In our centre, an initial study was undertaken in 2002 to examine outcomes of endoscopic sphincterotomy in patients under the age of 50 years. The aim of our current project was to examine the long-term outcomes until Nov 30, 2015. MethodsData from the study in 2002 were used to identify patients who had undergone endoscopic sphincterotomy between 1984 and 1992. The case notes for these patients were examined to identify outpatient hepatobiliary appointments, serial liver function tests, further investigations or procedures, and development of upper gastrointestinal malignancy or death. Data available included letters and scan reports. In the case of patient death, patients' general practitoners and the coroner's office were contacted. Findings42 patients (32 women [76%]) had undergone endoscopic sphincterotomy between 1984 and 1992. At data collection in November, 2015, mean age was 55 years (SD 6·49), and mean follow-up since endoscopic sphincterotomy was 25 years (SD 2·40). Eight patients (19%) had died, two during the 2002 study, and six between 2002 and 2016. Two deaths were due to pancreatic adenocarcinoma at 8 months and 19 years after endoscopic sphincterotomy. One patient died from hepatocellular carcinoma; no other deaths were due to hepatobiliary or pancreatic disease or malignancy. Ten patients had no follow-up scans, imaging, or outpatient appointments. Of the 32 patients who had follow-up or investigations, two required further endoscopic sphincterotomy for recurrent stone disease at 22 and 25 years after their initial endoscopic sphincterotomy. Three patients had abnormal liver function tests but had no further investigations; three patients underwent further imaging but had no further interventions. InterpretationTo our knowledge this is the first cohort study with such lengthy follow-up after endoscopic sphincterotomy. Our results suggest that endoscopic sphincterotomy is generally a safe and effective long-term treatment option that is not associated with major levels of recurrent disease or malignancy. This was a small single-centre cohort study and future population based studies should be conducted to better evaluate these findings in a larger cohort of patients. FundingNone.

Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents.

Severe bleeding is a potentially lethal complication after endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) for choledocholithiasis. This study aimed to evaluate the impact of antiplatelet agents and anticoagulants on this complication. Patients who underwent EST and EPBD were identified in a Japanese nationwide administrative database covering 1090 hospitals. Adjusting for other potential risk factors, we evaluated the association between oral administration of antiplatelet agents and/or anticoagulants (continuation, discontinuation, and non-use) and clinically significant bleeding within 3 days of the procedure. In total, 61 002 patients were analyzed (EST, 54 493 patients; EPBD, 6509). The rate of severe bleeding was 0.8 % in both groups, but EPBD was performed more frequently than EST in patients with chronic renal failure, liver cirrhosis, and in those receiving antiplatelet agents or anticoagulants. The impact of continuation/discontinuation of antiplatelet agents on severe bleeding was not statistically significant in the EST or EPBD groups. The use of anticoagulants was associated with a statistically significant increase in severe bleeding compared with non-use for EST (1.6 % 27 of 1688 patients vs. 0.8 % 429 of 52 805 patients; adjusted odds ratio [OR] 1.70; 95 % confidence interval [CI] 1.10 - 2.63) and for EPBD (3.0 % [8 of 263 patients] vs. 0.7 % 46 of 6246 patients; adjusted OR 2.91; 95 %CI 1.36 - 6.24). EST and EPBD can be safely performed in patients receiving antiplatelet agents. Users of anticoagulants are at high risk of bleeding, and the periprocedural management of these should be further investigated.

A meta-analysis of preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones

To compare the safety and efficiency of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES) in patients with gallbladder and common bile duct stones. Multiple electronic databases were searched for prospective, randomized, controlled trials on the safety and effectiveness of POES versus IOES. And the outcome parameters of clearance rate, post-procedural complications and hospital stay were analyzed. Five trials with 631 patients (POES, n=318; IOES, n=313) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95% CI: 0.91-1.01; P=0.13), the failure rate of CBD cannulation was significantly higher for IOES (RR 2.54, 95% CI: 1.23-5.26; P=0.01) during endoscopic retrograde cholangiopancreatography (ERCP). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95% CI: 0.94-2.59; P=0.09). However, as compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95% CI: 1.18-4.40, P=0.01). No significant inter-group differences existed in morbidity after laparoscopic cholecystectomy or subsequent conversion into open surgery. In subgroup analyses, the rates of hemorrhage, perforation, cholangitis, cholecystitis, and gastric ulceration showed no significant inter-group differences. With regards to stone clearance and overall complication rate, POES is comparable to IOES in patients with gallbladder and common bile duct stones. However, IOES has a lowered incidence of ERCP-related pancreatitis and a shorter hospital stay.

Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis?

Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). Group 1 included 15 patients (six women, nine men, mean age: 62.2±12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6±16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p=0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.

Effect of operation timing on efficacy of laparoscopic cholecystectomy combined with endoscopic sphincterotomy for patients with mild acute biliary pancreatitis

Effect of operation timing on efficacy of laparoscopic cholecystectomy combined with endoscopic sphincterotomy for patients with mild acute biliary pancreatitis

소아 연하장애의 임상적 평가와 선별검사

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are the mainstays of the diagnosis and treatment of variable hepatobiliary and pancreatic diseases. The success rate of ERCP and EST in patients who have undergone a Billroth II gastrectomy is lower than in patients with a normal anatomy. Because the view of the ampulla is rotated 180o in patients with Billroth II, several methods (ex, precut biliary needle-knife papillotome or wire-guided billroth II papillotome) have been used for endoscopic sphincterotomy instead of a pull-type papillotome. Using the recently devised pull-type and rotatable papillotome (Autotome), we performed successful ERCP and EST in 2 patients with a Billroth II gastrectomy without complications. (Korean J Gastrointest Endosc 2007;35:445-450)

Endoscopic procedures in patients under clopidogrel or dual antiplatelet therapy: a survey among German gastroenterologists and current guidelines.

Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy. A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK. 73 (33 %) chief gastroenterologists returned completed questionnaires, 35 (48 %) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85 %) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41 %) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49 %) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5 %) in the case of combined antiplatelet therapy. However, in emergency situations more than 60 % of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44 %) under clopidogrel monotherapy, but only in 4 (5.5 %) under dual antiplatelet therapy. Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.