Therapeutic Endoscopic Retrograde Cholangiography Research Articles

Primary sclerosing cholangitis with IgG4-positive plasma cells in bile duct biopsies - Frequency and characterization.

Patients diagnosed with primary sclerosing cholangitis (PSC) but with characteristics of immunoglobulin G4 (IgG4)-associated cholangitis (IAC) have been described. IAC often presents with biliary IgG4-positive plasma cell (IgG4+ PC) infiltration and responds to corticosteroids. In PSC, the frequencies or implications of biliary IgG4+ PC are unknown. We aimed to characterize the phenomenon of biliary IgG4+ PC in patients with an established PSC diagnosis. Bile duct biopsies from 191 surveillance or therapeutic endoscopic retrograde cholangiography of 58 PSC patients were retrospectively analyzed for IgG4+ PC infiltration. Patients with ≥10 IgG4+ PC per high-power field (HPF) were identified and characterized by clinical parameters, including serum IgG4 and cholangiographic presentations. Altogether 39.7% of the PSC patients showed ≥10 IgG4+ PC/HPF in bile duct biopsies. Patients with biliary IgG4+ PC infiltration were significantly younger at diagnosis of PSC (P = 0.023). There was no association between biliary IgG4+ PC infiltration and transplant-free survival (P = 0.618). Patients with IgG4+ PC infiltration in bile duct biopsies showed significantly higher baseline (P = 0.002) and maximum (P = 0.001) serum IgG4 compared to those without. Biliary IgG4+ PC infiltration was associated with high-grade bile duct strictures (P = 0.05). IgG4-positive plasma cell infiltrations were found multifocally in 72.7% of this subgroup of PSC patients. IgG4+ PC ≥10/HPF can be found abundantly in bile duct biopsies in PSC. Histological findings correlated with serum IgG4, age, and high-grade bile duct strictures. IgG4+ PC was located multifocally, hinting at a systemic biliary phenotype.

BISCIT: Biliary interventions in critically ill patients with secondary sclerosing cholangitis—a study protocol for a multicenter, randomized, controlled parallel group trial

BackgroundProgress of cholangitis to cholangiosepsis is a frequent observation in patients with secondary sclerosing cholangitis in critically ill patients (SSC–CIP). Adequate biliary drainage may reduce episodes of cholangiosepsis and therefore stabilize liver function and improve survival. The primary objective of the BISCIT study is to demonstrate that scheduled biliary interventions will reduce incidence of cholangiosepsis, liver transplantation, or death in patients with SSC–CIP.MethodsA total of 104 patients will be randomized at ten study sites. Patients with SSC–CIP, confirmed by endoscopic retrograde cholangiography (ERC), will be randomized 1:1 either in the intervention group which will be treated with scheduled biliary interventions (i.e., therapeutic ERC) every 8 weeks for 6 months or in the control group which will receive standard of care. The randomization will be stratified by center. The composite primary efficacy endpoint is defined as (1) occurrence of death, (2) necessity of liver transplantation, or (3) occurrence of cholangiosepsis within 6 months following randomization.DiscussionProspective evaluation of endoscopic treatment procedures is urgently needed to establish an evidence-based therapeutic treatment algorithm in SSC–CIP. A positive trial result could change the current standard of care for patients with SSC–CIP. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications.Trial registrationThe trial was registered at ClinicalTrials.gov (NCT05396755, date of registration: May 31, 2022, last update: May 31, 2022).

The second 'gallbladder operation'.

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Особливості діаґностики і лікування малосимптомного холедохолітіазу у пацієнтів з гострим калькульозним холециститом

Aim. Developing optimal approaches in the diagnostic algorithm and treatment of patients with acute calculous cholecystitis complicated by oligosymptomatic choledocholithiasis. Material and Methods. The results of treatment of 215 patients with acute calculous cholecystitis complicated by oligosymptomatic choledocholithiasis were analyzed, 166 of which-were studied retrospectively, and 49 - prospectively. Female patients predominated (74.0%); the average age was 56.0±1.06 years. Blood serum biochemistry, transabdominal ultrasound, magnetic resonance cholangiopancreatography, and blood and bile microRNA were used for the diagnosis. Results and Discussion. After verification of the diagnosis by applying several tests and developed multivariate models based on determining the blood and bile microRNA, and the model consisting of 5 factors for the prediction of the presence of choledocholithiasis (alkaline phosphatase, AST, ALT, total bilirubin, the common bile duct diameter according to transabdominal ultrasound), the main therapeutic option to resolve biliary duct problems in 183 (85.1%) patients were endoscopic retrograde cholangiography (ERC) with sphincterotomy and stone extraction. In the second step, 159 (74.0%) patients underwent laparoscopic cholecystectomy. One-step interventions (laparoscopic cholecystectomy and stones removal / intraoperative therapeutic ERC) due to association with acute cholecystitis changes in the hepatoduodenal ligament were performed on 7 (3.3%) patients only. Conclusions. In patients with acute calculous cholecystitis, using a 5-factor model has a fairly high prognostic value for the prediction of choledocholithiasis, and the additional use of quantifying the expression levels of miRNA-122 and miRNA-21 significantly improves the diagnosis of asymptomatic choledocholithiasis. The optimal approach to the treatment of such patients is to perform therapeutic ERCP followed by laparoscopic cholecystectomy. Keywords: acute calculous cholecystitis, oligosymptomatic choledocholithiasis, transabdominal ultrasound, endoscopic retrograde cholangiopancreatography, laparoscopic cholecystectomy

Dilatation Therapy and Demographic Characteristics Significantly Influence the Amount of Propofol for Therapeutic Endoscopic Retrograde Cholangiography.

Background and Study Aims Patients undergoing therapeutic endoscopic retrograde cholangiography (ERC) may require different amounts of sedative agents depending on demographic characteristics, indication of ERC, and/or endoscopic intervention. Patients and Methods We retrospectively analyzed all patients undergoing therapeutic ERC from 2008 – 2014 who received deep sedation with propofol ± midazolam. Results A total of 2448 ERC procedures were performed in 781 patients. The cumulative per procedure propofol dose in the different groups was as follows: PSC 479 mg (±256), bile duct stones 356 mg (±187), benign stenosis/cholestasis 395 mg (±228), malignant stenosis 401 mg (±283), and postliver transplant complications 391 mg (±223) (p < 0.05). Multivariable analysis showed that dilatation therapy (p = 0.001), age (p = 0.001), duration of the intervention (p = 0.001), BMI (p = 0.001), gender (p = 0.001), platelet count (p = 0.003), and bilirubin (p = 0.043) influence independently the propofol consumption. Conclusions Demographic characteristics and endoscopic interventions have a distinct influence on the amount of sedation required for therapeutic ERC. Although the sedation-associated complication rate is low optimization of sedative regimens is a prime goal to further reduce adverse events of therapeutic ERC.

Endoscopic interventions of the biliary system

Endoscopic interventions in the biliary system are defined by the elimination of an outflow obstruction such as in choledocholithiasis or the optimization of bile flow by means of stent drainage. Exclusive use of diagnostic endoscopic retrograde cholangiography (ERC) is now obsolete, but due to its minimally invasive approach, therapeutic ERC is the method of choice for intervention in appropriate indications. If access to the biliary system via the papilla is not possible, approaches as guided by endoscopic ultrasound appear to be avalid option for the experienced endoscopist.

Usefulness of combined percutaneous-endoscopic rendezvous techniques after failed therapeutic endoscopic retrograde cholangiography in the era of endoscopic ultrasound guided rendezvous.

The rendezvous approach is a salvage technique after failure of endoscopic retrograde cholangiography (ERC). In certain circumstances, percutaneous-endoscopic rendezvous (PE-RV) is preferred, and endoscopic ultrasound-guided rendezvous (EUS-RV) is difficult to perform. We aimed to evaluate PE-RV outcomes, describe the PE-RV techniques, and identify potential indications for PE-RV over EUS-RV.Retrospective analysis was conducted of a prospectively designed ERC database between January 2005 and December 2016 at a tertiary referral center including cases where PE-RV was used as a salvage procedure after ERC failure.During the study period, PE-RV was performed in 42 cases after failed therapeutic ERC; 15 had a surgically altered enteric anatomy. The technical success rate of PE-RV was 92.9% (39/42), with a therapeutic success rate of 88.1% (37/42). Potential indications for PE-RV over EUS-RV were identified in 23 cases, and either PE-RV or EUS-RV could have effectively been used in 19 cases. Endoscopic bile duct access was successfully achieved with PE-RV in 39 cases with accessible biliary orifice using one of PE-RV cannulation techniques (classic, n = 11; parallel, n = 19; and adjunctive maneuvers, n = 9).PE-RV uses a unique technology and has clinical indications that distinguish it from EUS-RV. Therefore, PE-RV can still be considered a useful salvage technique for the treatment of biliary obstruction after ERC failure.

Utility of newly developed short-type double-balloon endoscopy for endoscopic retrograde cholangiography in postoperative patients.

The utility of conventional short-type double-balloon endoscopy (DBE) for pancreatobiliary disease in patients with postoperative anatomy had been widely acknowledged and accepted. However, some technical difficulties yet remained. In an attempt to solve these problems, the new short-type DBE (N-short DBE) was uniquely designed for therapeutic endoscopic retrograde cholangiography (ERC) in postoperative patients. The aim of this study was to evaluate the usefulness of N-short DBE for ERC in postoperative patients. From August 2015 to April 2016, ERC using N-short DBE (DB-ERC) was performed in 100 postoperative patients (112 procedures). We retrospectively studied the success rate of reaching the blind end, the median time to reach the blind end, the diagnostic success rate, the therapeutic success rate, the median time to complete ERC-related interventions, the overall success rate, the median time to complete DB-ERC, and adverse events. The success rate of reaching the blind end was 99.1%. The median time to reach the blind end was 10min (interquartile range [IQR], 6-19min). The diagnostic success rate was 98.2%. The therapeutic success rate was 100%. The median time to complete ERC-related interventions was 36min (IQR, 22-62min). The overall DB-ERC success rate was 97.3%. The median time to complete DB-ERC was 54min (IQR, 37-73min). The occurrence of adverse events was 2.7%. The N-short DBE for ERC in postoperative patients is useful and safe. DB-ERC is promising therapeutic modality in such patients and should be selected as the first-line policy.

Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy : a multicenter prospective study in Japan 1）.

Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy : a multicenter prospective study in Japan^1）.

Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan.

To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy. This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study. A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery. ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.

Effectiveness of peroral direct cholangioscopy using an ultraslim endoscope for the treatment of hepatolithiasis in patients with hepaticojejunostomy (with video).

Hepatolithiasis is a postoperative complication of hepaticojejunostomy (HJ) performed for various pancreatobiliary diseases. Hepatolithiasis can cause repeated cholangitis. Complete stone removal and bile stasis elimination are therefore necessary. Here, we evaluated the effectiveness of peroral direct cholangioscopy (PDCS) using an ultraslim endoscope for treating hepatolithiasis in HJ patients. We studied 14 patients with hepatolithiasis who underwent bowel reconstruction with HJ between April 2012 and May 2014. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short double-balloon enteroscope (DBE) was initially performed. Following stone removal, the DBE was exchanged for an ultraslim endoscope through the balloon overtube for PDCS. The success rate of PDCS procedure was 85.7% (12/14). In 5 of 12 (41.7%) patients with successful PDCS, the residual stones were detected and removed completely using a 5-Fr basket catheter and suction after normal saline irrigation. In the remaining 7 (58.3%) patients, no residual stone was detected. The median procedure time was 14 min (range 8-36) with no serious postoperative complications. The median follow-up time after PDCS was 21 months (range 5-26), and only 1 patient (8.3%) had IHBD stone recurrence with an anastomotic stricture. PDCS using an ultraslim endoscope appears to be useful for detecting and removing residual stones following hepatolithiasis treatment using a DBE. The combined use of a DBE and PDCS may reduce the risk of hepatolithiasis recurrence in HJ patients.

Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial.

There are no guidelines for the timing of conversion from a single-guidewire to a double-guidewire technique to facilitate selective bile duct cannulation and reduce post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), when using wire-guided cannulation. We investigated whether early conversion to the double-guidewire method, at first unintentional insertion of a guidewire into the pancreatic duct, facilitated selective bile duct cannulation and reduced PEP compared with repeated single-guidewire attempts. A multicenter prospective randomized controlled trial included 274 patients with a naive papilla, undergoing endoscopic retrograde cholangiography (ERC) using wire-guided cannulation in whom there was unintentional insertion of the guidewire into the pancreatic duct. With the guidewire still in the duct, patients were randomly assigned to undergo the double-guidewire technique or repeated single-wire cannulation. Main outcomes were success rates for selective bile duct cannulation and PEP frequency. Success rates for selective bile duct cannulation within 10 attempts and 10 minutes were 75 % and 70 %, respectively, for the early double-guidewire (EDG) and repeated single-guidewire (RSG) cannulation groups (relative rate 1.07, 95 % confidence interval [95 %CI] 0.93 - 1.24, P = 0.42). Corresponding final selective bile duct cannulation rates were 98 % and 97 % (relative rate 1.01, 95 %CI 0.97 - 1.05, P = 1.00). PEP rates were 20 % and 17 %, respectively, for the EDG and RSG cannulation groups (relative risk 1.17, 95 %CI 0.71 - 1.94, P = 0.53). Double-guidewire cannulation was more effective in patients with malignant biliary stricture (relative rate 1.36, 95 %CI 1.05 - 1.77, P = 0.02). During therapeutic ERC using wire-guided cannulation, converting to a double-guidewire technique neither facilitated selective bile duct cannulation nor decreased PEP incidence compared with repeated use of a single-wire technique.

Endoscopic Ultrasound in Acute Pancreatitis

There are two main indicators of endoscopic ultrasound (EUS) in acute pancreatitis: (1) suspicion of a biliary cause and intermediate probability of a common bile duct stone and (2) idiopathic acute (recurrent) pancreatitis. In cases of suspected biliary pancreatitis, EUS reliably selects patients for therapeutic endoscopic retrograde cholangiography. In approximately two-third of cases with idiopathic acute pancreatitis, EUS reveals the etiology of acute pancreatitis (biliary microlithiasis and sludge, common bile duct stones, pancreas divisum and other abnormalities of the pancreatobiliary ducts, chronic pancreatitis, intraductal papillary mucinous neoplasms, and solid pancreatic tumors). This article is part of an expert video encyclopedia.

Sirolimus based immunosuppression is associated with need for early repeat therapeutic ERCP in liver transplant patients with anastomotic biliary stricture

Introduction. Sirolimus has inhibitory effects on epithelial healing and cholangiocyte regeneration. In liver transplantation (LT) patients, these effects may be greatest at the biliary anastomosis. We therefore investigated whether sirolimus use is associated with need for early or emergent repeat therapeutic endoscopic retrograde cholangiography (ERC) in LT patients with anastomotic biliary stricture (ABS).Material and methods. Medical records of patients who underwent LT from 1998–2009 at Johns Hopkins were reviewed and patients with ABS identified. Primary outcome was early repeat ERC, defined as need for unscheduled (i.e. unplanned) or emergent repeat therapeutic ERC. Univariate and multivariate logistic regression analyses (adjusting for age, sex, LT to ERC time, and stent number) were performed to assess association between sirolimus and early repeat ERC.Results. 45 patients developed ABS and underwent 156 ERCs total. Early (median 26 days) repeat ERC occurred in 14/56 (25%) and 6/100 (6%) ERCs performed with and without concomitant sirolimus-based immunosuppression, respectively (OR 1.22; 95% CI 1.02–1.45; p = 0.03). In multivariate analysis, sirolimus use was associated with early repeat ERC (OR 1.24; 95% CI 1.04–1.47; p = 0.015); this association remained significant when sirolimus dose was modeled as a continuous variable (OR 1.04 for each mg of sirolimus per day; 95% CI 1.02–1.08; p = 0.038).Conclusions. Sirolimus-based immunosuppression appears to be associated with a modest but significantly increased, dose-dependent risk of early repeat ERC in LT patients with ABS. Prospective studies are needed to further investigate these findings and determine if sirolimus use or dose should potentially be reconsidered once ABS is diagnosed.

Su1356 Single- and Double-Balloon Enteroscope for Therapeutic Endoscopic Retrograde Cholangiography After Roux-en-Y Small Bowel Surgery: a Single-Center Comparison

Roux-en-Y small bowel reconstructive surgery excludes the afferent limb and the biliopancreatic system from conventional endoscopic access. Balloon-assisted enteroscopy allows therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in these patients, avoiding biliopancreatic rescue surgery.

Tu1019 Development of the Metabolic Syndrome and Its Outcomes After Liver Transplantation

INTRODUCTION: Sirolimus has inhibitory effects on epithelial healing and cholangiocyte regeneration. In liver transplantation (LT) patients, these effects may be greatest at the biliary anastomosis. We therefore investigated whether sirolimus use is associated with need for early or emergent repeat therapeutic endoscopic retrograde cholangiography (ERC) in LT patients with anastomotic biliary stricture (ABS). METHODS: Medical records of patients who underwent LT from 1998-2009 at Johns Hopkins Hospital were reviewed, patients with ABS identified, and pertinent patient, surgical, and endoscopic data abstracted. The primary outcome was early repeat ERC, defined as need for early (i.e. unplanned) or emergent repeat therapeutic ERC accompanied by signs or symptoms suggestive of biliary obstruction and/or stent occlusion. Univariate and multivariate logistic regression analyses (adjusting for age, sex, LT to ERC time, and stent number) were performed to assess the association between sirolimus-based immunosuppression and early repeat ERC. RESULTS: 45 patients developed ABS and underwent a total of 156 ERCs. Early repeat ERC occurred (at a median of 26 days) in 14/56 (25%) and 6/100 (6%) ERCs performed with and without concomitant sirolimus-based immunosuppression, respectively (OR 1.22; 95% CI 1.02-1.45; p=0.03). In multivariate analysis, sirolimus use was associated with early repeat ERC (OR 1.24; 95% CI 1.04-1.47; p=0.015); this association remained significant when sirolimus dose was modeled as a continuous variable (OR 1.40 per mg/day; 95% CI 1.20-2.02; p=0.038). CONCLUSIONS: Sirolimus-based immunosuppression appears to be associated with a modest but significantly increased, dose-dependent risk of early repeat ERC in LT patients with ABS. Prospective studies are needed to further investigate these findings and determine if sirolimus use or dose should be reconsidered once ABS is diagnosed. Multivariate analysis of the association between sirolimus use and early repeat ERC

Therapeutic endoscopic retrograde cholangiography using a single‐balloon enteroscope in patients with Roux‐en‐Y anastomosis

The aim of the present study was to evaluate the usefulness of a single-balloon enteroscope (SBE) including a newly developed short SBE (SIF-Y0004) for therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y (R-Y) anastomosis. Therapeutic ERC using a SBE was attempted in 19 cases (41 procedures) with R-Y anastomosis after gastrectomy. A standard SBE (working length of 200 cm, working channel of 2.8 mm) was used in 11 cases (Group L), and a short SBE (working length of 152 cm, working channel of 3.2 mm) was used in eight cases (Group S). Insertion of the scope up to the major papilla was achieved in 79% (15/19) of cases. Average insertion time was 37.0 ± 13.8 min (range, 19-62 min). Bile duct cannulation rate was 79% (11/14) after exclusion of the initial case in which scope exchange was unsuccessful. Average procedure time was78.8 ± 26.9 min (18-119 min). The scheduled therapeutic procedure was completed in 67% (10/15) of the cases (53% [10/19] on an intention-to-treat basis). Cardiorespiratory suppression due to sedative agents resulting in scope withdrawal developed in one procedure (2.4%; 1/41). Although there was no significant difference in therapeutic results between the two groups, the number of procedures was smaller (1.8 ± 1.3 vs 3.6 ± 3.1; P = 0.286) in Group S than in Group L. Therapeutic ERC using a SBE for patients with R-Y anastomosis is considered to be safe and effective. A short SBE appears to be promising for further improvement in therapeutic results.

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejunoanastomosis

To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA). The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients with Roux-en-Y HJA who had signs of biliary obstruction. In total, 23 ERC procedures were performed in these patients and a single balloon videoenteroscope (Olympus SIF Q 180) was used in all of the cases. A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope. Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of ≤ 5.4 kPa. The technical limitations or rather the parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) showed the need for special endoscopic instrumentation. Cannulation success was reached in diagnostic ERC in 12 of 15 patients. ERC findings were normal in 1 of 12 patients. ERC in the remaining 11 patients showed some pathological changes. One of these (cystic bile duct dilation) was subsequently resolved surgically. Endoscopic treatment was initialized in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both). This treatment was successful in 9 of 10 patients. The endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis - 11 times (7 patients); choledocholitiasis extraction - five times (5 patients); biliary plastic stent placement - six times (4 patients); and removal of biliary stents placed by us - six times (4 patients). The mean time of performing a single ERC was 72 min. The longest procedure took 110 min and the shortest took 34 min. This shows that it is necessary to allow for more time in individual procedures. Furthermore, these procedures require the presence of an anesthesiologist. We did not observe any complications in these 15 patients. This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy. However, it is effective, safe, and widens the possibilities of resolving biliary pathology.

Therapeutic endoscopic retrograde cholangiography and cholangioscopy (ERCC) combining a single-balloon enteroscope and an ultraslim endoscope in altered gastrointestinal anatomy

Therapeutic endoscopic retrograde cholangiography and cholangioscopy (ERCC) combining a single-balloon enteroscope and an ultraslim endoscope in altered gastrointestinal anatomy

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography. A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively. A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC. Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.