Traditional Endoscopic Retrograde Cholangiopancreatography Research Articles

Endoscopic drainage of malignant distal biliary obstruction. Will ERCP no longer be necessary?

We read with interest the Editorial by Vila et al. on the paradigm shift for endoscopic biliary drainage of malignant distal biliary obstruction (MDBO) which places Endoscopic Ultrasound (EUS) drainage as the first option instead of traditional ERCP drainage. The modern biliary endoscopist must have the duodenoscope in one hand and the therapeutic echoendoscope in the other. ERCP training alone is no longer appropriate because the goal is to drain the obstruction during a single session. That is why in more and more centers the patient signs a single consent for endoscopic biliary drainage, whether by ERCP, EUS or combined. Should EUS drainage be used first for MDBO without attempting ERCP? A possible protocol for endoscopic drainage of MDBO could be to start with the duodenoscope for ERCP. If the papilla of Vater is accessible, try cannulation considering the ESGE criteria for a difficult cannulation: more than 5 contacts with the papilla; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification. If biliary cannulation is not achieved, immediately switch to EUS drainage during the same session. Occasionally, the double guidewire technique or even transpancreatic biliary sphincterotomy could be used, but not needle-knife precut.

Tips and tricks for endoscopic ultrasound-guided hepaticogastrostomy.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a treatment option for patients with biliary obstruction in whom traditional endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to altered upper gastrointestinal anatomy. In such cases, EUS-BD is a good alternative to surgery or percutaneous transhepatic biliary drainage (PTBD), with comparable clinical and technical success rates [1]. Two approaches have been described for EUS-guided transluminal biliary drainage. EUS-guided hepaticogastrostomy uses the transgastric approach and EUS-guided choledochoduodenostomy uses the transduodenal approach [2].

Efficacy analysis of hybrid operating room-based laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography in the treatment of cholelithiasis combined with choledocholithiasis - A case-control study.

The objective is to compare the therapeutic effects of laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) in hybrid operating room and ERCP + LC under traditional conditions in the treatment of cholelithiasis and choledocholithiasis. Data of 82 patients with cholelithiasis complicated with choledocholithiasis treated by our centre from November 2018 to March 2021 were retrospectively analysed. Amongst them, 40 patients treated with LC combined with intraoperative ERCP in a hybrid operating room were placed into Group A, and 42 patients treated with ERCP first followed by LC under traditional conditions were placed into Group B. The differences in operative time, intraoperative blood loss, surgical success rate, stone clearance rate, pain score, exhaust time, ambulation time, post-operative complications, length of hospital stay, hospitalisation cost and other indicators between the two groups were compared. There were no significant differences in operative time, intraoperative blood loss, surgical success rate and stone clearance rate between the two groups (P > 0.05), while there were significant differences in post-operative pain score, exhaust time, ambulation time, length of hospital stay, hospitalisation cost and complications (P < 0.05). LC combined with intraoperative ERCP in hybrid operating room for the treatment of cholelithiasis combined with choledocholithiasis has a better therapeutic effect than traditional ERCP followed by LC, which is worthy of further popularization. Notably, the reasonable selection should be made based on patients' own conditions and hospital facilities.

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

Endobiliary biopsy.

The differential diagnosis between benign and malignant biliary strictures is challenging and requires a multidisciplinary approach with the use of serum biomarkers, imaging techniques, and several modalities of endoscopic or percutaneous tissue sampling. The diagnosis of biliary strictures consists of laboratory markers, and invasive and non-invasive imaging examinations such as computed tomography (CT), contrast-enhanced magnetic resonance cholangiopancreatography, and endoscopic ultrasonography (EUS). Nevertheless, invasive imaging modalities combined with tissue sampling are usually required to confirm the diagnosis of suspected malignant biliary strictures, while pathological diagnosis is mandatory to decide the optimal therapeutic strategy. Although EUS-guided fine-needle aspiration biopsy is currently the standard procedure for tissue sampling of solid pancreatic mass lesions, its diagnostic value in intraductal infiltrating type of cholangiocarcinoma remains limited. Moreover, the “endobiliary approach” using novel slim biopsy forceps, transpapillary and percutaneous cholangioscopy, and intraductal ultrasound-guided biopsy, is gaining ground on traditional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography endobiliary forceps biopsy. This review focuses on the available endobiliary techniques currently used to perform biliary strictures biopsy, comparing the diagnostic performance of endoscopic and percutaneous approaches.

Endoscopic Papillary Large Balloon Dilation Reduces Further Recurrence in Patients With Recurrent Common Bile Duct Stones: A Randomized Controlled Trial.

Up to 60% of patients with common bile duct stone (CBDS) recurrence suffer from further recurrence after endoscopic retrograde cholangiopancreatography (ERCP). There are no effective methods to prevent recurrence in most patients. In this study, we aimed to assess the short-term and long-term efficacies of endoscopic papillary large balloon dilation (EPLBD) for the management of recurrent CBDS in a randomized controlled trial. Consecutive patients with recurrent CBDS were eligible and randomly assigned in a 1:1 ratio to the EPLBD group or the control group. The primary outcome was the CBDS recurrence rate within 2 years after ERCP. The analysis followed the intention-to-treat principle. From 2014 to 2021, 180 patients with recurrent CBDS were included, with 90 in each group. All patients underwent complete CBDS clearance by 1 or several sessions of ERCP. The rate of complete clearance in 1 session was significantly higher with EPLBD treatment (95.6% vs 85.6%, P = 0.017). During the follow-up, the CBDS recurrence rate within 2 years was significantly lower in the EPLBD group than in the control group (21.1% [19/90] vs 36.7% [33/90], relative risk 0.58, 95% confidence interval 0.36-0.93, P = 0.021). At a median follow-up of approximately 56 months, CBDS recurrence was found in 34.4% of the patients (31/90) in the EPLBD group and 51.1% (46/90) in the control group (hazard ratio 0.57, 95% confidence interval 0.36-0.89, P = 0.012). Multiple recurrences (≥2) were also decreased in the EPLBD group (4.4% vs 18.9%, P = 0.020). During the long-term follow-up, nearly half of the patients with recurrent CBDS experienced stone recurrence after traditional ERCP. Our study was the first to show that EPLBD effectively reduced the recurrence of CBDS.

Single session endoscopic ultrasound-guided double bypass (hepaticogastrostomy and gastrojejunostomy) for concomitant duodenal and biliary obstruction: A case series.

Concomitant malignant biliary and gastric outlet obstruction can be difficult to manage endoscopically with traditional endoscopic retrograde cholangiopancreatography (ERCP) and luminal stenting. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HG) and gastrojejunostomy (GJ) are novel techniques that can relieve both obstructions in a single session. This study aims to describe the outcomes of combined, single session EUS-HG and EUS-GJ. This is a two-center retrospective study of consecutive patients who underwent same session EUS-HG and EUS-GJ. The primary outcome was technical success. Secondary outcomes included adverse events (AE), reduction in total serum bilirubin, length of hospital stay (LOS), and re-intervention rates. A total of 23 patients underwent EUS-HG and EUS-GJ (12 males, mean age 66.4years). Twenty-one were performed for malignant obstruction. Technical success was 100% and 95.6% for HG and GJ, respectively. All patients subsequently tolerated a soft diet and 72.7% (16/22) of patients had a 50% reduction in bilirubin post-procedure. The median LOS for the 17 patients who were not discharged home immediately following the procedure was 2 (range 1-20) days. There were five AEs (2 mild, 3 moderate). Only three patients required reintervention (interventional radiology-guided biliary drainage, stent exchange for a benign biliary stricture, and placement of a second stent through an occluded distal common bile duct stent) over a median follow-up of 78days. One patient with pancreatic cancer underwent successful tumor resection. Single session EUS-guided double bypass (HG and GJ) is technically feasible and safe when conducted by experienced endosonographers. Larger, comparative studies are needed.

A204 PATIENT FACTORS AND STONE FEATURES AS PROGNOSTIC PREDICTORS IN BILIARY STONE LITHOTRIPSY BY SINGLE-OPERATOR CHOLANGIOPANCREATOSCOPY

Abstract Background Single-operator cholangiopancreatoscopy (SOC) is a therapeutic modality for pancreaticobiliary stone disease that is refractory to traditional ERCP. SOC is still considered a relatively novel technology with limited access in many centers and significant associated costs. Thus, it is imperative to understand the influence patient-based factors and ancillary actions have on the outcome of SOC. Aims We hope to determine if the differences in clinical outcomes amongst cohorts suffice to indicate a re-evaluation of SOC in unfavourable patient populations. We present a series of patients who underwent SOC for biliary stone lithotripsy at a tertiary center with exploratory analysis of factors related to efficacy and adverse events. Methods This is a retrospective, descriptive case series. Cases were identified via query of the electronic medical record between March 2016 and May 2019. We evaluated patient demographics, past medical history, clinical presentation, disease characteristics, complication rates, and patient outcomes. Descriptive statistics are reported. Results 25 unique patients underwent a total of 44 SOC procedures. Mean age was 68 (range 22–88). 13 patients were male. 29 procedures involved a stone in the Common Bile Duct (CBD), 5 in the Common Hepatic &amp; Intrahepatic Ducts (CIHD), 4 in the Pancreatic Duct (PD) and 6 in the Cystic Duct (CD). Symptomatic improvement was achieved in 100% of patients. After a single session, 22.7% of procedures resulted in complete clearance and 59.1% of cases led to partial fragmentation. CBD stones however had an 86.2% clearance rate, compared to an 88–91% success rate in literature. The total complication rate was 16% across age and sex groups. The most common complication was bacteremia in 4 (9.1%) cases. Undifferentiated complication rates were highest with CD stones, while bacteremia was most likely with PD stones. A strong trend was noticed between past SOC procedures and increasing ongoing stone burden, with repeat SOC required less often in patient’s with fewer past SOC procedures. We further observed poorer fragmentation rates for PD stones and a rising trend for repeat SOCs for proximal CBD stones. Conclusions SOC is useful against difficult biliary stones and can provide therapeutic relief without theoretical risks associated with surgery and ERCP. While our study was underpowered to provide generalizable statistics, it is one of the few studies that showed the influence certain comorbidities, stone characteristics and age have on the efficacy and safety of SOC. Our data illustrates the relative effect location and stone-size has on fragmentation and complications rates. Poorer outcomes are more frequent in those with systemic comorbidities and previous surgeries, and rates of complications and failed fragmentation are further exacerbated by age. Funding Agencies None

S1516 Malignant Biliary Obstruction Diagnosed by Percutaneous Transhepatic Cholangioscopy With Spyglass Direct Visualization System

INTRODUCTION: Malignant biliary obstruction associated with gastric cancer is uncommon. We report a patient with obstructive jaundice due to a new biliary stricture after gastrectomy and loop gastrojejunostomy. Conventionally, enteroscopy-assisted ERCP will be needed to biopsy the stricture which can be difficult and not widely available. Here we describe an easier approach using Percutaneous Transhepatic Cholangioscopy (PTCS) with SpyglassTM Direct visualization system (SDVS). CASE DESCRIPTION/METHODS: 51-year-old male with history of gastric adenocarcinoma status post distal gastrectomy with loop gastrojejunostomy presented 3 years later with painless jaundice. Initial imaging studies including US and CT scan showed severe biliary obstruction with pronounced intrahepatic and extrahepatic ductal dilatation. MRCP revealed a proximal common bile duct stricture with resultant severe intrahepatic ductal dilation spanning approximately 1.5 cm, highly suspicious for malignancy (Image1). ERCP was not attempted due to the altered anatomy and a percutaneous internal biliary drain was placed by Interventional radiology (IR). The drain was placed through the left biliary system into the common duct and into the duodenum. Cholangiogram showed two strictures in the proximal and mid bile duct. In order to obtain the diagnosis, the decision was made to proceed with a combined endoscopic and IR guided approach. A digital cholangioscope was passed through a 12Fr sheath catheter that was placed by IR. The stricture was endoscopically visualized and appeared erythematous, friable with whitish mucosa (Image 2). Multiple biopsies were obtained using a mini biopsy forceps. Pathology revealed poorly differentiated adenocarcinoma with associated fibrosis, inflammation and necrosis. DISCUSSION: Cholangioscopy through a percutaneous transhepatic route is an attractive alternative option when traditional ERCP is technically challenging or not feasible. SDVS provides direct visualization of the biliary system increasing the diagnostic yield, as in our case where it helped to diagnose a malignant biliary stricture in a patient who was in remission from primary gastric carcinoma. PTCS with SDVS also provides therapeutic potential for choledocholithiasis, biliary strictures and local tumor ablative therapy. Though it is an invasive procedure requiring collaboration between a gastroenterologist and an interventional radiologist, as demonstrated, it is a safe and technically easy procedure with unique diagnostic and therapeutic potentials.Figure 1.: blue arrow: Proximal common bile duct stricture causing severe intrahepatic ductal dilation.Figure 2.: Biliary stricture seen using direct visualization system.

Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience.

Successful combined Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) in the Same Session (LESS) has been reported in several studies in adult patients with choledocholithiasis. This was a retrospective analysis of data collected prospectively in the Pediatric ERCP Database Initiative using REDCAP. Adverse events were recorded separately and were reviewed for this study. The primary outcome was the hospitalization days. Secondary outcomes included total duration of anesthesia, morbidity, time from diagnosis to procedure. Twenty-five patients underwent LESS, and 42 underwent the traditional ERCP followed by laparoscopic cholecystectomy. The groups were similar in age, weight, ASA. The median length of stay in the LESS group was 3 days, compared with 4 days (P = .32). Total procedure time was similar between the 2 groups, but anesthesia time was shorter in the LESS group (P = .0401). Morbidity was similarly low between the 2 groups. Relative to 2 interventions, a single session combining ERCP and laparoscopic cholecystectomy in pediatric patients is effective with a similar adverse event rate and length of stay. The use of a single sedation and reduced total anesthesia time are potential benefits of this approach. This modality may be considered for pediatric patients with choledocholithiasis with or without hemolytic disease.

Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis.

ABSTRACT Introduction:Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. Aim: To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. Methods:Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. Results:Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). Conclusions:For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.

EUS-guided biliary drainage is equivalent to ERCP for primary treatment of malignant distal biliary obstruction: a systematic review and meta-analysis.

Background and study aims Although endoscopic retrograde cholangiopancreatography (ERCP) is standard of care for malignant biliary obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) as a primary treatment has become increasingly utilized. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness and safety of EUS-BD for primary treatment of malignant biliary obstruction and comparison to traditional ERCP. Methods Individualized search strategies were developed through November 2018 using PRISMA and MOOSE guidelines. A cumulative meta-analysis was performed by calculating pooled proportions. Subgroup analysis was performed for studies comparing EUS-BD versus ERCP. Heterogeneity was assessed with Cochran Q test or I 2 statistics, and publication bias by funnel plot and Egger’s tests. Results Seven studies (n = 193 patients; 57.5 % males) evaluating primary EUS-BD for malignant biliary obstruction were included. Mean age was 67.4 years (2.3) followed an average of 5.4 months (1.0). For primary EUS-BD, pooled technical success, clinical success, and adverse event (AE) rates were 95 % (95 % CI 91 – 98), 97 % (95 % CI 93 – 100), and 19 % (95 % CI 11 – 29), respectively. Among EUS-BD and ERCP comparator studies, technical and clinical success, and total AEs were not different with lower rates of post-ERCP pancreatitis and reintervention among the EUS-BD group. Conclusion Primary EUS-BD is an effective treatment with few AE. Comparing EUS-BD versus ERCP, EUS-BD has comparable efficacy and improved safety as a primary treatment for malignant biliary obstruction. Further randomized trials should be performed to identify patient populations and clinical scenarios in which primary EUS-BD would be most appropriate.

2164 Percutaneous Transhepatic Single-Operator Cholangioscopy With Electrohydraulic Lithotripsy in the Management of Intrahepatic Stones in a Post-Orthotopic Liver Transplant Patient With Ischemic Cholangiopathy

INTRODUCTION: Advancements in endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of biliary stones. However, endoscopic management of intrahepatic stones continues to be challenging. We discuss a patient with intrahepatic stones who was treated with percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy (EHL). CASE DESCRIPTION/METHODS: A 68-year-old man with alcoholic cirrhosis underwent orthotopic liver transplant from a deceased after cardiac death donor. His post-transplant course was complicated by ischemic cholangiopathy, biloma development and recurrent episodes of cholangitis. He underwent placement of an external biliary drain for management of his biloma. An MRCP demonstrated persistent biloma as well as mural irregularities within the intrahepatic ducts concerning for intrahepatic stones. Due to recurrent cholangitis, a combined IR (interventional radiology)-biliary endoscopic procedure was undertaken. IR performed a percutaneous cholangiogram (PTC) which demonstrated multiple filling defects in the left hepatic ducts consistent with stones. A 5 French Fogarty balloon was advanced and inflated with multiple sweeps in an attempt to extract the filling defects into the common bile duct. Antegrade cholangioscopy was then performed with single-operator cholangioscope (SpyGlass 2™) passed through a 14 French PTC sheath. Using the cholangioscope we were able to visualize impacted stones within the left intrahepatic system and treat them utilizing EHL with a catheter setting of 40-50 Watts for stone fragmentation and suction. The single-operator cholangioscope was then directed at the common bile duct and two large retained stones were treated with EHL. Subsequently, a traditional ERCP was performed which noted filling defects within the common bile duct. Balloon sphincteroplasty was performed and using an 8.5-11.5 mm balloon catheter, CBD exploration and balloon sweeps were performed with extraction of 2 large stones and sludge. Occlusion cholangiogram at the completion of the procedure revealed no further stones and patent anastomosis. To allow adequate biliary drainage, a retrievable 10 mm × 60 mm SEMS covered metal biliary stent and a new 14 French external biliary drain was placed. The biliary stent was removed 3 months later with ERCP demonstrating no recurrent stones. DISCUSSION: Complex intrahepatic lithiasis may be successfully managed with a multi-disciplinary collaborative approach between Interventional Radiology and biliary endoscopists.

New approach to decrease post-ERCP adverse events in patients with primary sclerosing cholangitis.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is often performed in patients with primary sclerosing cholangitis (PSC). Our aim was to validate a treatment approach with the objective of decreasing ERCP related adverse events (AEs). Patients and methods All patients who had undergone ERCP for PSC during the period from 2002 – 2012 were identified (group I). This group had traditional ERCP (no bile aspiration prior to contrast injection with balloon dilation and stent placement for treatment of dominant strictures). To decrease ERCP-related AEs, we changed the ERCP approach in which bile aspiration was performed prior to contrast injection and balloon dilation alone was performed for treatment of dominant strictures. This was tested prospectively in all patients undergoing ERCP for PSC from 2012 – 2014 (group II). Results The risk of overall AEs and cholangitis was relatively less in group II compared with group I [(2.1 % vs. 10.3 %; P = .38) and (0 % vs. 4.4 %; P = .68)]. On bivariate analysis, change in ERCP approach was associated with decreased risk of post-procedure cholangitis (0 % vs. 10.2 %, P = .03) and overall AE (0 % vs. 18.6 %, P = .03). There were no AEs in 22/46 patients in group II who had bile aspiration with balloon dilation. On multivariate analysis, only biliary stent placement was associated with increased risk of AEs (OR 4.10 (1.32 – 12.71); P = .02) and cholangitis (OR 5.43, 1.38 – 21.38; P = .02) respectively. Conclusion Biliary aspiration and avoidance of stenting approach after dilation of strictures during ERCP in PSC patients appears to be associated with decreased risk of cholangitis and overall AEs. Future prospective randomized controlled trials are needed to validate our observation.

ERCP for Septic Cholangitis Through a Peg Tube, a Life-Saving Procedure Using an Alternative Access Route to Approach the Biliary Tree When the Regular ERCP Fails

Acute cholangitis, is a product of bile stasis and infection of the biliary tract. Diagnostic and therapeutic role of the Endoscopic retrograde cholangiopancreatography (ERCP) has a critical role in the management. Anatomical variation following Roux-en-Y gastric bypass or people who had esophageal obstructions tend to make the early intervention by the ERCP a challenge. We report a case of septic cholangitis in a patient whom the ERCP was achived through a peg tube. Case report: 75-year-old male esophageal cancer & gastrostomy tube for malnutrition presented to the local hospital with fevers. Initial evaluation showed feature of sepsis with a fever, leukopenia, elevation in the liver enzymes & total bilirubin 1.2 and lactic acid 3.2. Ct scan showed a stone in the common bile duct & blood cultures showed Enterobacter cloacae. The patient started on ceftriaxone & transferred to our tertiary center for therapeutic intervention. The patient had a MRCP that demonstrates a 1.3 cm obstructive distal common bile duct stone for which the patient underwent an attempt with ERCP that shortly aborted given partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be pass the mass but the procedure terminated due to scope malfunction. Another route to access the biliray system was found; the peg tube was removed after an anchoring system was placed. Following the placement of the anchors an Axio stent was placed & a balloon dilitation was performed inside the stent up to 15 mm in size. Following dilitation an ERCP scope was placed and the papilla was accessed and sphincterotomy was made and stone was removed. After the stone removal, the stent was removed and a peg tube was replaced and the patient tolerated the procedure without any complication & discharged on stable condition. Discussion: ERCP is the treatment of choice in establishing biliary drainage in acute cholangitis. In the setting of anatomical variation, the success rate dramatically dropped below 70% when compare it to the traditional ERCP 90-95%. The literature showed that the success rate is higher using surgically created route through the stomach as a mature gastrostomy, trans-gastric or laproscopic- assisted port are all well tolerated. In patient with limited access for the traditional ERCP, alternative routes can allow the gastroenterologist to drain the blockage; such intervention can improve the mortality & morbidty.

A Variation to Traditional Rendezvous Procedure: A Proposed Change to Standard of Practice

ERCP was first reported by McCune in 1968. It involves passing a side-viewing duodenoscope into the second portion of the duodenum, followed by instrumentation of the biliary system through major ampulla. PTC was first described by Huard and Do-Xuan-Hop in 1937. It involves transhepatic insertion of a needle into the biliary system, followed by an injection of contrast material to opacify the bile ducts. The term rendezvous (French for appointment) was adopted when surgeon and endoscopist met one another in the duodenum [Fig 1]. The rendezvous procedure is a combined ERCP and PTC approach to access the bile duct after failed ERCP. Traditional technique has a one- and two-step approach. In a onestep approach, a guidewire is passed percutaneously through the biliary system into duodenum, followed immediately by ERCP (over-the-wire cannulation method) [Fig 2]. In a two-step approach, an externalinternal drain (EID) is inserted percutaneously and ERCP is performed at a later date with a guidewire passed in a retrograde fashion alongside of the EID (parallel cannulation method). We present a case of a 69 year old female who presented with acute cholangitis secondary to choledocholithiasis. ERCP was attempted, but was aborted after ampulla was not identified due to two large duodenal diverticula [Fig 3]. Interventional radiology was consulted and PTC with placement of EID was performed. Repeat ERCP consisted of multiple unsuccessful attempts to cannulate the common bile duct (CBD) alongside of the EID [Fig 4]. The interventional radiology consult was placed. EID was exchanged for a Bernstein catheter [Fig 5], and a guidewire was then inserted through the duodenoscope directly into the Bernstein catheter and externalized. The Bernstein catheter was then retracted into the right intrahepatic duct, the CBD was accessed with straight cannula, the guidewire was removed and a cholangiogram was performed revealing multiple filling defects. The Bernstein catheter was removed, the straight catheter was exchanged for sphincterotome, and a traditional ERCP with sphincterotomy, stone extraction and biliary stent insertion was performed. To our knowledge this is the first case reported in the United States of the modified rendezvous procedure. Traditional technique is cumbersome, time consuming and carries high risk of procedure complications, such as loss of wire and pancreatitis. We propose that our method should replace the traditional approach in all Rendezvous cases.Figure 1Figure 2Figure 3

Current status of laparoendoscopic rendezvous in the treatment of cholelithiasis with concomitant choledocholithiasis.

The current evidence in favor of the laparoendoscopic rendezvous is promising and demonstrates the main advantages of this technique in regard to shorter hospital stay and selective cannulation of the common bile duct (CBD), avoiding thus the inadvertent cannulation of the pancreatic duct. In addition, in the rendezvous technique the contrast medium is not injected retrogradely as during the traditional endoscopic retrograde cholangiopancreatography (ERCP), when the medium accidentally could be injected under pressure into the pancreatic duct. The RV technique minimizes that risk. Both these main advantages of the RV technique over the classic ERCP, are related with a significant lower incidence of hyperamylasemia and post-ERCP pancreatitis, compared with the traditional two stage procedure. Choledocholithiasis is present in 10% to 15% of patients undergoing cholecystectomy. To date, the ideal management of CBD stones remains controversial. Prospective randomized trials have shown that laparoscopic management of the CBD stones, as a single stage procedure, is the most efficient and cost effective method of treatment. Laparoendoscopic rendezvous has been proposed as an alternative single stage approach. Several studies have shown the effective use of this technique in the treatment of CBD stones by improving patient compliance and clinical results including shorter hospital stay, higher success rate and less cost. The current evidence about the use of this technique presented in this review article is promising and demonstrates the main advantages of the procedure.

Spyglass-Assisted Management of a Large Impacted Cystic Duct Stone

Introduction: Endoscopic therapy of an impacted cystic duct stone can be very challenging. Successful passage of a guidewire beyond the impaction is necessary for successful further treatment with extractor balloon or lithotripsy basket. We present a unique case of a large impacted cystic duct stone where we used spyglass cholangioscopy to direct the guidewire into the cystic duct with subsequent removal of the stone in a patient who failed conventional ERCP techniques. A 52-year-old woman with a history of cholecystectomy 10 years ago is referred to our center for further management of a large impacted cystic duct stone. She initially presented to an outside hospital with severe abdominal pain, nausea, vomiting and was subsequently diagnosed with gallstone pancreatitis. An ERCP was performed at the outside hospital that revealed a common bile duct dilated to 2cm and a 1.5cm cystic duct stone. A sphincterotomy was performed followed by removal of sludge and stone fragments. Multiple attempts to traverse the cystic duct remnant with a guidewire were unsuccessful. A temporary biliary stent was placed and the patient was referred to our center for further management. At presentation at our institute, the patient reported intermittent abdominal pain. Physical exam was unremarkable. She underwent a repeat ERCP at our institution. Cholangiogram revealed a markedly dilated bile duct to 2cm.The cystic duct remnant contained a 1.5cm stone causing extrinsic compression/obstruction of the bile duct suggestive of Mirrizzi’s Syndrome. We were unable to traverse the cystic duct using traditional ERCP maneuvers due to the large impacted stone. The spyglass system was then introduced into the biliary tree and a large stone was visualized in the cystic duct remnant. A guidewire was passed into the cystic duct remnant under direct vision. The papillary orifice was then dilated with a 15mm CRE balloon followed by balloon sweep with extraction of the large cystic duct stone. Abdominal pain, nausea and vomiting resolved after the procedure.The removal of an impacted cystic duct stone can be very challenging and time consuming. In our case, placement of a guidewire into the cystic duct under direct view lead to successful removal of an impacted stone. In addition, spyglass cholangioscopy allows for targeted therapy of refractory bile duct and cystic duct stones with electrohydraulic lithotripsy or laser therapy as well as targeted biopsy sampling of indeterminate biliary strictures. SpyGlass single-operator peroral cholangioscopy system is a safe and effective diagnostic and therapeutic tool.

828 Comparison of ERCP Versus EUS-Guided Biliary Interventions in Patients With Surgically Altered Anatomy

Traditional ERCP can be difficult in patients with surgically altered anatomy. EUS-guided interventions (EUS-I) are an alternative means of facilitating therapy (via EUS-rendezvous ERCP or direct interventions) in patients with a difficult-to-access biliary tree. There are limited data on the use of EUS-I in patients with surgically altered anatomy.

ERCP in the Management of Choledocholithiasis in Pregnancy

The physiological changes of pregnancy increase the risk of gallstone formation, and choledocholithiaisis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. ERCP has been performed during pregnancy for over 20years. Despite the apparent efficacy and lack of adverse fetal outcomes in published case series and reports, there remains a concern for the use of fluoroscopy during pregnancy. Recent focus has centered around avoidance of the use of fluoroscopy during ERCP, including the use of alternative techniques to confirm biliary cannulation and ductal clearance. The benefits of these techniques over traditional ERCP technique are unclear. In this article, we will review the epidemiology of gallstone disease during pregnancy, outline the risks of ERCP during pregnancy, and describe recent novel techniques in endoscopic biliary intervention for biliary drainage and ductal clearance.