Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

Amy Tyberg,Jose Nieto,Sanjay Salgado,Kristen Weaver,Prashant Kedia,Reem Z. Sharaiha,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.2

Background/Aims: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Roux-en-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS. Methods: All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection. Results: Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg. Conclusions: EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

The Effect of Fluoroscopy Control on Cannulation Rate and Fluoroscopy Time in Endoscopic Retrograde Cholangiopancreatography Training

( Raymond E. Kim ),( Lance T. Uradomo ),( Grace E. Kim ),( John D. Morris ),( Eric M. Goldberg ),( Peter E. Darwin ) 대한췌장담도학회 2021 대한췌담도학회지 Vol.26 No.1

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) training requires varying degrees of staff assistance regarding operation of the fluoroscopy machine via a foot pedal. Efficiency is important to acquire during this training due to radiation risks. In this study, we evaluate the effect of controlling endoscopy and fluoroscopy unit on duct cannulation rates (CRs) and total fluoroscopy time (FT) for fellows in training. Methods: 204 patients undergoing ERCP were randomized to one of two groups: 1) “Endoscopist Driven” group in which the endoscopist controlled the foot pedal for fluoroscopy, and 2) “Assistant Driven” group in which attending or fellow controlled the foot pedal while the other team member controlled the endoscope. Various measures including selective duct CR and total FT were recorded. Results: There was no significant difference in mean procedure duration between the two groups (32 minutes vs. 33 minutes, p=0.70). There was also no statistically significant difference in CR (83.7% vs. 77.4%, p=0.25) or FT (3.27 minutes vs. 3.54 minutes, p=0.48). Conclusions: ERCP is a technically challenging procedure which requires extensive supervision. This study demonstrates that CR and FT are not affected by who controls the fluoroscopy. Korean J Pancreas Biliary Tract 2021;26(1):43-48

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

( Ho Seok Ki ),( Chang Hwan Park ),( Chung Hwan Jun ),( Seon Young Park ),( Hyun Soo Kim ),( Sung Kyu Choi ),( Jong Sun Rew ) 대한소화기학회 2015 Gut and Liver Vol.9 No.1

Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap assisted ERCP in patients with altered GI anatomy. Methods: The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B II) gastrectomy (n=72), Roux en Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure related complications were analyzed. All of the procedures were conducted using a cap fitted forward viewing endoscope. Results: The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B II gastrectomy, 50% (2/4) for Roux en Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure related deaths. Conclusions: Cap assisted ERCP is efficient and safe in patients with altered GI anatomy. (Gut Liver 2015;9:109 112)

Cholelithiasis Fortunately Removed by Endoscopic Retrograde Cholangiopancreatography

Jun Gi Park,Jeong Ill Suh,Jun Hwa Song,Tae Ho Kwon,Byeung Woo Kang,Byeong Ju Cho 순천향대학교 순천향의학연구소 2015 Journal of Soonchunhyang Medical Science Vol.21 No.2

Stones in the common duct occur in 10% to 15% of patients with cholelithiasis. In our case, coexistent cholelithiasis and choledocholithiasis were diagnosed by endoscopic retrograde cholangiopancreatography. The stone basket was easily introduced into the gallbladder and common bile duct, then fortunately removed stones. However, endoscopic retrograde cholelithiasis removal is known to be difficult because of the anatomical approach. We herein present a rare case of cholelithiasis successfully treated by retrograde endoscopic removal.

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

Tsuyoshi Hamada,Yousuke Nakai,Hiroyuki Isayama 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.2

Placement of a plastic or metal stent via endoscopic retrograde cholangiopancreatography (ERCP) currently serves as the first-line procedure for obstructive jaundice and acute cholangitis. Dysfunction of the biliary stent causes recurrence of symptoms and often requires reinterventions and hospitalizations. Therefore, duration of stent patency is commonly used as the primary endpoint in clinical studies of biliary stents. However, owing to considerable heterogeneity between studies in reporting of biliary stent patency, it has been difficult to compare and integrate results of independent studies. There has been between-study heterogeneity in definitions of stent patency, statistics reported for survival curves of stent patency, and methods to treat censored cases. In addition to stent occlusion, stent migration is a major cause of recurrent biliary obstruction after covered metal stent placement, which further complicates the reporting of stent patency. Reporting of functional success and adverse events has been also inconsistent between the studies. From the perspective of evidence-based medicine, the variations in the definitions of outcome variables potentially hinder robust meta-analyses. To overcome the issues due to the lack of outcome reporting guidelines on the topic, the TOKYO criteria 2014 for reporting outcomes associated with endoscopic transpapillary placement of biliary stents have been proposed. Due to their comprehensiveness, the TOKYO criteria can be readily utilized to evaluate various types of biliary stent placement using ERCP, irrespective of types of stents and location of biliary stricture. In this article, we review the TOKYO criteria as a standardized reporting system for endoscopically-placed biliary stents. We also discuss potential controversial issues in the application of the TOKYO criteria. Given that endoscopic ultrasound-guided biliary drainage is increasingly utilized for cases with failed ERCP or altered gastrointestinal anatomy, we further propose a potential application of the TOKYO criteria to reporting of outcomes of this procedure.

Comparison of intraductal ultrasonography-directed and cholangiography-directed endoscop­ic retrograde biliary drainage in patients with a biliary obstruction

( Soo-jung Rew ),( Du-hyeon Lee ),( Chang-hwan Park ),( Jin Jeon ),( Hyun-soo Kim ),( Sung-kyu Choi ),( Jong-sun Rew ) 대한내과학회 2016 The Korean Journal of Internal Medicine Vol.31 No.5

Background/Aims: Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultraso­nography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholan­giography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extra­hepatic biliary obstruction. Methods: A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between Oc­tober 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates. Results: The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups. Conclusions: IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement

Tsuyoshi Hamada,Yousuke Nakai,Hiroyuki Isayama 소화기인터벤션의학회 2018 International journal of gastrointestinal interven Vol.7 No.2

Placement of a plastic or metal stent via endoscopic retrograde cholangiopancreatography (ERCP) currently serves as the first-line procedure for obstructive jaundice and acute cholangitis. Dysfunction of the biliary stent causes recurrence of symptoms and often requires reinterventions and hospitalizations. Therefore, duration of stent patency is commonly used as the primary endpoint in clinical studies of biliary stents. However, owing to considerable heterogeneity between studies in reporting of biliary stent patency, it has been difficult to compare and integrate results of independent studies. There has been between-study heterogeneity in definitions of stent patency, statistics reported for survival curves of stent patency, and methods to treat censored cases. In addition to stent occlusion, stent migration is a major cause of recurrent biliary obstruction after covered metal stent placement, which further complicates the reporting of stent patency. Reporting of functional success and adverse events has been also inconsistent between the studies. From the perspective of evidence-based medicine, the variations in the definitions of outcome variables potentially hinder robust meta-analyses. To overcome the issues due to the lack of outcome reporting guidelines on the topic, the TOKYO criteria 2014 for reporting outcomes associated with endoscopic transpapillary placement of biliary stents have been proposed. Due to their comprehensiveness, the TOKYO criteria can be readily utilized to evaluate various types of biliary stent placement using ERCP, irrespective of types of stents and location of biliary stricture. In this article, we review the TOKYO criteria as a standardized reporting system for endoscopically-placed biliary stents. We also discuss potential controversial issues in the application of the TOKYO criteria. Given that endoscopic ultrasound-guided biliary drainage is increasingly utilized for cases with failed ERCP or altered gastrointestinal anatomy, we further propose a potential application of the TOKYO criteria to reporting of outcomes of this procedure.

Current Issues in Duodenoscope-Associated Infections: Now Is the Time to Take Action

하정훈,손병관 대한소화기내시경학회 2015 Clinical Endoscopy Vol.48 No.5

A duodenoscope has a very complex structure that contains many small parts which make reprocessing more challenging. The difficulty in cleaning duodenoscopes contributes to a higher risk of infection than that of conventional gastrointestinal endoscopes. However, a duodenoscope shares similar disinfection process with other gastrointestinal endoscopes. Recent outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) infections associated with duodenoscopes used for endoscopic retrograde cholangiopancreatography procedures have raised many concerns worldwide. Duodenoscope-associated infections involving CRE or other multidrug-resistant bacteria pose a great threat to patients undergoing procedures using duodenoscopes and should be dealt with a great concern. Updated guidelines regarding cleaning and disinfection of duodenoscope needs to be developed urgently to prevent transmission of infection and ensure patient safety. Meanwhile, healthcare staff should pay special attention to thorough cleaning and disinfection of duodenoscopes.

내시경적 배액술로 치료한 주췌관 파열없이 발생한 췌장성 복수 및 흉막액

김광현(Kwang Hyun Kim),백순구(Soon Koo Baik),정연수(Yeon Soo Jung),김재권(Jae Gwon Kim),김현수(Hyun Soo Kim),이동기(Dong Ki Lee),권상옥(Sang Ok Kwon) 대한내과학회 2001 대한내과학회지 Vol.60 No.2

Pancreatic ascites and pleural effusion is a rare complication of inflammatory disease of pancreas. Disruption of the pancreatic duct secondary to inflammatory pancreatic disease results in an internal pancreatic fistula into the peritoneal or pleural cavities. Thus, pancreatic secretion through the internal pancreatic fistula accumulate within the peritoneal or pleural cavities. The diagnosis is strongly suspected by paracentesis and thoracentesis, which demonstrate a markedly elevated amylase and an albumin level in pancreatic ascites and pleural effusion, and is confirmed by observation of pancreatic duct contrast leakage at endoscopic retrograde pancreatography. We report a patient with pancreatic ascites and pleural effusion who had no demonstrable pancreatic duct disruption on endoscopic retrograde pancreatography, but successfully treated by pancreatic duct stent endoscopically.(Korean J Med 60:175-178, 2001)

담도 스텐트 이탈에 의한 십이지장 천공 환자에서 지혈클립과 Fibrin Glue를 이용한 내시경 치료 1예

김기원,이태훈,박상흠,손범석,이세환,이석호,정일권,김선주 대한소화기내시경학회 2011 Clinical Endoscopy Vol.42 No.6

Duodenal perforations caused by biliary prostheses are uncommon, but they are potentially life threatening and require immediate treatment. Here we describe an unusual case of duodenal perforation induced by a plastic biliary stent. It masqueraded as a case of cholecystitis and combined systemic upset with a localized peritonitis and fever. Primary endoscopic closure by hemoclips was difficult due to the position of the lateral wall and the complexity of aligning the perforation with the endoscope. To approximate the perforated hole and adherent hemoclips, glue injection and sprayings were successfully performed under cap-fitted endoscopy. The patient recovered without additional complications. 치료적 ERCP 시술에서 금속 또는 플라스틱 담도 스텐트에 의한 십이지장 천공은 비교적 드문 합병증이나 매우 치명적인 결과를 초래할 수 있는 합병증으로 즉각적인 진단과 수술적 치료를 요한다. 저자들은 담도 스텐트 삽입 후 초기에 담낭염으로 오인되어 경피경간 담낭배액술을 시행하였으나, 플라스틱 담도 스텐트 이탈에 의한 십이지장 천공과 이로 인한 국소적 복막염으로 최종 진단된 72세 남자에서 내시경 치료를 시도하였다. 일차적인 내시경 봉합술을 위해 내시경 선단에 투명캡을 장착 후 지혈클립을 이용해 봉합하였으나 천공 위치로 인해 완전한 봉합이 이루어지지 않아 일차 봉합한 점막에 fibrin glue의 주입과 도포를 시행해 성공적으로 치료한 증례를 보고하고자 한다.