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Alhaddad O, Elsabaawy M, El-Azab G, Edrees A, Amer M, Eissa M. Efficacy and safety of immediate vs. delayed endoscopic retrieval of large or multiple common bile duct stones in high-risk elderly patients: a prospective, randomized comparative study. Clin Exp Med 2025; 25:183. [PMID: 40439932 PMCID: PMC12122547 DOI: 10.1007/s10238-025-01712-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2025] [Accepted: 05/01/2025] [Indexed: 06/02/2025]
Abstract
INTRODUCTION Elderly patients with common bile duct (CBD) stones often present with large or multiple stones, making endoscopic retrograde cholangiopancreatography (ERCP)-guided extraction a technically complex and potentially high-risk procedure. AIM This study aimed to compare the efficacy and safety of a staged approach-biliary stenting followed by delayed stone extraction-versus immediate stone removal during the initial ERCP in frail elderly patients with large or multiple CBD stones. METHODS This prospective study included high-risk elderly patients with large or multiple CBD stones, defined as either a single stone ≥ 15 mm in diameter or three or more stones, each ≥ 10 mm in diameter. Participants were randomly assigned to two equal groups: Group A underwent initial biliary stenting with elective stone retrieval after 8-12 weeks, while Group B underwent immediate stone extraction during the first ERCP. RESULTS A total of 400 patients were included, with 200 in each group. Baseline characteristics and stone extraction methodologies were comparable between the two groups. In Group A, stone size and number significantly decreased after stenting (mean size: 1.42 ± 0.28 cm before vs. 0.98 ± 0.19 cm after stenting; P < 0.001). The overall stone clearance rate was significantly higher in Group A compared to Group B (94% vs. 80%, P < 0.001). Post-ERCP hospital stay was significantly shorter in Group A (6.41 ± 1.27 days vs. 11.3 ± 1.86 days, P < 0.001). Group B had higher rates of complications, including cholangitis (1% vs. 7%, P < 0.05) and pneumonia (2% vs. 11%, P < 0.05). CONCLUSION In high-risk elderly patients with large or multiple CBD stones, temporary placement of biliary plastic stents followed by elective endoscopic stone removal effectively reduces stone size, simplifies the removal process, enhances stone clearance rates, and decreases ERCP-related complications.
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Affiliation(s)
- Omkolsoum Alhaddad
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt
| | - Maha Elsabaawy
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt
| | - Gasser El-Azab
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt.
| | - Ahmed Edrees
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt
| | - Mohamed Amer
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt
| | - Mohamed Eissa
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebeen El-Kom, Menoufia, 32511, Egypt
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Kato H, Tomoda T, Matsumi A, Matsumoto K. Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc 2025; 37:362-372. [PMID: 39633248 DOI: 10.1111/den.14966] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 11/10/2024] [Indexed: 12/07/2024]
Abstract
Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama City Hospital, Okayama, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
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Wang J, Cao L, Xue K, Qi P, Mao Q, Cui M, Ju H, He B, Cao B. Endoscopic Papillary Large Balloon Dilatation With or Without Endoscopic Sphincterotomy in the Treatment of Common Bile Duct Stones. Dig Dis Sci 2025; 70:478-493. [PMID: 39708261 DOI: 10.1007/s10620-024-08797-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Accepted: 12/09/2024] [Indexed: 12/23/2024]
Abstract
PURPOSE OF REVIEW Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS. FINDINGS EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Jia Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Lichao Cao
- Health Care Management Master of Science, Johns Hopkins University, Baltimore, MD, USA
| | - Kuijin Xue
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Peng Qi
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Qingdong Mao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Mingjuan Cui
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Hui Ju
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Baoguo He
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China
| | - Bin Cao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong Province, China.
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Wang J, Cao L, Cong Y, Huang Y, Wang L, Wang W, Xue K, Mao Q, Qi P, Ju H, He B, Cao B. Comparative efficacy and safety of 3 endoscopic techniques for the treatment of large common bile duct stones (≥15 mm): long-term follow-up. Gastrointest Endosc 2024:S0016-5107(24)03829-X. [PMID: 39716537 DOI: 10.1016/j.gie.2024.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Revised: 11/30/2024] [Accepted: 12/15/2024] [Indexed: 12/25/2024]
Abstract
BACKGROUND AND AIMS The effectiveness of endoscopic papillary large balloon dilation (EPLBD) alone versus EPLBD combined with endoscopic sphincterotomy (EST) in treating large common bile duct stones (CBDSs; ≥15 mm) remains unclear. This study aimed to evaluate the safety and treatment outcomes of EPLBD combined with limited or large EST versus EPLBD alone in removing large CBDSs. METHODS Between January 2013 and September 2024, total of 408 patients underwent EPLBD, either alone or in combination with EST, to treat large CBDSs (≥15 mm). Patients were divided into 3 groups: EPLBD alone (n = 92), EPLBD with limited EST (n = 124), and EPLBD with large EST (n = 192). The study compared the first-session stone clearance rate, overall stone success rate, mechanical lithotripsy use, and adverse event rate. RESULTS Compared with the EPLBD alone group, the EPLBD with limited EST and the EPLBD with large EST groups exhibited higher initial stone clearance rates, required fewer endoscopic procedures for complete stone removal, and had lower rates of mechanical lithotripsy use and CBDS recurrence. Compared with the EPLBD with limited EST group, the EPLBD with large EST group showed a higher initial stone clearance rate, fewer endoscopic procedures required for complete CBDS removal, and no significant differences in adverse events. The multivariate analysis showed that the endoscopic technique and number of endoscopic operations were strongly associated with CBDS recurrence. CONCLUSIONS EPLBD combined with large EST may represent a more rational endoscopic technique for treating large CBDSs.
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Affiliation(s)
- Jia Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lichao Cao
- Health Care Management Master of Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuchen Cong
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yining Huang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lei Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Wenjing Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Kuijin Xue
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Qingdong Mao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Peng Qi
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Hui Ju
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Baoguo He
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Bin Cao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.
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Sharma SS, Maharshi S, Sapra B, Nijhawan S, Sharma D. Outcome of forgotten biliary stents for more than five years-A two-decade experience. Indian J Gastroenterol 2024; 43:768-774. [PMID: 38206449 DOI: 10.1007/s12664-023-01493-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. METHODS The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. RESULTS The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). CONCLUSIONS Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.
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Affiliation(s)
- Shyam Sunder Sharma
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sudhir Maharshi
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India.
| | - Bharat Sapra
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Dhruv Sharma
- Department of Surgery, Mahatma Gandhi Medical College and Hospitals, Jaipur, 303 905, India
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Meng K, Zhang DY, Chen DX, Liu WJ, Fang KX, Chen S, Wu L, Li MY. Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone removal or elective stone removal? A single-center retrospective study. BMC Gastroenterol 2023; 23:344. [PMID: 37798726 PMCID: PMC10552253 DOI: 10.1186/s12876-023-02976-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal. METHODS The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared. RESULTS A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214). CONCLUSION For high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal.
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Affiliation(s)
- Ke Meng
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Fuxing Road, #28, Haidian District, Beijing, 100853, China
| | - Da-Ya Zhang
- Graduate School, Hainan Medical University, Haikou, 571199, China
| | - De-Xin Chen
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Wen-Jing Liu
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Kai-Xuan Fang
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Shengxin Chen
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Lang Wu
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Ming-Yang Li
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Fuxing Road, #28, Haidian District, Beijing, 100853, China.
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Shionoya K, Koizumi K, Masuda S, Kubota J, Kimura K, Makazu M. A Case of Spurting Bleeding After Endoscopic Papillary Balloon Dilation. GASTRO HEP ADVANCES 2023; 2:889-892. [PMID: 39130757 PMCID: PMC11308825 DOI: 10.1016/j.gastha.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/06/2023] [Indexed: 08/13/2024]
Abstract
A 58-year-old male with acute cholangitis due to a common bile duct stone underwent endoscopic retrograde cholangiopancreatography for stone removal with endoscopic papillary balloon dilation (EPBD) due to his high bleeding risk owing to maintenance dialysis and antiplatelet and anticoagulant medications. He had a history of stone removal using an EPBD. The stone was removed; however, the patient subsequently developed spurting bleeding and underwent endoscopic hemostasis. Despite the subsequent mild pancreatitis, he recovered with conservative management. While EPBD is considered a low-risk procedure for bleeding, caution should still be exercised due to the possibility of massive postprocedural bleeding.
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Affiliation(s)
- Kento Shionoya
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage. J Clin Gastroenterol 2023; 57:553-568. [PMID: 36040964 DOI: 10.1097/mcg.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, WA
| | | | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA CA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Paspatis GA, Papastergiou V, Mpitouli A, Velegraki M, Nikolaou P, Fragkaki M, Voudoukis E, Theodoropoulou A, Chlouverakis G, Vardas E, Paraskeva KD. Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents. Dig Dis Sci 2022; 67:4557-4564. [PMID: 35305168 DOI: 10.1007/s10620-022-07461-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known complication, although data beyond the recommended interval of temporary stenting (3-6 months) are lacking. We compared the long-term incidence of DSM between straight and double-pigtail stents in patients with IBDS. METHODS Consecutive patients with IBDS undergoing plastic biliary stenting (1/2009-12/2019) were retrospectively reviewed. DSM was confirmed on follow-up examination when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Kaplan-Meier and Cox regression analyses were used to determine estimates and predictors of DSM. RESULTS Overall, 618 biliary stenting procedures (410 patients) were included: 289 with a straight stent (group A) and 329 with a double-pigtail (group B). By Kaplan-Meier analysis, the DSM rates were 8.4 and 14.6% at 6 months, 21.4 and 27.7% at 12 months, 27 and 43.5% at 18 months, and 37.2 and 60.4% at 24 months, for groups A and B, respectively (p = 0.004). Double-pigtail stents were at higher risk for DSM (HR = 7.38, p = 0.04), whereas an inverse correlation was noted with age (HR = 0.97, p = 0.0001). Considering only temporary stenting procedures (≤ 6 months; n = 297), the probability of DSM was not significantly different between the two groups (p = 0.07). CONCLUSIONS In a setting of prolonged stenting for IBDS, the probability of DSM appears to be higher when a double-pigtail stent is used and in younger patients. A relative anti-migratory advantage of double-pigtail over straight stents appears negligible in this study.
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Affiliation(s)
- Gregorios A Paspatis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece.
| | - Vasilios Papastergiou
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, Athens, Greece
| | - Afroditi Mpitouli
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Pinelopi Nikolaou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Maria Fragkaki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Angeliki Theodoropoulou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | | | - Emmanouil Vardas
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
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Phillpotts S, Webster G, Arvanitakis M. Endoscopic Management of Complex Biliary Stones. Gastrointest Endosc Clin N Am 2022; 32:477-492. [PMID: 35691692 DOI: 10.1016/j.giec.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.
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Affiliation(s)
- Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England.
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, Brussels 1070, Belgium
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11
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Jang DK. [Complete Endoscopic Clearance of Common Bile Duct Stones]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:199-202. [PMID: 35610549 DOI: 10.4166/kjg.2022.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/03/2022]
Abstract
Common bile duct stones (CBDS) are the most common cause of acute cholangitis. Removal by endoscopic retrograde cholangiopancreatography became the standard of care after endoscopic sphincterotomy was introduced. On the other hand, it is still difficult to remove 10-15% of CBDS completely in the first attempt for various reasons. This review describes the methods for the complete endoscopic clearance of CBDS, including difficult cases, reflecting the latest knowledge and techniques.
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Affiliation(s)
- Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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12
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Wang H, Zhang J, Lin X, Ou Y. Laparoscopic Common Bile Duct Exploration with Gallbladder Preservation: An Innovative Technique for Primary Common Bile Duct Stones. J Laparoendosc Adv Surg Tech A 2022; 32:974-977. [PMID: 35245097 DOI: 10.1089/lap.2021.0825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Primary common bile duct (CBD) stones can be treated with laparoscopic CBD exploration (LCBDE), during which cholecystectomy is routinely performed. For patients without gallstones, we have developed a new procedure, LCBDE with gallbladder preservation. The purpose of this study was to evaluate the management of LCBDE with gallbladder preservation at our institution. Methods: Retrospective analysis the clinical data of 105 patients with primary CBD stones. Demographic data, clinical characteristics, preoperative risk factors, and postoperative complications were evaluated. Results: All patients were divided into two groups depending on the presence of gallstones: the primary CBD stone coexistence gallstones group (Group A, n = 15) and the primary CBD stones absence gallstones group (Group B, n = 90). Complete stones clearance was achieved in all patients. There were no significant differences in postoperative complications rates and mortality between the two groups. The mean postoperative hospital stay was 3.2 days for Group A and 4.1 days for Group B (P = .03). Conclusion: This study found that LCBDE with gallbladder preservation can effectively and safely treat primary CBD stones without gallbladder stones.
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Affiliation(s)
- Huiling Wang
- Department of Hepatobiliary Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jianxing Zhang
- Department of Hepatobiliary Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Xingtao Lin
- Department of Hepatobiliary Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yingliang Ou
- Department of Hepatobiliary Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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13
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Masuda S, Koizumi K, Nishino T, Tazawa T, Kimura K, Tasaki J, Ichita C, Sasaki A, Kako M, Uojima H, Sugitani A. Direct oral anticoagulants increase bleeding risk after endoscopic sphincterotomy: a retrospective study. BMC Gastroenterol 2021; 21:401. [PMID: 34689751 PMCID: PMC8543952 DOI: 10.1186/s12876-021-01980-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background Bleeding 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. Methods We 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. Results The 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). Conclusions DOAC 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.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kazuya Koizumi
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Takashi Nishino
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Tomohiko Tazawa
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Karen Kimura
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Junichi Tasaki
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Chikamasa Ichita
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Akiko Sasaki
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Makoto Kako
- Department of Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, 252-0375, Japan
| | - Ayumu Sugitani
- Department of the Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, 065-0033, Japan
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14
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Hoekstra E, Veenendaal R, Inderson A. Direct peroral cholangioscopic retrieval of an inward migrated plastic stent lodged in the cystic duct and liver hilum. Endoscopy 2021; 53:E330-E331. [PMID: 33096571 DOI: 10.1055/a-1275-9571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Elmer Hoekstra
- Department of Gastroenterology and Hepatology, Leiden Universitair Medisch Centrum (LUMC), Albinusdreef 2, Leiden, Netherlands
| | - Roeland Veenendaal
- Department of Gastroenterology and Hepatology, Leiden Universitair Medisch Centrum (LUMC), Albinusdreef 2, Leiden, Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden Universitair Medisch Centrum (LUMC), Albinusdreef 2, Leiden, Netherlands
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15
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Ozcan N, Riaz A, Kahriman G. Percutaneous Management of Biliary Stones. Semin Intervent Radiol 2021; 38:348-355. [PMID: 34393345 DOI: 10.1055/s-0041-1731373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bile duct stone disease is the most common causes of nonmalignant bile duct obstructions. The range of common bile duct stone formation in patients with cholecystectomy is 3 to 14.7%. Hepatolithiasis, although endemic in some parts of the world, is a rare disease that is difficult to manage. Endoscopic intervention is accepted as the first-line management of common bile duct stones. However, when the bile duct cannot be cannulated for various reasons, the endoscopic procedure fails. In this circumstance, percutaneous approach is an alternative technique for the nonsurgical treatment of bile duct stones. This article reviews the indications, technique, outcomes, and complications of the percutaneous treatment of bile duct stone disease.
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Affiliation(s)
- Nevzat Ozcan
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Erciyes, Medical Faculty, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Ahsun Riaz
- Division of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Guven Kahriman
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Erciyes, Medical Faculty, Gevher Nesibe Hospital, Kayseri, Turkey
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16
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Tomoda T, Kato H, Miyamoto K, Matsumi A, Ueta E, Fujii Y, Saragai Y, Yamazaki T, Uchida D, Matsumoto K, Horiguchi S, Tsutsumi K, Okada H. Efficacy of low dose rectal diclofenac for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: Propensity score-matched analysis. Dig Endosc 2021; 33:656-662. [PMID: 32881078 DOI: 10.1111/den.13828] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute pancreatitis is a major adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) decreases the incidence of post-ERCP pancreatitis (PEP). However, the efficacy of low dose rectal NSAIDs for preventing PEP remains controversial. METHODS We performed a retrospective study of 301 patients with native papilla and a body weight of <50 kg who underwent ERCP between September 2010 and October 2019. After July 2016, a 25 mg dose of rectal diclofenac was routinely administered within 15 min before ERCP (NSAIDs group, n = 72) and the control group (n = 229) consisted of patients undergoing ERCP before this date without treatment. We compared the incidence of PEP between the two groups using propensity score matching. RESULTS A total of 66 pairs of patients in each group were selected. The patients and procedural-related factors were similar in both groups. In total, 15 patients (11.4%) developed PEP: 12.1% (8/66) in the NSAIDs group and 10.6% (7/66) in the control group (Odds ratio (OR) 1.2; 95% confidence interval (CI) 0.4-3.5; P = 0.78). There was no significant difference in incidence of other adverse events related to ERCP between the two groups. CONCLUSIONS Prophylactic administration of a 25 mg dose of rectal diclofenac did not reduce the incidence of PEP in patients with a native papilla and a body weight of <50 kg in this study and a certain dose of rectal NSAIDs, such as a 100-mg dose, should be administered regardless of body weight to prevent PEP.
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Affiliation(s)
- Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Kazuya Miyamoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Eijiro Ueta
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Yuuki Fujii
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Yousuke Saragai
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Tatsuhiro Yamazaki
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Daisuke Uchida
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
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Kim MU, Lee Y, Lee JH, Cho SB, Lee MS, So YH, Choi YH. Predictive factors affecting percutaneous drainage duration in the percutaneous treatment of common bile duct stones. PLoS One 2021; 16:e0248003. [PMID: 33651811 PMCID: PMC7924786 DOI: 10.1371/journal.pone.0248003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/17/2021] [Indexed: 12/24/2022] Open
Abstract
The duration of percutaneous transhepatic biliary drainage (PTBD) is a critical factor that determines the duration of treatment. This study aimed to evaluate factors affecting the PTBD duration in patients who underwent percutaneous treatment of common bile duct (CBD) stones. This study analyzed data of 169 patients who underwent percutaneous treatment of CBD stones from June 2009 to June 2019. Demographic data, characteristics of stone, procedure-related factors, and laboratory findings before the insertion of PTBD tubes were retrospectively evaluated. To assess the effect of confounding factors on the PTBD duration, multivariate linear regression analysis was applied, incorporating significant predictive factors identified in the univariate regression analysis. In the univariate regression analysis, the predictive factor that showed high correlation with the PTBD duration was the initial total bilirubin level (coefficient = 0.68, P < .001) followed by the short diameter of the largest stone (coefficient = 0.19, P = .056), and previous endoscopic sphincterotomy (coefficient = -2.50, P = .086). The multivariate linear regression analysis showed that the initial total bilirubin level (coefficient = 0.50, P < .001) and short diameter of the largest stone (coefficient = 0.16, P = .025) were significantly related to the PTBD duration. The total bilirubin level before PTBD tube insertion and the short diameter of the largest CBD stone were predictive factors for the PTBD duration in patients who underwent percutaneous CBD stone removal. Careful assessment of these factors might help in predicting the treatment period, thereby improving the quality of patient care.
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Affiliation(s)
- Min Uk Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yoontaek Lee
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, Korea
- * E-mail:
| | - Jae Hwan Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Soo Buem Cho
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Myoung Seok Lee
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Ho So
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Ho Choi
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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18
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Choi JH, Lee TY, Cheon YK. Effect of stent placement on stone recurrence and post-procedural cholangitis after endoscopic removal of common bile duct stones. Korean J Intern Med 2021; 36:S27-S34. [PMID: 32829571 PMCID: PMC8009149 DOI: 10.3904/kjim.2020.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS After endoscopic treatment of common bile duct (CBD) stones, recurrence of choledocholithiasis due to small stone fragments and post-endoscopic retrograde cholangiopancreatography (post-ERCP) cholangitis can occur. We determined the effect of biliary stenting after removal of CBD stones on the recurrence of CBD stones and the incidence of post-ERCP cholangitis. METHODS We performed a retrospective single-center study involving 483 patients who underwent ERCP for the removal of CBD stones. The patients were classified into two groups according to their biliary stenting status. The primary outcome was the rate of CBD stone recurrence and the secondary outcome was the incidence of post-ERCP cholangitis. RESULTS Among the 483 patients, 219 and 264 did and did not receive a biliary stent after CBD stone removal, respectively. The incidence of stone recurrence was 15.5% and 7.6% in the non-stenting and stenting groups (p = 0.006), respectively, while the incidence of post-ERCP cholangitis was 4.6% and 2.7% (p = 0.256). In a multivariate analysis, biliary stenting significantly reduced the stone recurrence rate (odds ratio, 0.30; p = 0.004). CONCLUSION Biliary stenting after the removal of CBD stones reduces the stone recurrence rate and assisted recovery. For patients with large and multiple stones who undergo lithotripsy, preventive biliary stent insertion can reduce the rate of stone recurrence.
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Affiliation(s)
| | | | - Young-Koog Cheon
- Correspondence to Young-Koog Cheon, M.D. Division of Gastroenterology, Department of Internal Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea Tel: + 82-2-2030-7490 Fax: + 82-2-2030-6190 E-mail:
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19
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Sabbah M, Nakhli A, Bellil N, Ouakaa A, Bibani N, Trad D, Elloumi H, Gargouri D. Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones. Heliyon 2020; 6:e05515. [PMID: 33294669 PMCID: PMC7683307 DOI: 10.1016/j.heliyon.2020.e05515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/13/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. METHODS A retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). RESULTS One hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3-40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272-0.979], an intra-diverticular papilla OR 0.179 [0.035-0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068-0.385] and a stenosis of the common bile duct OR 0.068 [0.008-0.605]. The success rate of the second line treatment was 73%. CONCLUSION Endoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.
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Affiliation(s)
- Meriam Sabbah
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Abdelwahab Nakhli
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Nawel Bellil
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Asma Ouakaa
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Norsaf Bibani
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Dorra Trad
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Héla Elloumi
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
| | - Dalila Gargouri
- Department of Gastroenterology, Habib Thameur Hospital, Tunisia
- Faculty of Medecine of Tunis, University of Tunis El Manar, Tunisia
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20
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Fairchild AH, Hohenwalter EJ, Gipson MG, Al-Refaie WB, Braun AR, Cash BD, Kim CY, Pinchot JW, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Biliary Obstruction. J Am Coll Radiol 2020; 16:S196-S213. [PMID: 31054746 DOI: 10.1016/j.jacr.2019.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia; American College of Surgeons
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
| | | | - Matthew J Scheidt
- Central Illinois Radiological Associates, University of Illinois College of Medicine, Peoria, Illinois
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21
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Sbeit W, Khoury T, Kadah A, M. Livovsky D, Nubani A, Mari A, Goldin E, Mahamid M. Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study. J Clin Med 2020; 9:2953. [PMID: 32932631 PMCID: PMC7564722 DOI: 10.3390/jcm9092953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction. AIM We aimed to report the safety of retained biliary stone. METHODS a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis. RESULTS Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively). CONCLUSION endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Dan M. Livovsky
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Adi Nubani
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Amir Mari
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
- Gastroenterology and Endoscopy Units, The Nazareth Hospital, EMMS, Nazareth 16100, Israel
| | - Eran Goldin
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Mahmud Mahamid
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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22
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Sugiura R, Naruse H, Yamato H, Kudo T, Yamamoto Y, Hatanaka K, Ito J, Kinoshita K, Miyamoto S, Higashino M, Hayasaka S, Sakamoto N. Long-term outcomes and risk factors of recurrent biliary obstruction after permanent endoscopic biliary stenting for choledocholithiasis in high-risk patients. J Dig Dis 2020; 21:246-251. [PMID: 32223015 DOI: 10.1111/1751-2980.12859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To elucidate the long-term outcomes of permanent endoscopic biliary stenting (EBS) and risk factors for recurrent biliary obstruction (RBO) in high-risk or elderly patients with common bile duct (CBD) stones. METHODS The electronic database of Hakodate Municipal Hospital was searched to identify elderly or high-risk patients with CBD stones who had undergone permanent EBS using a plastic stent without stone removal and were followed up between April 2011 and May 2019, with no further intervention until symptoms occurred. RESULTS We analyzed a total of 47 patients, of whom 19 (40.4%) were men, with a median age of 86 years (interquartile range 80-90 years). RBO and death without biliary disease occurred in 14 (29.8%) and 19 (40.4%) patients, respectively. The cumulative RBO rates at 20, 40, and 60 months were 22.1%, 31.8%, and 35.5%, respectively. The median time to RBO was 13.0 and 38.0 months in the group with CBD stone ≥15 mm and 11-14 mm in diameter, respectively. The cumulative RBO incidence rate in the group with CBD stone ≤10 mm in diameter did not reach 50%. The cumulative RBO incidence rates were significantly different among the three groups based on the CBD stone diameter (competing risk analysis, P < 0.01). Multivariate analysis showed that an increase in CBD stone diameter predicted the increased risk of RBO (hazard ratio 1.26, P = 0.01). CONCLUSIONS Permanent EBS is a feasible option for high-risk patients with small CBD stones.
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Affiliation(s)
- Ryo Sugiura
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Hirohito Naruse
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Hiroaki Yamato
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology, Iwamizawa Municipal General Hospital, Iwamizawa, Japan
| | - Taiki Kudo
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Yoshiya Yamamoto
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Kazuteru Hatanaka
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Jun Ito
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Kenji Kinoshita
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Shuichi Miyamoto
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Masayuki Higashino
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Shuhei Hayasaka
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
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23
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Muro S, Kato H, Ishida E, Ueki T, Fujii M, Harada R, Seki H, Hirao K, Wato M, Akimoto Y, Takatani M, Tsugeno H, Miyaike J, Toyokawa T, Nishimura M, Yunoki N, Okada H. Comparison of anticoagulants and risk factors for bleeding following endoscopic sphincterotomy among anticoagulant users: Results from a large multicenter retrospective study. J Gastroenterol Hepatol 2020; 35:37-42. [PMID: 31237013 DOI: 10.1111/jgh.14764] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIM Bleeding is an inevitable and often severe complication after endoscopic sphincterotomy (EST). We aimed to investigate the factors associated with post-EST bleeding in patients treated with anticoagulants. METHODS The data of patients who underwent EST at 15 hospitals between July 2015 and June 2017 were extracted. We investigated the incidence of post-EST bleeding and risk factors for bleeding in patients treated with anticoagulants. RESULTS One hundred forty-nine patients undergoing EST who met the inclusion criteria were included in this study. The total-EST bleeding (bleeding occurring during or after EST) rate did not differ between the heparin replacement (8.0%, 6/75) and continuation (16.6%, 2/12; P = 0.37) groups of warfarin users. The total-EST-bleeding rate in the heparin replacement group (12.9%, 4/31) was significantly higher than that in the continuation group (0%, 0/31; P = 0.016) in direct oral anticoagulant (DOAC) users. The rate of total-EST bleeding with continuation of DOAC (0%, 0/31) was significantly lower with continuation of warfarin (16.6%, 2/12; P = 0.021). During-EST bleeding (bleeding occurring during EST) (P = 0.0083) and precut (P = 0.033) were significant risk factors for post-EST bleeding in all 149 patients. Heparin replacement was only a significant risk factor for total-EST bleeding (P = 0.033) in DOAC users. CONCLUSION Heparin replacement was a significant risk factor for post-EST bleeding in DOAC users; however, there was no significant difference between the bleeding rate of heparin replacement and that of continuation groups in patients taking warfarin. During EST and precut were significant risk factors for post-EST bleeding in all patients treated with anticoagulants.
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Affiliation(s)
- Shinichiro Muro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Etsuji Ishida
- Department of Gastroenterology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Masakuni Fujii
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Ryo Harada
- Department of Gastroenterology, Okayama Red Cross General Hospital
| | - Hiroyuki Seki
- Department of Internal Medicine, Mitoyo General Hospital, Kannonji, Japan
| | - Ken Hirao
- Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masaki Wato
- Department of Internal Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Yutaka Akimoto
- Department of Gastroenterology, National Hospital Organization Iwakuni Medical Center, Iwakuni, Japan
| | - Masahiro Takatani
- Department of Internal Medicine, Japanese Red Cross Society Himeji Hospital, Himeji, Japan
| | - Hirofumi Tsugeno
- Department of Internal Medicine, Tsuyama Central Hospital, Tsuyama, Japan
| | - Jiro Miyaike
- Department of Internal Medicine, Saiseikai Imabari General Hospital, Imabari, Japan
| | - Tatsuya Toyokawa
- Department of Gastroenterology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan
| | - Mamoru Nishimura
- Department of Gastroenterology, Okayama City Okayama Citizens Hospital, Okayama, Japan
| | - Naoko Yunoki
- Department of Internal Medicine, Akaiwa Medical Association Hospital, Akaiwa, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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24
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Cappelli A, Mosconi C, Cucchetti A, Pettinari I, Andreone A, Zanardi S, Modestino F, De Benedittis C, Serenari M, Golfieri R. Outcomes following percutaneous treatment of biliary stones. HPB (Oxford) 2019; 21:1057-1063. [PMID: 30738713 DOI: 10.1016/j.hpb.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The percutaneous approach (PA) for management of biliary stones (BS) with or without an underlying biliary stenosis is an option for patients in whom an endoscopic approach (EA) is not possible. The aim of this study was to evaluate the efficacy of a PA in patients with BS unsuitable for an EA. METHODS A retrospective review of a database was performed. Inclusion criteria included patients with benign disease, BS who had undergone a PA. The outcomes were technical success rate, short (≤90 days) and long-term (>90 days) efficacy and safety. RESULTS A total of 91 patients enrolled were divided into those with (n = 38) or without (n = 53) a biliary stenosis. A median of 5 (IQR:3-7) treatments/patient were performed. During a median follow-up of 23 months (IQR:3-52), the median time free from recurrence was 21 months (CI:14-29). In the long term, the PA was most efficacious in those patients without a biliary stenosis with long term success in 68% of patients as compared to 36% of patients with a biliary stenosis (p = 0.003). CONCLUSION A PA is an effective procedure with high initial success rate, however the coexistence of stenosis affects long-term efficacy, especially in patients with chronic biliary disease.
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Affiliation(s)
- Alberta Cappelli
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cristina Mosconi
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, Italy; Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Irene Pettinari
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Andrea Andreone
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sara Zanardi
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Modestino
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Caterina De Benedittis
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Matteo Serenari
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Diagnostic and Preventive Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
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25
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Tomoda T, Kato H, Ueki T, Akimoto Y, Hata H, Fujii M, Harada R, Ogawa T, Wato M, Takatani M, Matsubara M, Kawai Y, Okada H. Combination of Diclofenac and Sublingual Nitrates Is Superior to Diclofenac Alone in Preventing Pancreatitis After Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2019; 156:1753-1760.e1. [PMID: 30772342 DOI: 10.1053/j.gastro.2019.01.267] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/23/2019] [Accepted: 01/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Acute pancreatitis is a major adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreases the incidence of post-ERCP pancreatitis (PEP). Little is known about the combined effects of sublingual nitrate and NSAIDs. We performed a randomized trial to assess whether the combination of NSAIDs and sublingual nitrate is more effective than NSAIDs alone in preventing PEP. METHODS In a prospective superiority trial, eligible patients underwent ERCP at 12 endoscopic units in Japan, from March 2015 through May 2018. Patients were randomly assigned to groups given diclofenac suppositories (50 mg) within 15 minutes after the endoscopic procedure alone (diclofenac-alone group, n = 442) or in combination with sublingual isosorbide dinitrate (5 mg) 5 minutes before the endoscopic procedure (combination group, n = 444). The primary endpoint was the occurrence of PEP. RESULTS PEP developed in 25 patients in the combination group (5.6%), and in 42 patients in the diclofenac-alone group (9.5%) (relative risk 0.59; 95% confidence interval 0.37-0.95; P = .03). Moderate to severe pancreatitis developed in 4 patients (0.9%) in the combination group, and 10 patients (2.3%) in the diclofenac-alone group (relative risk 0.12; 95% confidence interval 0.13-1.26; P = .12). There was no serious adverse event related to the additional administration of sublingual nitrate. CONCLUSIONS In a randomized controlled trial, we found that prophylaxis with rectal diclofenac and sublingual nitrate significantly reduces the overall incidence of PEP compared with diclofenac suppository alone. ClinicalTrials.gov, no: UMIN 000016274.
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Affiliation(s)
- Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Yutaka Akimoto
- Department of Gastroenterology, Iwakuni Clinical Center, Iwakuni, Japan
| | - Hidenori Hata
- Department of Gastroenterology, Mitoyo General Hospital, Kanonji, Japan
| | - Masakuni Fujii
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Ryo Harada
- Department of Gastroenterology, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Tsuneyoshi Ogawa
- Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masaki Wato
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Masahiro Takatani
- Department of Internal Medicine, Japanese Red Cross Society Himeji Hospital, Himeji, Japan
| | - Minoru Matsubara
- Department of Internal Medicine, Sumitomo Besshi Hospital, Niihama, Japan
| | - Yoshinari Kawai
- Department of Gastroenterology, Onomichi Municipal Hospital, Onomichi, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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26
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Hakuta R, Kawahata S, Kogure H, Nakai Y, Saito K, Saito T, Hamada T, Takahara N, Uchino R, Mizuno S, Tsujino T, Tada M, Sakamoto N, Isayama H, Koike K. Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis. Dig Endosc 2019; 31:59-68. [PMID: 29943385 DOI: 10.1111/den.13220] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/22/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Endoscopic papillary large balloon dilation (EPLBD) without endoscopic sphincterotomy (EST) may facilitate extraction of large bile duct stones through achieving adequate dilation of the ampulla. However, contrary to favorable long-term outcomes after endoscopic papillary balloon dilation (EPBD), that of EPLBD without EST has been little investigated. Therefore, we conducted the current study to evaluate short- and long-term outcomes of EPLBD without EST and EPBD after removal of large bile duct stones (LBDS; ≥10 mm). METHODS This retrospective study included patients without a previous history of EST, EPBD or EPLBD who underwent EPLBD without EST or EPBD for removal of LBDS. Each patient in the EPLBD without EST group was matched to a patient in the EPBD group using propensity scores. RESULTS Forty-four patients in each group were matched for the analysis. Baseline characteristics were balanced after propensity matching. Rate of complete stone removal in a single session was higher (80% vs 16%, P < 0.001), number of ERCP sessions (1.3 ± 0.7 vs 2.4 ± 1.5, P < 0.001) and rate of lithotripsy use (30% vs 80%, P < 0.001) were smaller in the matched EPLBD without EST group. Contrary to null between-group differences in early adverse events (P = 0.99), a cumulative rate of late biliary complications was higher in the EPLBD without EST group (P = 0.02). CONCLUSION EPLBD without EST showed higher efficacy for removal of LBDS but was associated with worse long-term outcomes when compared to EPBD.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, USA
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rie Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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27
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Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc 2018; 87:1050-1060. [PMID: 28866457 DOI: 10.1016/j.gie.2017.08.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Bile duct stones >1 cm have a decreased incidence of successful endoscopic extraction and often require lithotripsy. Although previous guidelines suggested mechanical lithotripsy for large common bile duct stones, current guidelines suggest cholangioscopy-guided lithotripsy as an adjunct with or without balloon dilation or mechanical lithotripsy. However, no randomized trials have assessed the usefulness of this practice. METHODS Patients with bile duct stones >1 cm in diameter were randomized in a 2:1 ratio to cholangioscopy-guided laser lithotripsy versus conventional therapy only. Conventional therapies such as mechanical lithotripsy or balloon dilation were also allowed in the laser lithotripsy group. Randomization was stratified by history of ERCP in the past 3 months. The primary outcome was endoscopic clearance of the bile duct stones. RESULTS Endoscopic clearance was achieved in 39 (93%) of 42 patients treated with cholangioscopy-guided laser lithotripsy and 12 (67%) of 18 treated with conventional therapy only (P = .009). The 9 patients in whom ERCP was unsuccessful underwent surgical common duct exploration with stone removal. Mean procedure time was 120.7 ± 40.2 minutes for the cholangioscopy-guided laser lithotripsy group compared with 81.2 ± 49.3 minutes for the conventional therapy group (P = .0008). There was no significant difference in fluoroscopy time, number of procedures, or adverse events (cholangitis) (cholangioscopy, 2; conventional, 1) and post-ERCP pancreatitis (cholangioscopy, 2; conventional, 1). CONCLUSION Cholangioscopy-guided laser lithotripsy increases the incidence of endoscopic clearance of large bile duct stones and decreases the need for surgery compared with conventional therapy alone. However, it is associated with longer procedure times. (Clinical trial registration number: NCT0175997.).
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28
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Tsiopoulos F, Kapsoritakis A, Psychos A, Manolakis A, Oikonomou K, Tzovaras G, Baloyiannis I, Tsikrika A, Potamianos S. Laparoendoscopic rendezvous may be an effective alternative to a failed preoperative endoscopic retrograde cholangiopancreatography in patients with cholecystocholedocholithiasis. Ann Gastroenterol 2017; 31:102-108. [PMID: 29333074 PMCID: PMC5759603 DOI: 10.20524/aog.2017.0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/20/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy (LC), remains the standard way of management for patients with cholecystocholedocholithiasis. Laparoendoscopic rendezvous (LERV), a combined procedure for removing the gallbladder laparoscopically and clearing the common bile duct (CBD) endoscopically at the same time, could be an attractive alternative. The aim of this study was to compare LERV with classic ERCP in patients with cholecystocholedocholithiasis. Methods: 886 patients with cholecystocholedocholithiasis were treated either with the LERV technique (90 patients), or with the 2-stage approach, which includes preoperative ERCP followed by LC (796 patients). The primary endpoint was any difference in the success of CBD cannulation and clearance; secondary endpoints were the detection of differences in morbidity (especially post-ERCP pancreatitis [PEP]), and the feasibility of the two approaches. Results: Successful cannulation of the CBD was more frequent with conventional ERCP compared with the LERV technique (89.8% vs. 75.5%, P=0.0001). LERV appears to be as effective as conventional ERCP for complete CBD clearance (85.5% vs. 82.8%, P<0.1). None of the patients in the LERV group had an episode of clinical PEP, whereas in the conventional ERCP group there were 23 episodes of PEP and one death. The median amylase level was higher in patients undergoing conventional ERCP group compared to patients in LERV group. Conclusion: Classic ERCP has a higher rate of successful CBD cannulation and a similar rate of CBD clearance compared to LERV.
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Affiliation(s)
- Fotios Tsiopoulos
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
| | - Andreas Kapsoritakis
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
| | - Athanassios Psychos
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
| | - Anastasios Manolakis
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
| | - Konstantinos Oikonomou
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
| | - George Tzovaras
- Department of Surgery (George Tzovaras, Ioannis Baloyiannis), Greece
| | | | - Alexandra Tsikrika
- Department of Radiology (Alexandra Tsikrika), Larissa University Hospital, Larissa, Greece
| | - Spyros Potamianos
- Department of Gastroenterology (Fotios Tsiopoulos, Andreas Kapsoritakis, Athanassios Psychos, Anastasios Manolakis, Konstantinos Oikonomou, Spyros Potamianos), Greece
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29
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Hakuta R, Hamada T, Nakai Y, Isayama H, Kogure H, Mizuno S, Naminatsu T, Yagioka H, Togawa O, Matsubara S, Ito Y, Yamamoto N, Tsujino T, Koike K. Multicenter retrospective and comparative study of 5-minute versus 15-second endoscopic papillary balloon dilation for removal of bile duct stones. Endosc Int Open 2017; 5:E1027-E1034. [PMID: 29090241 PMCID: PMC5658216 DOI: 10.1055/s-0043-118479] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/24/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic papillary balloon dilation (EPBD) is a method of bile duct stone removal that has a better long-term outcome but a high risk of post-ERCP pancreatitis (PEP). Recent studies have suggested that 5-minute EPBD can reduce the incidence of PEP. This study aimed to examine the safety and effectiveness of longer duration EPBD compared with shorter duration EPBD (5 minutes vs. 15 seconds after disappearance of the waist of a dilation catheter). PATIENTS AND METHODS Patients without a history of endoscopic sphincterotomy or EPBD who underwent EPBD to remove bile duct stones were selected retrospectively from five centers. The incidence of PEP, other early adverse events, and outcomes of EPBD were compared between the groups. A multivariable analysis of risk factors for PEP was performed. RESULTS A total of 607 patients (157 and 450 in the 5-minute and 15-second EPBD groups, respectively) were included. There were no statistically significant differences between the groups in terms of the incidence of PEP (8.3 % and 8.9 % in the 5-minute and 15-second EPBD groups, respectively; P = 0.871) and the incidence of overall early adverse events ( P = 0.999). Although 5-minute EPBD elongated the procedure time (45 vs. 37 minutes, P < 0.001), it increased the rate of complete stone removal during a single session ( P < 0.001) and decreased the use of lithotripsy ( P < 0.001). CONCLUSIONS Compared with 15-second EPBD, 5-minute EPBD did not reduce the incidence of PEP.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Corresponding author Hiroyuki Isayama, MD PhD Department of GastroenterologyGraduate School of MedicineThe University of Tokyo7-3-1 Hongo Bunkyo-kuTokyoJapan 113-8655+81-3-58009801
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahara Naminatsu
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Toshiba General Hospital, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan,Division of Gastroenterology and Hepatology, H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine School of Medicine, CA, USA
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Hou YC, Hu Q, Huang J, Fang JY, Xiong H. Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis. Sci Rep 2017; 7:46650. [PMID: 28440297 PMCID: PMC5404221 DOI: 10.1038/srep46650] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 03/24/2017] [Indexed: 12/16/2022] Open
Abstract
Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are not commonly used clinically for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To evaluate the efficacy and safety of NSAIDs for post-ERCP prophylaxis, we systematically reviewed sixteen randomized controlled trials (involving 6458 patients) that compared rectal NSAIDs with placebo or no treatment for post-ERCP pancreatitis prophylaxis updated to August 2016. GRADE framework was used to assess the quality of evidence. There was “high quality” evidence that rectal NSAIDs were associated with significant reduction in the risk of overall post-ERCP pancreatitis (RR, 0.55; 95% CI, 0.42–0.71). Subgroup analyses demonstrated that diclofenac (RR, 0.41; 95% CI, 0.19–0.90) was probably superior to indomethacin (RR, 0.58; 95% CI, 0.45–0.75), post-ERCP administration (RR, 0.46; 95% CI, 0.24–0.89) was probably superior to pre-ERCP (RR, 0.53; 95% CI, 0.42–0.67), and that mixed-risk population received more benefits (RR, 0.54; 95% CI, 0.33–0.88) than average-risk population (RR, 0.60; 95% CI, 0.41–0.88), but less than high-risk population (RR, 0.41; 95% CI, 0.19–0.91). Moreover, “high quality” evidence showed that rectal NSAIDs were safe when given as a standard dose (RR = 0.80; 95% CI, 0.47–1.36). In conclusion, this meta-analysis revealed that rectal NSAIDs are effective and safe in the prevention of post-ERCP pancreatitis in populations with all levels of risk.
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Affiliation(s)
- Yi-Chao Hou
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Qiang Hu
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Jiao Huang
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Jing-Yuan Fang
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Hua Xiong
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
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Donatelli G, Cereatti F, Dumont JL, Dhumane P, Tuszynski T, Derhy S, Meduri A, Vergeau BM, Meduri B. Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study. Endosc Int Open 2016; 4:E957-63. [PMID: 27652301 PMCID: PMC5025317 DOI: 10.1055/s-0042-107070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/18/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures. PATIENTS AND METHODS This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary. RESULTS Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 - 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting. CONCLUSIONS Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.
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Affiliation(s)
- Gianfranco Donatelli
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Fabrizio Cereatti
- Unit of Interventional Endoscopy, Department of General Surgery “P. Stefanini”, “Sapienza” University of Rome, Rome, Italy
| | - Jean-Loup Dumont
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Parag Dhumane
- Department of General and Laparoscopic Surgery, Lilavati Hospital and Research Center, Bandra(w), Mumbai, India
| | - Thierry Tuszynski
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Serge Derhy
- Unité de Radiologie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Alexandre Meduri
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Bertrand Marie Vergeau
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Bruno Meduri
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
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Mohammed N, Pinder M, Harris K, Everett SM. Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management-tertiary-centre experience and systematic review. Frontline Gastroenterol 2016; 7:176-186. [PMID: 28839855 PMCID: PMC5369546 DOI: 10.1136/flgastro-2015-100566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/08/2015] [Accepted: 05/05/2015] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Conventional endoscopic duct clearance may not be possible in up to 10%-15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6-12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable. METHODS AND AIMS A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents. RESULTS During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12 months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively. CONCLUSIONS Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12 months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.
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Affiliation(s)
- Noor Mohammed
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK,Leeds institute of Biomedical and Clinical Sciences, St James's University Hospital, University of Leeds, Leeds, UK
| | - Matthew Pinder
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Keith Harris
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon M Everett
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Kanamori A, Kiriyama S, Tanikawa M, Hisanaga Y, Toyoda H, Tada T, Kitabatake S, Kaneoka Y, Maeda A, Kumada T. Long- and short-term outcomes of ERCP for bile duct stones in patients over 80 years old compared to younger patients: a propensity score analysis. Endosc Int Open 2016; 4:E83-90. [PMID: 26793790 PMCID: PMC4713177 DOI: 10.1055/s-0041-108194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED Backgrounds and study aims: Endoscopic sphincterotomy (ES) is widely accepted as first-line therapy for bile duct stones (BDS). The major long-term pancreaticobiliary complication is BDS recurrence. Whether cholecystectomy should be performed after ES, especially in elderly patients, remains controversial. The aim of this study is to investigate the short-term and long-term outcomes after therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for BDS and to analyze risk factors for pancreaticobiliary complications. We also compared long-term outcomes in patients older and younger than age 80. PATIENTS AND METHODS A total of 1210 patients who underwent therapeutic ERCP for BDS were retrospectively reviewed to identify risk factors for pancreaticobiliary complications. We divided these patients into two groups: Group Y (< 80 years; 960 patients) and Group O (≥ 80 years; 250 patients). There were 192 matched pairs in the propensity score analysis. RESULTS The incidence of pancreaticobiliary complications was 13.1 % (126/960) in Group Y and 20.4 % (51/250) in Group O (P < 0.00001). Multivariate analysis showed that a gallbladder left in situ with stones was a significant independent risk factor (hazard ratio, 2.81; 95 % confidence interval, 1.62 - 4,89; P = 0.0002). There were no significant differences in the incidence of pancreaticobiliary complications between the propensity score-matched groups. CONCLUSIONS A gallbladder in situ with stones was the only significant risk factor for pancreaticobiliary complications after treatment for BDS. Age per se should not be the major factor when deciding on treatment that minimizes the occurrence of pancreaticobiliary disease.
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Affiliation(s)
- Akira Kanamori
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan,Corresponding author Akira Kanamori MD, PhD Department of GastroenterologyOgaki Municipal Hospital4-86 minaminokawa-choOgaki, Gifu, 503-8502Japan+81-584-81-3341+81-584-75-5715
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Makoto Tanikawa
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yasuhiro Hisanaga
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Toshifumi Tada
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | | | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takashi Kumada
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
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Akiyama D, Hamada T, Isayama H, Nakai Y, Tsujino T, Umefune G, Takahara N, Mohri D, Kogure H, Matsubara S, Ito Y, Yamamoto N, Sasahira N, Tada M, Koike K. Superiority of 10-mm-wide balloon over 8-mm-wide balloon in papillary dilation for bile duct stones: A matched cohort study. Saudi J Gastroenterol 2015; 21:213-219. [PMID: 26228364 PMCID: PMC4542419 DOI: 10.4103/1319-3767.161634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 05/26/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy (EST) for common bile duct (CBD) stones. To date, 10- and 8-mm EPBD have not been fully compared. PATIENTS AND METHODS Patients who underwent EPBD for CBD stones at two Japanese tertiary care centers between May 1994 and January 2014 were identified. Matched pairs with 10- and 8-mm EPBD were generated. Short- and long-term outcomes were compared between the two groups. RESULTS A total of 869 patients were identified (61 and 808 patients for 10- and 8-mm EPBD, respectively), and 61 well-balanced pairs were generated. The rate of complete stone removal within a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%, P < 0.001), and use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%, P < 0.001). The rates of post-ERCP pancreatitis were similar between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% [95% confidence interval (CI): 79-97%] and 94% (95% CI: 88-100%) at 1 year and 69% (95% CI: 56-85%) and 80% (95% CI: 69-93%) at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not observed, and pneumobilia was found in 5% of cases during the follow-up period. CONCLUSIONS EPBD using a 10-mm balloon for CBD stones is safe and more effective than 8-mm EPBD. The sphincter function is highly preserved after 10-mm EPBD.
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Affiliation(s)
- Dai Akiyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Gyotane Umefune
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Fuentes-Orozco C, Dávalos-Cobián C, García-Correa J, Ambriz-González G, Macías-Amezcua MD, García-Rentería J, Rendón-Félix J, Chávez-Tostado M, Cuesta-Márquez LA, Alvarez-Villaseñor AS, Cortés-Flores AO, González-Ojeda A. Antioxidant drugs to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: What does evidence suggest? World J Gastroenterol 2015; 21:6745-6753. [PMID: 26074713 PMCID: PMC4458785 DOI: 10.3748/wjg.v21.i21.6745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/30/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether or not the use of antioxidant supplementation aids in the prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis.
METHODS: A systematic review of randomized controlled trials (RCTs) was made to evaluate the preventive effect of prophylactic antioxidant supplementation in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The inclusion criteria included: acute post-endoscopic retrograde cholangiopancreatography pancreatitis in adults; randomized clinical trials with the use of any antioxidant as an intervention compared with placebo, to reduce PEP. The outcome measure was the incidence and severity of PEP. Twelve RCTs involving 3110 patients since 1999 were included. The antioxidants used were selenite, β-carotene, and pentoxifylline (each one in one trial), N-acetylcysteine (NAC) in three trials, and allopurinol in six trials. The group of patients treated with NAC received different doses; either oral or intravenous, and allopurinol-treated patients received five different oral doses in two different administration periods. The results are expressed with raw numbers, proportions, as well as mean and standard deviations. The incidence of pancreatitis between groups was analyzed with Pearson’s χ2 test or Fisher’s exact test (F). The main outcome is expressed as relative risks and 95%CI.
RESULTS: The incidence of pancreatitis in all antioxidant treatment groups was 8.6%, whereas it was 9.7% in the control group. The antioxidants used were selenite, β-carotene, and pentoxifylline (each one in one trial), NAC in three trials, and allopurinol in six trials. In allopurinol trials, three different dosifications were used; two trials reported a low dosage (of less than 400 mg), two trials reported a moderate dose (600 mg) and the remaining two employed higher doses (more than 900 mg). Supplementation was not associated with a significant reduction in the incidence of PEP [relative risk (RR) = 0.93; 95%CI: 0.82-1.06; P = 0.28]. In addition, the incidences of PEP in patients treated with allopurinol and those treated with other antioxidants were similar to that observed in patients who received the placebo (RR for trials with allopurinol, 0.92; 95%CI: 0.78-1.08; P = 0.31) and, with the use of other antioxidants, the incidence of PEP was 8.9%, whereas it was 9.7% in the control group (RR = 0.95; 95%CI: 0.77-1.18; P = 0.19).
CONCLUSION: Antioxidant supplementation shows no beneficial effect on the incidence of PEP. There is a lack of robust trials to support the use of antioxidants for prevention.
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Mwengela D, Buxbaum J. Dilation-assisted stone extraction: does one balloon fit all? Dig Dis Sci 2014; 59:708-9. [PMID: 24414477 DOI: 10.1007/s10620-013-2989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 12/05/2013] [Indexed: 12/09/2022]
Affiliation(s)
- Didi Mwengela
- Division of Gastrointestinal and Liver Diseases, Hoffman Medical Research Center, Keck School of Medicine, University of Southern California, 2001 Zonal Avenue HMR 1201, Los Angeles, CA, 90033, USA
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Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014; 2:E28-36. [PMID: 26134610 PMCID: PMC4423280 DOI: 10.1055/s-0034-1365281] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. PATIENTS AND METHODS Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. RESULTS Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.
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Affiliation(s)
- Lukejohn W. Day
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
| | - Lisa Lin
- Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
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A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2014; 43:190-7. [PMID: 24518496 DOI: 10.1097/mpa.0000000000000090] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinical trials evaluating the protective effect of nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) have yielded inconclusive results. Our objective was to conduct a meta-analysis of the data to date to evaluate the efficacy and safety of rectal NSAIDs for PEP prophylaxis. We did a systematic search of PubMed/MEDLINE, Embase, and Web of Science databases and the Cochrane Central Register of Controlled Trials. The meta-analysis was performed using a fixed-effect method because of the absence of significant heterogeneity in the included trials. Seven randomized, controlled trials involving 2133 patients were included. The meta-analysis showed that rectal NSAIDs decreased the overall incidence of PEP (risk ratio, 0.44; 95% confidence interval, 0.34-0.57; P < 0.01). The number needed to treat was 11. The NSAID prophylaxis also decreased the incidence of moderate to severe PEP (risk ratio, 0.37; 95% confidence interval, 0.27-0.63; P < 0.01). The number needed to treat was 34. No differences of the adverse events attributable to NSAIDs were observed. In conclusion, prophylactic use of rectal NSAIDs reduces the incidence and severity of PEP. There is neither a difference in efficacy between rectal indomethacin and diclofenac nor a difference in efficacy between the timing of administration of rectal NSAIDs, that is, immediate pre-ERCP and post-ERCP.
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Kogure H, Tsujino T, Isayama H, Takahara N, Uchino R, Hamada T, Miyabayashi K, Mizuno S, Mohri D, Yashima Y, Kawakubo K, Sasaki T, Yamamoto N, Nakai Y, Hirano K, Sasahira N, Tada M, Koike K. Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones. Scand J Gastroenterol 2014; 49:121-128. [PMID: 24164293 DOI: 10.3109/00365521.2013.848470] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Removal of large bile duct stones by endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been proven safe and effective. Little evidence supports the benefits of a preceding EST in reducing complications. Recent studies suggest that large bile duct stone removal by EPLBD alone may be safe and effective. MATERIAL AND METHODS We removed large bile duct stones by EPLBD with EST from March 2008 to February 2010 and without EST from March 2010 to October 2011. Efficacy and safety of EPLBD with or without EST and late biliary complication outcomes were assessed. RESULTS Forty-two patients (men/women, 27/15; mean age, 76 years) underwent EPLBD: 14 underwent EPLBD with EST and 28 underwent EPLBD without EST. The mean stone size was 14 mm (9-30 mm). Overall complete stone removal rate was 98%, with 83% achieved in 1 session. Complete duct clearance by EPLBD alone was achieved in 79%. Mechanical lithotripsy was required in 4 (10%) patients. Extracorporeal shock wave lithotripsy and electrohydraulic lithotripsy were required in 4 (10%) and 1 (2%) patients, respectively. Pancreatitis and perforation occurred in 2 (5%) and 1 (2%) patients, respectively. Patients treated by EPLBD with EST and by EPLBD alone did not differ in complication outcomes. Six (14%) patients had recurrent bile duct stones, with a significant correlation to dilated common bile duct (p = 0.0351). CONCLUSIONS EPLBD is safe and effective in patients with large bile duct stones. Preceding EST may be unnecessary.
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Affiliation(s)
- Hirofumi Kogure
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
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Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26:231-54. [PMID: 23554415 DOI: 10.1128/cmr.00085-12] [Citation(s) in RCA: 311] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.
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Abstract
It is imperative for gastroenterologists to understand the different formations of bile duct stones and the various medical treatments available. To minimize the complications of endoscopic retrograde cholangiopancreatography (ERCP), it is critical to appropriately assess the risk of bile duct stones before intervention. Biliary endoscopists should be comfortable with the basic techniques of stone removal, including sphincterotomy, mechanical lithotripsy, and stent placement. It is important to be aware of advanced options, including laser and electrohydraulic stone fragmentation, and papillary dilatation for problematic cases. The timing and need for ERCP in those who require a cholecystectomy is also a consideration.
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Affiliation(s)
- James Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, Los Angeles County Hospital, University of Southern California, Los Angeles, CA 90033-1370, USA.
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Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents. Hepatobiliary Pancreat Dis Int 2012; 11:643-9. [PMID: 23232637 DOI: 10.1016/s1499-3872(12)60238-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases. METHODS In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated. RESULTS SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups. CONCLUSIONS ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.
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Zhang ZH, Wu YG, Qin CK, Su ZX, Xu J, Xian GZ, Wu SD. Severe acute cholangitis after endoscopic sphincterotomy induced by barium examination: A case report. World J Gastroenterol 2012; 18:5658-60. [PMID: 23112564 PMCID: PMC3482658 DOI: 10.3748/wjg.v18.i39.5658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 06/07/2012] [Accepted: 06/15/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic sphincterotomy (EST) is considered as a possible etiological factor for severe cholangitis. We herein report a case of severe cholangitis after endoscopic sphincterotomy induced by barium examination. An adult male patient presented with epigastric pain was diagnosed as having choledocholithiasis by ultrasonography. EST was performed and the stone was completely cleaned. Barium examination was done 3 d after EST and severe cholangitis appeared 4 h later. The patient was recovered after treated with tienam for 4 d. Barium examination may induce severe cholangitis in patients after EST, although rare, barium examination should be chosen cautiously. Cautions should be also used when EST is performed in patients younger than 50 years to avoid the damage to the sphincter of Oddi.
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Tammaro S, Caruso R, Pallone F, Monteleone G. Post-endoscopic retrograde cholangio-pancreatography pancreatitis: Is time for a new preventive approach? World J Gastroenterol 2012; 18:4635-8. [PMID: 23002332 PMCID: PMC3442201 DOI: 10.3748/wjg.v18.i34.4635] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 07/17/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangio-pancreatography (ERCP) and its incidence may exceed 25% in some high-risk patient subsets. In some patients, pancreatitis may follow a severe course with pancreatic necrosis, multiorgan failure, permanent disability and even death. Hence, approaches which minimize both the incidence and severity of post-ERCP pancreatitis are worth pursuing. Pancreatic stents have been used with some success in the prevention of post-ERCP, while so far pharmacological trials have yielded disappointing results. A recent multicenter, randomized, placebo-controlled, double-blind trial has shown that rectally administered indomethacin is effective in reducing the incidence of post-ERCP pancreatitis, the occurrence of episodes of moderate-to-severe pancreatitis and the length of hospital stay in high-risk patients. These results together with the demonstration that rectal administration of indomethacin is not associated with enhanced risk of bleeding strongly support the use of this drug in the prophylaxis of post-ERCP pancreatitis.
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Low-dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial. J Gastroenterol 2012; 47:912-7. [PMID: 22350703 DOI: 10.1007/s00535-012-0554-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 01/25/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (specifically, 100 mg of diclofenac or indomethacin) have shown promising prophylactic activity in post-ERCP pancreatitis (PEP). However, the 100-mg dose is higher than that ordinarily used in Japan. METHODS We performed a prospective randomized controlled study to evaluate the efficacy of low-dose rectal diclofenac for the prevention of PEP. Patients who were scheduled to undergo ERCP were randomized to receive a saline infusion either with 50 mg of rectal diclofenac (diclofenac group) or without (control group) 30 min before ERCP. The dose of diclofenac was reduced to 25 mg in patients weighing <50 kg. The primary outcome measure was the occurrence of PEP. RESULTS Enrollment was terminated early because the planned interim analysis found a statistically significant intergroup difference in the occurrence of PEP. A total of 104 patients were eligible for this study; 51 patients received rectal diclofenac. Twelve patients (11.5%) developed PEP: 3.9% (2/51) in the diclofenac group and 18.9% (10/53) in the control group (p = 0.017). After ERCP, the incidence of hyperamylasemia was not significantly different between the two groups. Post-ERCP pain was significantly more frequent in the control group than in the diclofenac group (37.7 vs. 7.8%, respectively; p < 0.001). There were no adverse events related to diclofenac. CONCLUSIONS Low-dose rectal diclofenac can prevent PEP.
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Takahara N, Isayama H, Sasaki T, Tsujino T, Toda N, Sasahira N, Mizuno S, Kawakubo K, Kogure H, Yamamoto N, Nakai Y, Hirano K, Tada M, Omata M, Koike K. Endoscopic papillary balloon dilation for bile duct stones in patients on hemodialysis. J Gastroenterol 2012; 47:918-923. [PMID: 22354661 DOI: 10.1007/s00535-012-0551-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 01/25/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic papillary balloon dilation (EPBD) is a less hazardous alternative to endoscopic sphincterotomy for managing bile duct stones in patients with a coagulopathy. However, little information on EPBD is available for patients with bile duct stones who are undergoing hemodialysis (HD). We aimed to evaluate the safety and efficacy of EPBD for such patients. PATIENTS This was a retrospective cohort study with prospectively collected data for 37consecutive patients with bile duct stones who were undergoing HD and who also underwent EPBD between December 1995 and April 2010 at four institutions in Tokyo, Japan. The main outcome was the safety and efficacy of EPBD for managing bile duct stones in patients undergoing HD. RESULTS The bile duct stones were completely removed in one session in 24 patients (64.8%). Overall success was achieved using EPBD alone in all patients. Complications occurred in five patients (13.5%), including two with hemorrhage (5.4%). No hemorrhage developed in any of the 33 patients who had no additional bleeding risk except for HD. Pancreatitis and perforation developed in two (5.4%) and one (2.7%) patient, respectively. CONCLUSIONS EPBD seems to be a safe and effective treatment to extract bile duct stones in patients undergoing HD. However, EPBD should be performed carefully in patients with additional bleeding risk factors, such as Child-Pugh class C liver cirrhosis and those taking anti-platelet agents at the time of EPBD.
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Affiliation(s)
- Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Khajanchee YS, Cassera MA, Hammill CW, Swanström LL, Hansen PD. Outcomes following laparoscopic choledochoduodenostomy in the management of benign biliary obstruction. J Gastrointest Surg 2012; 16:801-5. [PMID: 22331393 DOI: 10.1007/s11605-011-1768-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/19/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION With the advent of endoscopic retrograde choledochoduodenostomy, the need for choledochoduodenostomy to treat common bile duct obstruction is less common, but occasionally required. METHODS Patients considered for laparoscopic choledochoduodenostomy secondary to benign conditions between 1999 and 2009 at a single institution were included. Charts were retrospectively reviewed for preoperative, operative, and long-term outcomes data. RESULTS Twenty patients were identified; 15 with chronic choledocholithiasis causing benign biliary obstruction or chronic recurrent cholangitis, 3 with chronic relapsing pancreatitis, and 2 with distal common bile duct strictures. Mean operative time was 270 min. No major operative complications were reported. Five patients with severe adhesions or portal hypertension required conversion to laparotomy. Median hospital stay was 6 days (range, 2-32). Postoperatively, three (20%) patients completed laparoscopically and three (66.7%) patients converted to laparotomy had complications. In addition, one death due to myocardial infarction was reported 4 weeks after hospital discharge. With an average follow-up of 21 months, only one patient (5%) developed recurrent symptoms. CONCLUSION Laparoscopic choledochoduodenostomy is a useful technique in patients with benign, refractory common bile duct obstruction. This technically demanding procedure is feasible; however, the associated comorbidities in this complex group of patients result in a relatively high complication rate.
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Affiliation(s)
- Yashodhan S Khajanchee
- Hepatobiliary and Pancreatic Surgery Program, Providence Portland Medical Center, Portland, OR, USA
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Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc 2011; 74:96-102. [PMID: 21531412 DOI: 10.1016/j.gie.2011.03.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 03/06/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Temporary biliary stenting is both technically easy and feasible, and choleretic agents such as ursodeoxycholic acid (UDCA) and a terpene preparation may promote a reduction in stone size. However, there are few comparative data on the effectiveness of choleretic agents available. OBJECTIVE To investigate the efficacy of multiple double-pigtail stents with or without UDCA and terpene on difficult common bile duct (CBD) stones. DESIGN A prospective, multicenter study. SETTING Four tertiary-care referral centers. PATIENTS This study involved 51 patients. INTERVENTION In total, 51 elderly patients with comorbidities who had difficult CBD stones refractory to conventional methods were randomized to receive either multiple 7F double-pigtail stents (group A) or stents in combination with UDCA and terpene (group B) for a period of 6 months. MAIN OUTCOME MEASUREMENTS Stone size reduction, successful duct clearance, and complications. RESULTS Complete endoscopic duct clearance was achieved in 14 patients (73.7%) in group A and 19 patients (86.4%) in group B (P = .826). The mean size of CBD stones (transverse/longitudinal diameter, mean ± SD) was 19.12 ± 4.48 mm/20.47 ± 3.86 mm in group A and 21.30 ± 7.08 mm/22.58 ± 7.61 mm in group B. Stone size decreased significantly to 12.04 ± 3.26 mm/13.31 ± 5.12 mm and 13.67 ± 5.40 mm/14.04 ± 6.12 mm, respectively (P < .01). However, there was no statistical difference in stone size reduction between the two groups (P = .685, P = .289). No serious complications related to the stent or endoscopic procedures were observed, except for cholangitis (n = 1, group A) and distal stent migration (n = 2, group B). LIMITATIONS Small number of patients in East Asia. CONCLUSION Temporary multiple double-pigtail biliary stenting was a safe and feasible method of treating difficult and large CBD stones in elderly patients and contributed to a reduction in stone size and successful duct clearance. However, the addition of choleretic agents did not result in a statistical difference in stone size or rate of successful duct clearance.
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Abstract
Benign biliary diseases include benign biliary strictures (BBS), choledocholithiasis, and leaks. BBS encompass postoperative injury, anastomotic stricture, chronic pancreatitis, primary sclerosing cholangitis, and gallstone-related stricture. Therapeutic options for benign biliary diseases include surgical, percutaneous, and endoscopic interventions. Endoscopic options include placement of plastic stents as well as self-expanding metal stents (SEMS). SEMS can be uncovered, partially covered, and fully covered, and have been used with some success in resolution of strictures and leaks; however, complications limit their use. This article reviews the currently published experience on SEMS and attempts to define their current role in the treatment of benign biliary diseases.
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Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol 2011; 35:621-7. [PMID: 21647808 DOI: 10.1007/s00270-011-0190-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 05/09/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. METHODS Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14-92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones=248 patients and hepatolithiasis=13 patients) were included in the study. First, percutaneous transhepatic cholangiography was performed and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. RESULTS Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 (6.8%) major complications, including cholangitis (n=7), subcapsular biloma (n=4), subcapsular hematoma (n=1), subcapsular abscess (n=1), bile peritonitis (n=1), duodenal perforation (n=1), CBD perforation (n=1), gastroduodenal artery pseudoaneurysm (n=1), and right hepatic artery transection (n=1), were seen after the procedure. There was no mortality. CONCLUSION Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.
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