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Miyamoto S, Serikawa M, Ishii Y, Tatsukawa Y, Nakamura S, Ikemoto J, Tamura Y, Nakamura K, Furukawa M, Yamashita Y, Iijima N, Arihiro K, Oka S. The Significance of Histopathological Findings on Clinical Outcomes in Endoscopic Papillectomy with Endocut. J Clin Med 2023; 12:6853. [PMID: 37959318 PMCID: PMC10648105 DOI: 10.3390/jcm12216853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/21/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
This study aimed to evaluate primary clinical outcomes in patients who underwent endoscopic papillectomy (EP) using the Endocut mode while examining the pathological characteristics of the margin of the resected specimen. To this end, 70 patients who underwent Endocut EP were included. Resection margins were classified according to pathological findings as "negative", "positive", or "uncertain (difficult pathological evaluation)". The effect of pathological resection margins on residual tumor recurrence rates was evaluated. The median follow-up was 47 months (range, 22-84). Eleven patients (15.7%) were diagnosed with residual tumors, ten of whom were diagnosed within 6 months after EP. The resection margins were pathologically negative in 27 patients, positive in 15, and uncertain in 28; residual tumors occurred in 5 patients (33.3%) in the positive group, 5 (17.9%) in the uncertain group, and 1 (3.7%) in the negative group. The patient in the negative group had familial adenomatous polyposis (FAP). Female sex, FAP, and uncertain or positive resection margins were significantly more common in residual patients (p = 0.009, 0.044, and 0.041, respectively). Pathological resection margins can be used to infer the residual tumor incidence, leading to early post-treatment of residual tumors.
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Affiliation(s)
- Sayaka Miyamoto
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Masahiro Serikawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Yasutaka Ishii
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Yumiko Tatsukawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Shinya Nakamura
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Juri Ikemoto
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Yosuke Tamura
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Kazuki Nakamura
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Masaru Furukawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Yumiko Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Noriaki Iijima
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
| | - Koji Arihiro
- Department of Pathology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (S.M.)
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Pereira Funari M, Ottoboni Brunaldi V, Mendonça Proença I, Aniz Gomes PV, Almeida Queiroz LT, Zamban Vieira Y, Eiji Matuguma S, Ide E, Prince Franzini TA, Lera Dos Santos ME, Cheng S, Kazuyoshi Minata M, Dos Santos JS, Turiani Hourneaux de Moura D, Kemp R, Guimarães Hourneaux de Moura E. Pure Cut or Endocut for Biliary Sphincterotomy? A Multicenter Randomized Clinical Trial. Am J Gastroenterol 2023; 118:1871-1879. [PMID: 37543748 DOI: 10.14309/ajg.0000000000002458] [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] [Received: 12/20/2022] [Accepted: 07/13/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Adverse events (AE) after endoscopic retrograde cholangiopancreatography (ERCP) are not uncommon and post-ERCP acute pancreatitis (PEP) is the most important one. Thermal injury from biliary sphincterotomy may play an important role and trigger PEP or bleeding. Therefore, this study evaluated the outcomes of 2 electric current modes used during biliary sphincterotomy. METHODS From October 2019 to August 2021, consecutive patients with native papilla undergoing ERCP with biliary sphincterotomy were randomized to either the pure cut or endocut after cannulation. The primary outcome was PEP incidence. Secondary outcomes included intraprocedural and delayed bleeding, infection, and perforation. RESULTS A total of 550 patients were randomized (272 pure cut and 278 endocut). The overall PEP rate was 4.0% and significantly higher in the endocut group (5.8% vs 2.2%, P = 0.034). Univariate analysis revealed >5 attempts ( P = 0.004) and endocut mode ( P = 0.034) as risk factors for PEP. Multivariate analysis revealed >5 attempts ( P = 0.005) and a trend for endocut mode as risk factors for PEP ( P = 0.052). Intraprocedural bleeding occurred more often with pure cut ( P = 0.018), but all cases were controlled endoscopically during the ERCP. Delayed bleeding was more frequent with endocut ( P = 0.047). There was no difference in perforation ( P = 1.0) or infection ( P = 0.4999) between the groups. DISCUSSION Endocut mode may increase thermal injury leading to higher rates of PEP and delayed bleeding, whereas pure cut is associated with increased intraprocedural bleeding without clinical repercussion. The electric current mode is not related to perforation or infection. Further RCT assessing the impact of electric current on AE with overlapping preventive measures such as rectal nonsteroidal anti-inflammatory drugs and hyperhydration are needed. The study was submitted to the Brazilian Clinical Trials Platform ( http://www.ensaiosclinicos.gov.br ) under the registry number RBR-5d27tn.
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Affiliation(s)
- Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Igor Mendonça Proença
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Pedro Victor Aniz Gomes
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Lucas Tobias Almeida Queiroz
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Yuri Zamban Vieira
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Edson Ide
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Spencer Cheng
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Maurício Kazuyoshi Minata
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - José Sebastião Dos Santos
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
| | | | - Rafael Kemp
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
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Jena A, Jain S, Sundaram S, Singh AK, Chandnani S, Rathi P. Electrosurgical unit in GI endoscopy: the proper settings for practice. Expert Rev Gastroenterol Hepatol 2023; 17:825-835. [PMID: 37497836 DOI: 10.1080/17474124.2023.2242243] [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: 02/12/2023] [Revised: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients. AREAS COVERED ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers. EXPERT OPINION Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Shubham Jain
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Chandnani
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Pravin Rathi
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
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Funari MP, Sagae VMT, Moura EGHD, Bernardo WM. Endoscopic biliary sphincterotomy: electric current mode. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2022; 68:277-295. [PMID: 35442349 DOI: 10.1590/1806-9282.2022d683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 01/03/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Mateus Pereira Funari
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Gastrointestinal Endoscopy Unit - São Paulo (SP), Brazil
| | - Vitor Massaro Takamatsu Sagae
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Gastrointestinal Endoscopy Unit - São Paulo (SP), Brazil
| | | | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Gastrointestinal Endoscopy Unit - São Paulo (SP), Brazil
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Bai Y, Yang F, Liu C, Li DF, Wang S, Lin R, Ding Z, Meng WB, Li ZS, Linghu EQ. Expert consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy (2020, Shanghai). J Dig Dis 2022; 23:2-12. [PMID: 34953023 DOI: 10.1111/1751-2980.13074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/11/2022]
Abstract
High-frequency electrosurgery has been widely applied in digestive endoscopy with constantly expanding indications. However, high-frequency electrosurgery may cause possible complications such as hemorrhage or perforation during or after the procedure, of which endoscopists must be cautious. Digestive endoscopists must have a firm grasp of the principles of high-frequency electrosurgery as well as its safety issues so as to improve the safety of its clinical application. To this end, experts in gastroenterology and hepatology, digestive endoscopy, surgery, nursing and other related fields were invited to draft a consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy based on relevant domestic and international literatures and their experiences.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Fan Yang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Cui Liu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shi Wang
- Endoscopy Center, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, Zhejiang Province, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Wen Bo Meng
- Department of General Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - En Qiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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Hedjoudje A, Cheurfa C, Farha J, Jaïs B, Aubert A, Lorenzo D, Maire F, Badurdeen D, Kumbhari V, Prat F. Safety of different electrocautery modes for endoscopic sphincterotomy: a Bayesian network meta-analysis. Ther Adv Gastrointest Endosc 2021; 14:26317745211062983. [PMID: 34993472 PMCID: PMC8725216 DOI: 10.1177/26317745211062983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background and aims: Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PAP)
and post-sphincterotomy hemorrhage are known adverse events of
post-endoscopic retrograde cholangiopancreatography. Various electrosurgical
currents can be used for endoscopic sphincterotomy. The extent to which this
influences adverse events remains unclear. We assessed the comparative
safety of different electrosurgical currents, through a Bayesian network
meta-analysis of published studies merging direct and indirect comparison of
trials. Methods: We performed a Bayesian random-effects network meta-analysis of randomized
controlled trials that compared the safety of different electrocautery modes
for endoscopic sphincterotomy. Results: Nine studies comparing four electrocautery modes (blended cut, pure cut,
endocut, and pure cut followed by blended cut) with a combined enrollment of
1615 patients were included. The pooled results of the network meta-analysis
did not show a significant difference in preventing post-sphincterotomy
pancreatitis when comparing electrocautery modes. However, pure cut was
associated with a statistically significant increased risk of bleeding
compared with endocut [relative risk = 4.30; 95% confidence interval
(1.53–12.87)]. On the other hand, the pooled results of the network
meta-analysis showed no significant difference in prevention of bleeding
when comparing blended cut versus endocut, pure cut
followed by blended cut versus endocut, pure cut followed
by blended cut versus blended cut, pure cut
versus blended cut, and pure cut
versus pure cut followed by blended cut. The results of
rank probability found that endocut was most likely to be ranked the
best. Conclusion: No electrocautery mode was superior to another with regard to preventing PAP.
Endocut was superior with respect to preventing bleeding. Therefore, we
suggest performing endoscopic sphincterotomy with endocut.
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Affiliation(s)
- Abdellah Hedjoudje
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, 100 boulevard du Général Leclerc, 92110 Clichy, France. Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Chérifa Cheurfa
- Université de Paris, Epidemiology and Statistics, Sorbonne Paris Cité Research Center, (CRESS-UMR1153), INSERM, Cochrane France, Paris, France
| | - Jad Farha
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bénédicte Jaïs
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Alain Aubert
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Diane Lorenzo
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Frédérique Maire
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Dilhana Badurdeen
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Frédéric Prat
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
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Funari MP, Ribeiro IB, de Moura DTH, Bernardo WM, Brunaldi VO, Rezende DT, Resende RH, de Marco MO, Franzini TAP, de Moura EGH. Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials. Clin Res Hepatol Gastroenterol 2020; 44:739-752. [PMID: 32088149 DOI: 10.1016/j.clinre.2019.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/24/2019] [Accepted: 12/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis. AIM To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events. METHODS We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar. RESULTS A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: -0.11 [-0.31, 0.08], P=0.27, I2=86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [-0.03, 0.04], P=0.62, I2=48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: -0.19 [-0.27, -0.12], P<0.00001, I2=0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [-0.01, 0.11], P=0.12, I2=57%), perforation (0.4% vs 0%; RD: 0.00 [-0.01, 0.02], P=0.7, I2=0%) or cholangitis (1.8% vs 3.2%; RD: -0.01 [-0.09, 0.06], P=0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P<0.00001, I2=0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: -0.10 [-0.24, 0.04], P=0.18, I2=61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [-0.02, 0.13], P=0.12, I2=0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD -0.01 [-0.11, 0.09], P=0.82, I2=0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P=0.01). CONCLUSION Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.
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Affiliation(s)
- Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil; Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Daniel Tavares Rezende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Ricardo Hannum Resende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Michele Oliveira de Marco
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Tomazo Antonio Prince Franzini
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Instituto Central, Prédio dos Ambulatórios, Av. Dr. Enéas de Carvalho Aguiar 255, Pinheiros, São Paulo, Brazil
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Soh JS, Seo M, Kim KJ. Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding. BMC Gastroenterol 2020; 20:68. [PMID: 32164613 PMCID: PMC7069010 DOI: 10.1186/s12876-020-01210-5] [Citation(s) in RCA: 9] [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: 05/03/2019] [Accepted: 02/28/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although prophylactic clip application before polypectomy may prevent postpolypectomy bleeding (PPB), the usefulness of prophylactic clipping in the treatment of large pedunculated polyps is controversial in some prospective randomized studies. This study was conducted to evaluate the efficacy of prophylactic clip application and to investigate the predictors of PPB in large pedunculated colorectal polyps. METHODS A total of 137 pedunculated polyps (size ≥1 cm) in 116 patients were prospectively included and randomized into group A (with clipping) and group B (without clipping), and resected. The occurrences of immediate PPB (graded 1-4) and delayed PPB were compared. RESULTS Sixty-seven polyps were allocated in group A and 70 polyps in group B. In both groups, the median polyp diameter was 15 mm (P = 0.173) and the median stalk diameter was 3 mm (P = 0.362). Twenty-eight (20.4%) immediate PPB episodes in 137 polyps occurred, 6 (9.0%) in group A and 22 (31.4%) in group B (P = 0.001). However, the occurrence of delayed PPB was not different between the groups (P = 0.943). Prophylactic clip application decreased the occurrence of immediate PPB (odds ratio 0.215, 95% confidence interval 0.081-0.571). Moreover, polyp size ≥20 mm and stalk diameter ≥ 4 mm increased the risk of immediate PPB. CONCLUSIONS Clip application before polypectomy of ≥1 cm pedunculated polyps is effective in decreasing the occurrence of immediate PPB. Thus, clip application should be considered before performing snare polypectomy, especially for large polyps with a thick stalk. TRIAL REGISTRATION This research was studied a prospective maneuver and enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT01437631). This study was registered on September 19, 2011.
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Affiliation(s)
- Jae Seung Soh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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9
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Iwasaki E, Minami K, Itoi T, Yamamoto K, Tsuji S, Sofuni A, Tsuchiya T, Tanaka R, Tonozuka R, Machida Y, Takimoto Y, Tamagawa H, Katayama T, Kawasaki S, Seino T, Horibe M, Fukuhara S, Kitago M, Ogata H, Kanai T. Impact of electrical pulse cut mode during endoscopic papillectomy: Pilot randomized clinical trial. Dig Endosc 2020; 32:127-135. [PMID: 31222794 DOI: 10.1111/den.13468] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/16/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic papillectomy is increasingly being used for ampullary adenoma treatment. However, it remains challenging despite increased safety with treatment advances. The ideal power output and electrosurgical current mode for mucosal resection are not established. We aimed to identify the ideal electrical pulse for use during resection. METHODS This pilot randomized, single-blind, prospective, multicenter trial, recruited patients with ampullary adenomas and conventional anatomy who were scheduled to undergo endoscopic papillectomy. Endoscopic treatment was performed using a standardized algorithm and patients were randomized for endoscopic papillectomy with Endocut or Autocut. The primary outcome was the incidence of delayed bleeding. Incidence of procedure-related pancreatitis, successful complete resection, pathological findings, and other adverse events were secondary endpoints. RESULTS Sixty patients were enrolled over a 2-year period. The incidences of delayed bleeding (13.3% vs. 16.7%, P = 1.00) and pancreatitis (27% vs. 30%, P = 0.77) were similar between both groups. The rate of crush artifacts was higher in the Endocut than in the Autocut group (27% vs. 3.3%, P = 0.03). Immediate bleeding when resecting tumors greater than 14 mm in diameter was more common in the Autocut than in the Endocut group (88% vs. 46%, P = 0.04). CONCLUSIONS The Autocut and Endocut modes have similar efficacy and safety for endoscopic papillectomy. The Endocut mode may prevent immediate bleeding in cases with large tumor sizes, although it causes more frequent crush artifacts. REGISTRY AND THE REGISTRATION NUMBER The Japanese UMIN Clinical Trials Registry (UMIN-CTR: 000021382).
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Affiliation(s)
- Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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10
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Minami K, Iwasaki E, Fukuhara S, Horibe M, Seino T, Kawasaki S, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Kanai T, Itoi T. Electric Endocut and Autocut Resection for Endoscopic Papillectomy: A Systematic Review. Intern Med 2019; 58:2767-2772. [PMID: 31243201 PMCID: PMC6815892 DOI: 10.2169/internalmedicine.2720-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Youichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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11
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Li DF, Yang MF, Chang X, Wang NN, Tan FF, Xie HN, Fang X, Wang SL, Fan W, Wang JY, Yu ZC, Wei C, Xiong F, Liu TT, Luo MH, Wang LS, Li ZS, Yao J, Bai Y. Endocut Versus Conventional Blended Electrosurgical Current for Endoscopic Biliary Sphincterotomy: A Meta-Analysis of Complications. Dig Dis Sci 2019; 64:2088-2094. [PMID: 30778871 DOI: 10.1007/s10620-019-05513-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/01/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Endoscopic biliary sphincterotomy (EST) is commonly performed during therapeutic endoscopic retrograde cholangiopancreatography (ERCP), but is an independent risk factor for post-ERCP pancreatitis, bleeding and duodenal perforation. These are partly ascribed to the electrosurgical current mode used for EST, and currently the optimal current model for EST remains controversial. In this study, we aimed to compare the rate of complications undergoing EST using the Endocut versus the blended current. METHODS A systematic search of databases was performed for relevant published and prospective studies including randomized clinical trials (RCTs) to compare Endocut with blended current modes for EST. Data were collected from inception until 1 July 2018, using post-ERCP pancreatitis, bleeding and perforation as primary outcomes. RESULTS Three RCTs including a total of 594 patients met the inclusion criteria. Our meta-analysis results showed the rate of post-ERCP pancreatitis, primarily mild to moderate pancreatitis, was no different between Endocut versus blended current modes [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.25-1.52, P = 0.29]. However, the risk of endoscopically bleeding events, primarily mild bleeding, was lower in studies using Endocut versus blended current (RR 0.54, 95% CI 0.31-0.95, P = 0.03). Notably, none of the patients experienced perforation in these three trials. CONCLUSIONS The rate of post-ERCP pancreatitis was not significantly different when using the Endocut versus blended current during EST. Nevertheless, compared with the blended current, Endocut reduced the incidence of endoscopically evident bleeding; however, the available data were insufficient to assess the perforation risk.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China.,Integrated Chinese and Western Medicine Postdoctoral Research Station, Jinan University, Guangzhou, 510632, China.,Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, 421001, China
| | - Mei-Feng Yang
- Department of Hematology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, 421001, China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Yangpu District, Shanghai, 200433, China
| | - Nan-Nan Wang
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, 421001, China
| | - Fang-Fang Tan
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, 421001, China
| | - Hai-Na Xie
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, University of South China, Hengyang, 421001, China
| | - Xue Fang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Yangpu District, Shanghai, 200433, China
| | - Shu-Ling Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Yangpu District, Shanghai, 200433, China
| | - Wei Fan
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jian-Yao Wang
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Zhi-Chao Yu
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Cheng Wei
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Feng Xiong
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Ting-Ting Liu
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Ming-Han Luo
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Li-Sheng Wang
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Yangpu District, Shanghai, 200433, China
| | - Jun Yao
- Department of Gastroenterology, The 2nd Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Yangpu District, Shanghai, 200433, China.
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12
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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13
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 517] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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14
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Abstract
Electrosurgery allows both cutting and coagulation of tissue and is an essential tool for therapeutic endoscopy. Electrosurgery is also the most commonly used and misunderstood technology by all surgical and medical disciplines. In other words, everyone uses it, but few understand it! The aims of this article are to (1) present a useful review of the fundamentals of electrosurgery technology; (2) relate the fundamentals to commonly performed flexible endoscopy procedures; and (3) provide a review of the safe application of grounding pads, careful management of accessories, and special patient safety considerations.
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15
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Tanaka Y, Sato K, Tsuchida H, Mizuide M, Yasuoka H, Ishida K, Mori M, Kusano M, Yamada M. A prospective randomized controlled study of endoscopic sphincterotomy with the Endocut mode or conventional blended cut mode. J Clin Gastroenterol 2015; 49:127-131. [PMID: 24583745 PMCID: PMC4292865 DOI: 10.1097/mcg.0000000000000096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 01/13/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the potential advantages of the Endocut mode (E-mode) of endoscopic sphincterotomy (EST) over the conventional blended cut mode (C-mode) have been reported, the problems, including the small sample size and retrospective analysis, that occurred in previous studies make it difficult to conclude the advantage of the E-mode regarding the safety and efficacy. We performed a prospective randomized controlled study to compare these modes. METHODS A total of 360 patients with choledocholithiasis or stenosis of the bile duct were randomly assigned to one of the modes. To avoid the technical bias due to multiple operators or institutions, the main operator and the institution were restricted to only one experienced doctor and 3 institutions at his place of employment, respectively. We defined pancreatitis, bleeding, and perforation as complications of EST. Besides, bleeding includes endoscopically evident bleeding that was defined as visible during the procedure of sphincterotomy and temporary slight oozing. RESULTS The complications occurred in 20 (11.2%) patients from the E-mode group: pancreatitis in 6 (3.4%) and endoscopically evident bleeding in 14 (7.8%). In contrast, the complications occurred in 25 (13.8%) patients from the C-mode group: pancreatitis in 7 (3.9%) and endoscopically evident bleeding in 18 (9.9%), although these findings were not statistically significant. Overall, there were no severe complications. There were no significant differences in completion ratio of EST and the time taken for the sphincterotomy between both groups. CONCLUSIONS The E-mode could not surpass the C-mode in safety and efficacy under the operation by a single endoscopist.
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Affiliation(s)
- Yoshiki Tanaka
- Department of Gastroenterology, Saiseikai Maebashi Hospital, Maebashi
| | - Ken Sato
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
| | - Hiroyuki Tsuchida
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
| | - Masafumi Mizuide
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
| | | | | | - Masatomo Mori
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
| | - Motoyasu Kusano
- Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi
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16
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Parlak E, Köksal AŞ, Öztaş E, Dişibeyaz S, Ödemiş B, Yüksel M, Yıldız H, Şaşmaz N, Şahin B. Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis? Wien Klin Wochenschr 2015; 128:573-8. [PMID: 25576330 DOI: 10.1007/s00508-014-0677-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 11/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. METHODS The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). RESULTS Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. CONCLUSIONS Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Sakarya University, Sakarya, Turkey
| | - Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University, Sakarya, Turkey. .,Kızılırmak mahallesi, 1443. Cadde, 40/13, Çukurambar, Ankara, Turkey.
| | - Erkin Öztaş
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Selçuk Dişibeyaz
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Bülent Ödemiş
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Mahmut Yüksel
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Hakan Yıldız
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Nurgül Şaşmaz
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
| | - Burhan Şahin
- Department of Gastroenterology, Türkiye Yüksek İhtisas Hospital, Sıhhiye, Ankara, Turkey
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17
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Ghoz HM, Abu Dayyeh BK. Hemorrhagic complications following endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014; 16:175-182. [DOI: 10.1016/j.tgie.2014.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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18
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Morita Y. Electrocautery for ESD: settings of the electrical surgical unit VIO300D. Gastrointest Endosc Clin N Am 2014; 24:183-9. [PMID: 24679230 DOI: 10.1016/j.giec.2013.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
An electrical surgical unit (ESU) performs incisions and coagulation through applying Joule heat, generated by a high-frequency current onto tissue without neuromuscular stimulation. Output by the ESU includes incision output and coagulation output. Incision output is needed to generate a steam explosion (spark) by quickly increasing the intracellular fluid temperature through continuous application of Joule heat generated by the high-frequency current (unmodulated pulse: continuous wave). To perform safe and successful endoscopic submucosal dissection, one must fully understand the principles and features of an ESU to use settings that match the device and to adjust the settings appropriately for each situation.
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Affiliation(s)
- Yoshinori Morita
- Department of Gastroenterology, Kobe University School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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19
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Tokar JL, Barth BA, Banerjee S, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Wang A, Rodriguez SA. Electrosurgical generators. Gastrointest Endosc 2013; 78:197-208. [PMID: 23867369 DOI: 10.1016/j.gie.2013.04.164] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 02/08/2023]
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20
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Karsenti D. Endoscopic management of bile duct stones: residual bile duct stones after surgery, cholangitis, and "difficult stones". J Visc Surg 2013; 150:S39-46. [PMID: 23817008 DOI: 10.1016/j.jviscsurg.2013.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic treatment has become, according to the latest recommendations, the standard treatment for common bile duct stones (CBDS), although in certain situations, surgical clearance of the common duct at the time of laparoscopic cholecystectomy is still considered a possible alternative. The purpose of this article is not to compare endoscopic with surgical treatment of CBDS, but to describe the various techniques of endoscopic treatment, detailing their preferential indications and the various treatment options that must sometimes be considered when faced with "difficult calculi" of the CBD. The different techniques of lithotripsy and the role of biliary drainage with plastic or metallic stents will be detailed as well as papillary balloon dilatation and particularly the technique of sphincterotomy with macrodilatation of the sphincter of Oddi (SMSO), a recently described approach that has changed the strategy for endoscopic management of CBDS. Finally, the overall strategy for endoscopic management of CBDS, with description of different techniques, will be exposed.
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Affiliation(s)
- D Karsenti
- Digestive Endoscopic Unit, Clinique de Bercy, 9, quai de Bercy, 94220 Charenton-le Pont, France.
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21
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Itoi T, Gotoda T, Baron TH, Sofuni A, Itokawa F, Tsuji S, Tsuchiya T, Tanaka R, Tonozuka R, Honjo M, Ryozawa S, Kawai T, Moriyasu F, Isayama H. Creation of simulated papillae for endoscopic sphincterotomy and papillectomy training by using in vivo and ex vivo pig model (with videos). Gastrointest Endosc 2013; 77:793-800. [PMID: 23453186 DOI: 10.1016/j.gie.2012.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are few in vivo and ex vivo models for training in endoscopic sphincterotomy (ES) and endoscopic papillectomy (EP). OBJECTIVE We describe in vivo and ex vivo training pig models that use a simulated papilla for hands-on teaching of ES and EP. DESIGN Animal experiment. SETTING A referral center. MATERIALS AND INTERVENTIONS Hyaluronate solution (0.4%) was injected submucosally using a 25-gauge sclerotherapy needle to create a submucosal bleb by using porcine in vivo stomach, ex vivo stomach, and ex vivo rectum. ES and EP were then performed by using a pull-type sphincterotome and snare, respectively. MAIN OUTCOME MEASUREMENT The feasibility of creating a simulated papilla for ES and EP procedures was tested by experienced and nonexperienced ERCP endoscopists. RESULTS Creation of a hemispheroidal bulge was successful in 13 of 17 (76%) areas within an in vivo stomach, 13 of 16 (81%) areas of an ex vivo stomach, and 16 of 16 (100%) areas in an ex vivo rectum. In the in vivo stomach model, ES was successfully and realistically performed on the anterior wall of the stomach rather than in other walls. In the ex vivo stomach model, endoscopists experienced in ERCP and trainees performed ES without difficulty, whereas it was difficult or impossible for nonexperienced trainees to perform ES. In the ex vivo rectum model, all 3 endoscopists were able to complete not only ES but also EP. LIMITATIONS Pilot study. CONCLUSIONS Although further studies are necessary to evaluate the reproducibility and cost-effectiveness, this novel pig model appears useful for ES and EP training.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Sakurazawa N, Kato S, Fujita I, Kanazawa Y, Onodera H, Uchida E. Supportive techniques and devices for endoscopic submucosal dissection of gastric cancer. World J Gastrointest Endosc 2012; 4:231-5. [PMID: 22720124 PMCID: PMC3377865 DOI: 10.4253/wjge.v4.i6.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 02/26/2012] [Accepted: 05/27/2012] [Indexed: 02/05/2023] Open
Abstract
The indications for endoscopic treatment have expanded in recent years, and relatively intestinal-type mucosal stomach carcinomas with a low potential for metastasis are now often resected en bloc by endoscopic submucosal dissection (ESD), even if they measure over 20 mm in size. However, ESD requires complex maneuvers, which entails a long operation time, and is often accompanied by complications such as bleeding and perforation. Many technical developments have been implemented to overcome these complications. The scope, cutting device, hemostasis device, and other supportive devices have been improved. However, even with these innovations, ESD remains a potentially complex procedure. One of the major difficulties is poor visualization of the submucosal layer resulting from the poor countertraction afforded during submucosal dissection. Recently, countertraction devices have been developed. In this paper, we introduce countertraction techniques and devices mainly for gastric cancer.
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Affiliation(s)
- Nobuyuki Sakurazawa
- Nobuyuki Sakurazawa, Shunji Kato, Itsuo Fujita, Yoshikazu Kanazawa, Hiroyuki Onodera, Eiji Uchida, Department of Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan
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Matsui N, Akahoshi K, Nakamura K, Ihara E, Kita H. Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: A technical review. World J Gastrointest Endosc 2012; 4:123-36. [PMID: 22523613 PMCID: PMC3329612 DOI: 10.4253/wjge.v4.i4.123] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 11/13/2011] [Accepted: 03/30/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.
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Affiliation(s)
- Noriaki Matsui
- Noriaki Matsui, Department of Gastroenterology and Hepatology, National Hospital Organization Fukuoka Higashi Medical Center, Koga 811-3195, Japan
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Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Electrosurgical current for endoscopic biliary sphincterotomy (EBS) for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Hippokratia 2012. [DOI: 10.1002/14651858.cd009643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Frances Tse
- McMaster University; Department of Medicine, Division of Gastroenterology; 1200 Main Street West 2F8-53 Hamilton Ontario Canada L8N 3Z5
| | - Yuhong Yuan
- McMaster University; Department of Medicine, Division of Gastroenterology; 1200 Main Street West 2F8-53 Hamilton Ontario Canada L8N 3Z5
| | - Paul Moayyedi
- McMaster University; Department of Medicine, Division of Gastroenterology; 1200 Main Street West 2F8-53 Hamilton Ontario Canada L8N 3Z5
| | - Grigorios I Leontiadis
- McMaster University; Department of Medicine, Division of Gastroenterology; 1200 Main Street West 2F8-53 Hamilton Ontario Canada L8N 3Z5
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Abstract
The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.
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Affiliation(s)
- Daniel Blero
- ISPPC, 1 Boulevard Zoé Drion, 6000 Charleroi, Belgium.
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Morris ML, Tucker RD, Baron TH, Song LMWK. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009; 104:1563-74. [PMID: 19491874 DOI: 10.1038/ajg.2009.105] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An electrosurgery generator unit is a critical piece of equipment in any therapeutic endoscopy setting. Electrosurgery generators produce high-frequency alternating electric current and differ from electrocautery units in that both cutting and coagulation effects can be achieved. This ability to cut and coagulate at the same time makes electrosurgery an ideal therapeutic tool for gastrointestinal endoscopy. Although education and familiarity with these devices are accepted as the primary avenue to the safest and most effective clinical outcomes, concise information linking the basic properties of electrosurgery directly to clinical practice is not widespread. The following are the aims of this article: (i) to relate the fundamental electrosurgical principles to commonly performed procedures such as snare polypectomy, hot biopsy, sphincterotomy, bipolar hemostasis, and argon plasma coagulation, and (ii) to provide practical suggestions for the use of these devices on the basis of an understanding of electrosurgical principles and the available clinical data.
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Ono S, Fujishiro M, Goto O, Kodashima S, Omata M. Submerging endoscopic submucosal dissection leads to successful en bloc resection of colonic laterally spreading tumor with submucosal fat. Gut Liver 2008; 2:209-12. [PMID: 20485649 DOI: 10.5009/gnl.2008.2.3.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 08/12/2008] [Indexed: 12/12/2022] Open
Abstract
A 72-year-old female with a colonic laterally spreading tumor (LST) was referred to our department. A total colonoscopy revealed a large nongranular LST, 30 mm in diameter, in the ascending colon. Detailed examination with chromoendoscopy confirmed that the lesion was an intramucosal tumor, and endoscopic submucosal dissection (ESD) was performed. After a circumferential incision around the lifted lesion with a submucosal fluid cushion, diffuse adipose tissue was observed in the submucosal layer beneath the lesion. The endoscopic view was blurred when dissecting the submucosal layer due to fat adhering to the lens. Since this made it difficult to continue the procedures, we infused water into the lumen and kept the endoscope tip immersed in the collected water. The resulting improved view made it possible to complete all procedures without withdrawing the endoscope to wipe the lens. The lesion was successfully resected en bloc without complications. The pathological examination indicated the curative resection of a tubulovillous adenoma. We propose that a submerged ESD could also be an effective procedure for colonic neoplasms with submucosal fat by avoiding blurring of the endoscopic view.
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Affiliation(s)
- Satoshi Ono
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Fukatsu H, Kawamoto H, Harada R, Tsutsumi K, Fujii M, Kato H, Hirao K, Nakanishi T, Mizuno O, Ogawa T, Ishida E, Okada H, Sakaguchi K. Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy. Surg Endosc 2008; 23:2066-72. [PMID: 18528622 DOI: 10.1007/s00464-008-9969-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Revised: 04/22/2008] [Accepted: 05/01/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although needle-knife precut papillotomy (NKPP) is considered a useful alternative for achieving selective biliary cannulation, controversy remains regarding the technical proficiency needed to perform the procedure and its safety. This study evaluated whether procedural experience with NKPP predicted either successful cannulation or the development of complications. METHODS This study retrospectively investigated 104 patients, out of 589 consecutive patients with native papillary, who underwent NKPP performed by a single endoscopist between October 2002 and July 2006. To demonstrate changes in NKPP, the 104 patients were divided chronologically into two groups according to periods: period A (October 2002 to September 2004) and period B (October 2004 to July 2006). RESULTS Of the 104 consecutive patients who underwent NKPP, 41 (41/267, 15%) were treated in period A and 63 (63/322, 20%) in period B. There was no significant difference in the overall success rate between periods A (90%) and B (98%) (p = 0.08). However, the initial success rate was higher in period B (95%) than in period A (80%) (p < 0.05). The complication rates were not significantly different between the two groups (10% vs 16%; p = 0.56). Although all complications involved pancreatitis, severe pancreatitis was not observed. CONCLUSION Whereas the initial success rate for NKPP can increase with procedural experience, the complication rate does not seem to decrease. Furthermore, the need for NKPP does not appear to decrease with increasing endoscopic retrograde cholangiopancreatography (ERCP) experience.
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Affiliation(s)
- Hirotoshi Fukatsu
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
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Abstract
Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Bleeding is one of the most frequent complications following ES. Rates of post-ES bleeding vary widely and its presentation may be immediate (intraprocedural) or several days later. Clinically, bleeding can range from insignificant to life threatening. Most bleeding episodes are managed successfully by conservative measures with or without endoscopic therapy. Endoscopic treatment options include injection, thermal, and mechanical methods-alone or in combination. For refractory cases, angiographic embolization, or surgery, is necessary. Both technical risk factors and patient risk factors contribute to the development of post-ES bleeding. When these risk factors are present, measures can be taken to reduce the risk of bleeding. In this manuscript the literature on post-ES bleeding is reviewed.
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Affiliation(s)
- Lincoln E V V C Ferreira
- Department of Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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30
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Campoli PMDO, Ejima FH, Cardoso DMM, Mota ED, Fraga Jr. AC, Mota OMD. Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants. ARQUIVOS DE GASTROENTEROLOGIA 2007; 44:250-6. [DOI: 10.1590/s0004-28032007000300014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 03/02/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND: When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM: This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS: Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS: Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION: The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.
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Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc 2007; 66:283-90. [PMID: 17643701 DOI: 10.1016/j.gie.2007.01.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 01/08/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic biliary sphincterotomy (ES) can cause bleeding, pancreatitis, and perforation. This has, in part, been attributed to the type of electrosurgical current used for ES. No consensus exists on the optimal type of electrosurgical current for ES to maximize safety. OBJECTIVE To compare the rates of complications in patients undergoing ES via pure current versus mixed current. DESIGN A systematic review of published, prospective, randomized trials that compared pure current with mixed current for ES. PATIENTS Patients undergoing ES, with random assignment to either current group. INTERVENTIONS Data were standardized for pancreatitis and postsphincterotomy bleeding. There were insufficient data to analyze perforation risk. A random-effects model was used. MAIN OUTCOME MEASUREMENTS Bleeding, pancreatitis, and perforation. RESULTS A total of 804 patients from 4 trials that compared pure current to mixed current were analyzed. The aggregated rate of pancreatitis was 3.8%, 95% confidence interval (CI) 1.0%-6.6%, for the pure-current group versus 7.9%, 95% CI 3.1%-12.7%, for the mixed-current group; the difference was not statistically significant. The rate of bleeding (all severity groups) for the pure-current group was 37.3% (95% CI 27.3%, 47.3%), which was significantly higher than that of the mixed-current group (12.2% [95% CI 4.1%, 20.3%]). Mild bleeding was significantly more frequent with pure current (28.9% [95% CI 16.3, 41.4]) compared with mixed current (9.4% [95% CI 2.1%, 16.8%]). LIMITATIONS Variables, including endoscopist skill and cannulation difficulty, were difficult to measure. CONCLUSIONS The rate of pancreatitis in patients who underwent ES when using pure current was not significantly different from those when using mixed current. Pure current was associated with more episodes of bleeding, primarily mild bleeding. Data were insufficient to analyze the perforation risk.
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Affiliation(s)
- Dharmendra Verma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas-Houston Medical School, Houston, TX, USA
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Mummadi R, Raju GS. Is the histologic quality of polyps affected by the type of electrosurgical generator used in resection? NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2007; 4:194-5. [PMID: 17325723 DOI: 10.1038/ncpgasthep0745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 01/12/2007] [Indexed: 05/14/2023]
Affiliation(s)
- Rajasekhara Mummadi
- Division of Gastroenterology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
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Ringold DA, Jonnalagadda S. Complications of Therapeutic Endoscopy: A Review of the Incidence, Risk Factors, Prevention, and Endoscopic Management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Fry LC, Lazenby AJ, Mikolaenko I, Barranco B, Rickes S, Mönkemüller K. Diagnostic quality of: polyps resected by snare polypectomy: does the type of electrosurgical current used matter? Am J Gastroenterol 2006; 101:2123-7. [PMID: 16848810 DOI: 10.1111/j.1572-0241.2006.00696.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Traditionally, snare polypectomy is performed using blended, coagulation, or pure cutting electrical current (EC). The aim of this study was to assess and compare the diagnostic quality of polyps obtained by snare polypectomy using two different electrosurgical currents. METHODS Consecutive patients undergoing colonoscopy underwent polypectomy using either blended EC with a conventional electrosurgical generator (ESG) or using an ESG with a microprocessor that automatically controls cutting and coagulation (Endocut). An experienced blinded gastrointestinal (GI) pathologist evaluated the specimens for diameter, cautery damage (amount and degree), margin evaluability, architecture, and general histologic diagnostic quality. RESULTS One hundred sixteen patients (69% men, mean age 63.8 +/- 15 yr) underwent 148 polypectomies (78 using blended current and 70 using Endocut). We found that the cautery degree was less with the Endocut than with the blended current (p < 0.02). Cautery amount was also higher in polyps resected using blended current (56%) than Endocut (51%) but this difference did not reach statistical significance (p= 0.1). Polyps resected using Endocut had better margin evaluability (75.7% to 60.3%, p= 0.046). The overall tissue architecture was similar in both groups. Polyps removed with blended current had less overall quality as compared to polyps removed by Endocut (p= 0.024). CONCLUSIONS More extensive tissue damage occurred using blended EC with the conventional ESG than when using Endocut. The quality of the polypectomy specimens was overall better using Endocut. Finally, the ability to evaluate resected polyp margins and overall tissue histology was better with the microprocessor-controlled ESG than with the conventional ESG.
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Affiliation(s)
- Lucía C Fry
- Department of Medicine, Division of Gastroenterology and Hepatology, VA Medical Center Hospital and University of Alabama Hospital, University of Alabama, Birmingham, Alabama, USA
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Abstract
An electrosurgery generator is a critical piece of equipment in any therapeutic endoscopy setting. Electrosurgery uses rapidly alternating current, provided by the electrosurgery generator, for both therapeutic cutting and coagulation of tissue. Basic variables important to electricity in general are also important to electrosurgery: current, voltage, circuit, and impedance (resistance). Monopolar and bipolar accessories (electrodes) are used in the endoscopy suite and these terms refer to the way in which the electric circuit is completed by the flowing current. Impedance resists current flow and changes with tissue type and degree of therapeutic coagulation. Waveforms are the high-frequency output selected by the operator when using an electrosurgery generator. Waveforms may be continuous or interrupted (modulated) and differ in voltage and degree of modulation. Certain waveforms are typically chosen for particular applications or accessories, such as polypectomy with a snare, because of predictable tissue-effect attributes of that waveform. Safe application of grounding pads, careful management of active accessories, and good care of electrosurgical equipment are crucial to patient and operator safety.
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Affiliation(s)
- Marcia L Morris
- Medical Service Associates, Inc., Maplewood, Minnesota 55119, USA.
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Dobrowolski S, Dobosz M, Babicki A, Głowacki J, Nałecz A. Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy. Gastrointest Endosc 2006; 63:1004-9. [PMID: 16733117 DOI: 10.1016/j.gie.2005.11.063] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2004] [Accepted: 11/08/2005] [Indexed: 12/25/2022]
Abstract
BACKGROUND The most common complication of endoscopic polypectomy is hemorrhage. Several factors have been reported to increase the risk of hemorrhage after polypectomy, but controversies still exist. Additionally, the pathomechanism of this complication is not well understood. OBJECTIVE To investigate the risk factors of colonoscopic postpolypectomy bleeding in patients without bleeding disorders and the blood supply of resected polyps. PATIENTS Two hundred forty-five patients (147 men, 98 women; median age, 62.8 +/- 9.5 years [SD]) with 283 colorectal polyps, measuring > or =1 cm in diameter, were included in this prospective study. INTERVENTIONS The polypectomies were performed using the conventional endoscopic method. Data on the patients' age and sex, as well as polyp location, size, shape, and pathology findings were recorded. The patients were observed for bleeding complications. Microscopic examination of the vascular supply of the removed polyps was performed. RESULTS Twenty-nine postpolypectomy hemorrhages (10.2%) occurred. The bleeding rate correlated with the size, shape, and pathology results of resected polyps. The microscopic analysis revealed that sessile and thick-stalked pedunculated polyps are supplied with more vessels than other polyps. CONCLUSIONS Patients with polyps larger than 17 mm, pedunculated polyps with a stalk diameter >5 mm, sessile polyps, and malignant lesions of the colorectal region are at high risk of hemorrhage after endoscopic excision. Moreover, on the basis of microscopic study, broad-based polyps are supplied with a considerable number of blood vessels.
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Affiliation(s)
- Sebastian Dobrowolski
- Department of General, Endocrinological and Transplantation Surgery, Medical Academy of Gdansk, Witosa 21/30, Gdansk 80-809, Poland
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Akiho H, Sumida Y, Akahoshi K, Murata A, Ouchi J, Motomura Y, Toyomasu T, Kimura M, Kubokawa M, Matsumoto M, Endo S, Nakamura K. Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis. World J Gastroenterol 2006; 12:2086-2088. [PMID: 16610062 PMCID: PMC4087690 DOI: 10.3748/wjg.v12.i13.2086] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 09/21/2005] [Accepted: 10/09/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate whether an automatically controlled cut system (endocut mode) could reduce the complication rate of endoscopic sphincterotomy (EST) and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group (9%): hyperamylasemia (5 times higher than normal) in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group (16%): hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST (P<0.02). The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group (P<0.05). CONCLUSION Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.
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Affiliation(s)
- Hirotada Akiho
- Division of Gastroenterology, Aso Iizuka Hospital, Japan.
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Kaffes AJ, Sriram PVJ, Rao GV, Santosh D, Reddy DN. Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique. Gastrointest Endosc 2005; 62:669-74. [PMID: 16246677 DOI: 10.1016/j.gie.2005.05.022] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 05/12/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques. METHODS We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-upward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later. RESULTS A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of pre-cut techniques. CONCLUSIONS The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.
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Affiliation(s)
- Arthur J Kaffes
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Perini RF, Sadurski R, Cotton PB, Patel RS, Hawes RH, Cunningham JT. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference? Gastrointest Endosc 2005; 61:53-7. [PMID: 15672056 DOI: 10.1016/s0016-5107(04)02454-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bleeding as a complication of endoscopic sphincterotomy is influenced by several factors. The objective of this study was to compare rates of bleeding after sphincterotomy performed with two different electrosurgical current generators (Valleylab SSE2L and ERBE ICC200). METHODS A total of 6179 consecutive reports of ERCP were analyzed to compare the frequency of endoscopically and clinically evident bleeding after sphincterotomy when using the Valleylab SSE2L generator (from February 1994 to November 1997) and the ERBE ICC200 generator (from December 1997 to September 2000). Relevant risk factors were assessed by univariate analysis and significant predictors were included in a multiple logistic regression model. RESULTS A total of 2711 sphincterotomies were performed in 2309 patients (1749 biliary, 962 pancreatic). Endoscopically observed bleeding occurred in 68 patients (5.5%) in the ValleyLab group and 13 (1.2%) in the ERBE group. The ValleyLab generator was independently associated with an increase in endoscopically observed bleeding (OR 4.02: 95% CI[2.13, 7.61], p <0.001). There was no significant difference in clinically evident bleeding between the two groups. CONCLUSIONS Use of the microprocessor-controlled ERBE electrosurgical generator for endoscopic sphincterotomy was associated with a significantly lower frequency of endoscopically observed bleeding but not clinically evident bleeding.
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, MN 55415, USA
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Dobrowolski S, Dobosz M, Babicki A, Dymecki D, Hać S. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004; 18:990-3. [PMID: 15108107 DOI: 10.1007/s00464-003-9214-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 01/04/2004] [Indexed: 01/01/2023]
Abstract
BACKGROUND Endoscopic polypectomy is a standard method of treatment of gastrointestinal polyps, but is associated with substantial risk of complications. The most common is hemorrhage, the rate of which varied between 0.3%, and 6%. Various prophylactic techniques have been used to reduce this incidence. The aim of this study was to establish whether the prophylactic injection of adrenaline-saline solution reduces the risk of postpolypectomy bleeding in colonoscopic polypectomy. METHODS Between May 2000 and June 2002, patients with colorectal polyps of size > or =1 cm were randomized to receive submucosal epinephrine injection (group A) or no injection (group B). The polypectomies were carried out using the conventional method. In group A, epinephrine (1/10,000) was injected into the stalk or base of the polyp. The patients were observed for complications. RESULTS A total of 69 patients with 100 polyps were enrolled in this study: n = 50 in group A, and n = 50 in group B, according to randomization. There were a total of nine episodes of postpolypectomy hemorrhage, one in the epinephrine group and eight in the control group (1/50 vs 8/50, p < 0.05). The bleeding correlated with the size of the polyps and the diameter of the stalks. CONCLUSIONS Epinephrine injection prior to colonoscopic polypectomy is effective in preventing bleeding.
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Affiliation(s)
- S Dobrowolski
- Department of General, Gastroenterological and Endocrinological Surgery, Medical University of Gdansk, Ul. Kieturakisa 1, 80-742, Gdansk, Poland.
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Slivka A, Bosco JJ, Barkun AN, Isenberg GA, Nguyen CC, Petersen BT, Silverman WB, Taitelbaum G, Ginsberg GG. Electrosurgical generators: MAY 2003. Gastrointest Endosc 2003; 58:656-60. [PMID: 14595296 DOI: 10.1016/s0016-5107(03)02012-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Adam Slivka
- Technology Committee of the American Society for Gastrointestinal Endoscopy, USA
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Enya M, Yasuda I, Tomita E, Shirakami Y, Otsuji K, Shinoda T, Moriwaki H. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts using a large-channel echoendoscope and a conventional polypectomy snare. Dig Endosc 2003. [DOI: 10.1046/j.1443-1661.2003.t01-2-00264.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Hirata N. ENDOSCOPIC SPHINCTEROTOMY: MY METHOD. Dig Endosc 2002. [DOI: 10.1046/j.1443-1661.14.s1.19.x] [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: 02/23/2023]
Affiliation(s)
- Nobuto Hirata
- Division of Gastroenterology, Sagamidai Hospital, Kanagawa, Japan
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Igarashi Y, Ukita T, Inoue H, Maetani I, Sakai Y. WHICH MODALITY CAN BE STANDARDERIZED for ENDOSCOPIC SPHINCTEROTOMY in JAPAN? Dig Endosc 2002. [DOI: 10.1046/j.1443-1661.14.s1.18.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Yoshinori Igarashi
- Third Department of Internal Medicine Toho University School of Medicine,
| | - Takeo Ukita
- Third Department of Internal Medicine Toho University School of Medicine,
| | - Hirokazu Inoue
- Third Department of Internal Medicine Toho University School of Medicine,
| | - Iruru Maetani
- Division of Digestive Endoscopy, Toho University Ohashi Hospital, Tokyo, Japan
| | - Yoshihiro Sakai
- Division of Digestive Endoscopy, Toho University Ohashi Hospital, Tokyo, Japan
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Abstract
The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.
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Affiliation(s)
- K F Binmoeller
- Department of Medicine and Surgery, University of California, San Diego 92103-8413, USA.
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