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Akca S, Atar GE, Ocal S, Buldukoglu OC, Koker G, Isik MD, Kaya B, Deniz H, Harmandar FA, Cekin AH. Association of periampullary diverticulum types with post-ERCP hyperamylasemia: a retrospective observational study. BMC Gastroenterol 2025; 25:284. [PMID: 40269757 PMCID: PMC12016130 DOI: 10.1186/s12876-025-03896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2024] [Accepted: 04/14/2025] [Indexed: 04/25/2025] Open
Abstract
BACKGROUND This study aimed to assess the prevalence of periampullary diverticulum (PAD) among endoscopic retrograde cholangiopancreatography (ERCP) patients in Southwestern Turkey and investigate the association between the new PAD classification, post-ERCP hyperamylasemia, and post-ERCP pancreatitis (PEP). MATERIALS AND METHODS We retrospectively reviewed 1,317 ERCP procedures performed between January 1, 2022, and December 31, 2023, at Antalya Training and Research Hospital. The PAD type was determined according to the He-xian Shi classification. Hyperamylasemia was defined as an increase of three times the normal level of amylase at 4 to 6 h, and PEP was defined as hyperamylasemia along with abdominal pain lasting more than 24 h. RESULTS A total of 594 naive patients who underwent ERCP were analyzed. PAD was present in 137 patients (23.1%), and the success rate of choledochal cannulation in the first ERCP procedure was 94.3%. There was no difference in the choledochal cannulation rate between patients with and without PAD (95.6%-93.4%, p = 0.59). Asymptomatic hyperamylasemia was observed in 19.3% of the patients. Post-ERCP hyperamylasemia rates were similar between patients with and without PAD (17.5% and 21.2% respectively, p = 0.31). PEP was observed in 8.0% of the patients. Presence of PAD was not a risk factor for post-ERCP pancreatitis (7.3% compared to 8.8%, p = 0.82). When we checked the results according to the type of PAD, the prevalence of post-ERCP hyperamylasemia was significantly lower in patients with type 2b PAD than in those with type 1 and type 2a patients. CONCLUSION PAD is a common finding in ERCP patients, with a prevalence of 23.1% in our cohort. The rate of choledochal cannulation, post ERCP hyperamylasemia and PEP did not differ between the patients with and without PAD. However, the type of PAD is important; post-ERCP hyperamylasemia is significantly lower in patients with type 2b than in type 1 and type 2a PAD patients. Different subtypes of PAD may have different associations on ERCP outcomes. Further investigations with refined and standardized PAD classification systems are needed.
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Affiliation(s)
- Serdar Akca
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey.
| | - Galip Egemen Atar
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Serkan Ocal
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Osman Cagin Buldukoglu
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Gokhan Koker
- Department of Internal Medicine, Antalya Training and Research Hospital, Antalya, Turkey
| | - Muhammed Devran Isik
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Besir Kaya
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Hatice Deniz
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Ferda Akbay Harmandar
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
| | - Ayhan Hilmi Cekin
- Department of Gastroenterology, Antalya Training and Research Hospital, Varlik mah. Kazim Karabekir Cd., Antalya, 07100, Turkey
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Gustafsson A, Tingstedt B, Olsson G. The impact of periampullary diverticula on cannulation and adverse events in endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2024; 17:17562848241279105. [PMID: 39398975 PMCID: PMC11470493 DOI: 10.1177/17562848241279105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/11/2024] [Indexed: 10/15/2024] Open
Abstract
Background Periampullary diverticulum (PAD) is commonly encountered in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Objectives We sought to determine whether PADs are associated with a lower success rate of cannulation and an increased risk of adverse events. Design A retrospective cohort study was conducted using prospectively gathered nationwide registry data. Methods Using the Swedish registry for gallstone surgery and ERCP, we analyzed a cohort of 66,974 prospectively registered ERCP procedures performed in 2006-2021. The presence of PAD was divided into two groups based on the PAD type: Boix type 1 (the papilla located inside the PAD) and Boix types 2-3 (the papilla located either at the edge of the PAD or immediately adjacent to the PAD). The primary outcomes were the success rate of cannulation and overall adverse events within 30 days. Results PADs were registered in 8130 (12.1%) of ERCPs included in the study population. In total, 2114 (3.9%) patients had Boix type 1 PAD, while 5035 (8.2%) patients had Boix type 2 or 3 PAD. The chance of successful cannulation was lower in patients with type 1 PAD compared to no PAD (80.1% vs 88.7%; odds ratio: 0.42, 95% confidence interval: 0.38-0.46). No differences were seen in overall adverse events or post-ERCP pancreatitis. Adverse events occurred in 14.6% of patients with PAD type 1 and 16.0% of patients with PAD type 2 or 3, compared to 16.5% of patients without a PAD. Conclusion Cannulation appears less successful during ERCP when the papilla is located in the PAD (i.e., type 1). Adverse events seem not to increase with the presence of a PAD, but they could theoretically be influenced by the inability to cannulate.
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Affiliation(s)
- Arvid Gustafsson
- Departments of Research and Development and Surgery, Central Hospital, Region Kronoberg, Strandvägen 8, Växjö SE-351 85, Sweden
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Greger Olsson
- Departments of Research and Development and Surgery, Central Hospital, Region Kronoberg, Växjö, Sweden
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Xie XX, Li X, Chen YH, Geng C, Wang CH. Impact of periampullary diverticula on the rates of successful cannulation and ERCP complications: An up-to-date systematic review and meta-analysis. J Dig Dis 2024; 25:573-586. [PMID: 39557071 DOI: 10.1111/1751-2980.13315] [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: 03/11/2024] [Revised: 09/29/2024] [Accepted: 10/04/2024] [Indexed: 11/20/2024]
Abstract
OBJECTIVES Periampullary diverticulum (PAD) is usually incidentally discovered during abdominal imaging, gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The influence of PAD on ERCP outcomes is unclear. The aim of this systematic review and meta-analysis was to provide an up-to-date evaluation of the impact of PAD on cannulation and ERCP-related complications. METHODS PubMed, Web of Science, Cochrane Library and EMBASE databases were searched for relevant articles published up to October 31, 2023. The rates of successful cannulation and post-ERCP complications were compared between the PAD and non-PAD groups. The quality of the studies was evaluated with the Newcastle-Ottawa Scale (NOS). The meta-analysis was conducted using Review Manager 5.3. RESULTS Twenty-eight articles were included. Non-PAD was associated with a relatively high cannulation success rate (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54-0.97, p = 0.03). However, after 2015, PAD was not correlated with cannulation failure (OR 0.81, 95% CI 0.59-1.11, p = 0.20). Compared with intradiverticular papilla (IDP), non-IDP had a higher successful cannulation rate (OR 0.42, 95% CI 0.25-0.72, p = 0.002), while IDP increased the difficult cannulation rate (OR 1.60, 95% CI 1.05-2.44, p = 0.03). Additionally, PAD increased the incidence of ERCP-related pancreatitis (OR 1.24, 95% CI 1.10-1.40, p = 0.0006) and bleeding (OR 1.34, 95% CI 1.03-1.73, p = 0.03). CONCLUSIONS Although PAD, especially IDP, decreased the cannulation success rate, PAD was no longer considered a significant obstacle to cannulation after 2015. PAD increased the incidence of post-ERCP pancreatitis and bleeding.
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Affiliation(s)
- Xiao Xi Xie
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao Li
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yong Hao Chen
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Chong Geng
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Chun Hui Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Ali IM, Shetty SK, Shetty V. Lemmel Syndrome: A Surgical Enigma. Cureus 2024; 16:e65620. [PMID: 39205778 PMCID: PMC11350480 DOI: 10.7759/cureus.65620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
A periampullary diverticulum (PAD) is the most common type of duodenal diverticula found in patients undergoing upper gastrointestinal tract assessments. Even while PAD typically does not manifest any symptoms, it can nevertheless be a source of obstructive jaundice in the absence of a tumor or choledocholithiasis, a condition known as Lemmel's syndrome. We report a case of a 60-year-old woman who presented with abdominal discomfort and multiple episodes of vomiting. After comprehensive clinical examination and investigations, a provisional diagnosis of Lemmel's syndrome was made, leading to initial conservative management for diverticulitis, followed by an exploratory procedure. This case underscores the importance of recognizing Lemmel's syndrome as a differential diagnosis for obstructive jaundice when duodenal diverticula are present, to prevent misdiagnosis and ensure timely, appropriate treatment.
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Affiliation(s)
- Iqbal M Ali
- Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Saurav K Shetty
- Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Varun Shetty
- Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Vikash F, Parajuli S, Kumar V, Patel S, Ho S. Lemmel Syndrome: Unveiling the Underrecognized Pancreatobiliary Diagnosis, Management Strategies, and Future Directions. Cureus 2024; 16:e61673. [PMID: 38966462 PMCID: PMC11223750 DOI: 10.7759/cureus.61673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/06/2024] Open
Abstract
Lemmel syndrome, a rare condition, is characterized by biliary obstruction caused by a periampullary diverticulum (a pouch-like outgrowth of the duodenum near the ampulla of Vater). In our case, a 76-year-old male patient presented with epigastric pain and exhibited a cholestatic pattern on liver function tests. Imaging revealed dilated pancreatic and common bile ducts due to compression by a periampullary diverticulum (double duct sign: simultaneous dilation of the common bile duct and pancreatic duct). Upper endoscopy showed one medium-sized periampullary diverticulum. This case emphasizes the diagnostic process and the importance of considering Lemmel syndrome in differential diagnosis in elderly patients with biliary obstruction. We discuss the prevalence, diagnostic considerations, including imaging modalities, and treatment options, emphasizing the need for further research.
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Affiliation(s)
- Fnu Vikash
- Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York City, USA
| | - Sandesh Parajuli
- Department of Medicine, Reading Hospital, Tower Health, West Reading, USA
| | - Vikash Kumar
- Department of Internal Medicine, The Brooklyn Hospital Center, New York City, USA
| | - Sunny Patel
- Department of Gastroenterology and Hepatology, Albert Einstein College of Medicine, Jacobi Medical Center, New York City, USA
| | - Sammy Ho
- Department of Gastroenterology, Albert Einstein College of Medicine, Jacobi Medical Center, New York City, USA
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Ju J, Su Y, Zeng Q, Liang J, Zhang X, Ren J, Wu L, Zheng R. Sonographic features of Lemmel's syndrome: Differential diagnosis from stones in the lower portion of the common bile duct. Arab J Gastroenterol 2024; 25:143-149. [PMID: 38403494 DOI: 10.1016/j.ajg.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 09/28/2023] [Accepted: 01/03/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND STUDY AIMS Periampullary diverticula (PAD), a location-specific type of duodenal diverticula, can cause serious complications. PAD is difficult to differentially diagnose, mainly due to its nonspecific symptoms. This study aimed to identify sonographic features of PAD and to evaluate their value in the differential diagnosis of PAD from stones in the lower common bile duct (CBD). PATIENTS AND METHODS A total of 30 patients with PAD and 60 patients with lower CBD stones were retrospectively enrolled, and sonographic features were analyzed. Measurements of sonographic features included echo shaped, posterior echo changes, location and relation to surrounding organs, and status of intrahepatic and extrahepatic bile duct dilation, and their diagnostic performance was assessed. RESULTS Characteristic sonographic features of PAD were identified, including strong echoes (28/30, 93.3 %), strip shape (28/30, 93.3 %), multiple reflections in the posterior echo (27/30, 90.0 %), and location outside the CBD or near the biliary wall in connection with the duodenum (27/30, 90.0 %). Inter-observer agreement was good (Kappa values = 0.69-0.82). Comparative analysis of sonographic features revealed significant differences in echo shape, posterior echo changes (multiple reflections and acoustic shadowing), location and relation to surrounding organs, and intrahepatic and extrahepatic bile duct dilatation status between the dilatation status of the two groups. In particular, these characteristics achieved a sensitivity of 100 % and a specificity of 98 % for the differential diagnosis of PAD and lower CBD stones. CONCLUSIONS This study identified characteristic sonographic features of PAD, which could be used as potential diagnostic indicators to distinguish PAD from lower CBD stones.
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Affiliation(s)
- Jinxiu Ju
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China
| | - Yating Su
- Department of Ultrasound, The First Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Qingjing Zeng
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China.
| | - Jiayi Liang
- Huangpu District Luogang Street Community Health Service Center, Guangzhou, Guangdong, P.R. China
| | - Xiaodan Zhang
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China.
| | - Jie Ren
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China.
| | - Lili Wu
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China.
| | - Rongqin Zheng
- Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Key Laboratory of Liver Disease Research, Guangzhou, China.
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Shi HX, Ye YQ, Zhao HW, Kong DC, Huang SZ, Yan Q, Chen YB, Zhang P, Chen S, Hou BH, Zhang CZ. A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging. BMC Gastroenterol 2023; 23:252. [PMID: 37491210 PMCID: PMC10369787 DOI: 10.1186/s12876-023-02862-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/22/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis. METHODS Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation. RESULTS The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation. CONCLUSIONS The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.
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Affiliation(s)
- He-Xian Shi
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- Department of Hepatobiliary Surgery, HeZe Municipal Hospital, HeZe, 274000, Shandong, China
| | - Yong-Qiang Ye
- Department of Hepatobiliary Surgery, HeZe Municipal Hospital, HeZe, 274000, Shandong, China
| | - Hai-Wang Zhao
- Department of Hepatobiliary Surgery, HeZe Municipal Hospital, HeZe, 274000, Shandong, China
| | - De-Cai Kong
- Department of Gastrointestinal Surgery, HeZe Municipal Hospital, HeZe, 274000, Shandong, China
| | - Shan-Zhou Huang
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Qian Yan
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- School of Medicine, South China University of Technology, Guangzhou, 51000, China
| | - Yu-Bin Chen
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
- School of Medicine, South China University of Technology, Guangzhou, 51000, China
| | - Ping Zhang
- Department of Hepatobiliary Surgery, HeZe Municipal Hospital, HeZe, 274000, Shandong, China
| | - Sheng Chen
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Bao-Hua Hou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China.
- School of Medicine, South China University of Technology, Guangzhou, 51000, China.
| | - Chuan-Zhao Zhang
- Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China.
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Aslan S, Önder RO. A Rare Cause of Obstructive Jaundice and Pancreatitis; Lemmel's Syndrome. Curr Med Imaging 2023; 20:CMIR-EPUB-130007. [PMID: 36876840 DOI: 10.2174/1573405619666230306104924] [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: 11/15/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION/BACKGROUND Lemmel's syndrome is defined as obstructive jaundice due to a PDD in the absence of choledocholithiasis or a neoplasm. The most common cause is the presence of PDD which arise within 2-3 cm from the ampulla of Vater. Currently, there are very few case reports of this condition, which was first named in 1934 after Dr. Gerhard Lemmel. CASE PRESENTATION A 74-year-old female patient presented to the emergency department with complaints of abdominal pain and jaundice, and also had signs of pancreatitis, with laboratory results showing elevated liver and pancreatic enzymes and hyperbilirubinemia. We present a case of a patient who was diagnosed with Lemmel's syndrome after abdominal CT, MRCP, and ERCP. CONCLUSION Although rare, it is imperative for physicians to recognize this syndrome in order to deliver prompt care. Because making the correct diagnosis in these patients is very important for correct treatment and preventing the development of complications.
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Affiliation(s)
- Serdar Aslan
- Department of Radiology, Giresun University, Faculty of Medicine, Giresun, Turkey
| | - Ramazan Orkun Önder
- Department of Radiology, Giresun University, Faculty of Medicine, Giresun, Turkey
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Ak Ç, Aykut H, Pala E, Sayar S, Tarikçi Kiliç E, Adali G, Kahraman R, Öztürk O, Özdil K. Post-ERCP Complication Analysis of an Experienced Center. Surg Laparosc Endosc Percutan Tech 2022; 32:707-713. [PMID: 36468895 DOI: 10.1097/sle.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 09/13/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND/AIM Post-ERCP pancreatitis (PEP), post-sphincterotomy bleeding (PSB), and Post-ERCP perforation are the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Identification of risk factors for post-ERCP complications is critical for postoperative follow-up. This study aimed to evaluate the most common post-ERCP complication risk factors in an experienced center. METHODS/DESIGN The sample consisted of 1288 patients with naive papillae. Demographic characteristics, patient-related risk factors, procedure-related risk factors and postoperative complications were recorded. RESULTS Patients had a mean age of 61.5±18.4 years. The prevalence of PEP, PSB, and post-ERCP perforation was 7.9%, 11.9%, and 0.5%, respectively. Among patient-related factors, female sex (OR 1.672 95% Cl 1.046 to 2.672) and narrowing of the choledochal diameter (OR 2.910 95% Cl 1.830 to 4.626) were associated with PEP. From procedure-related factors; precut sphincterotomy (OR 2.172 95% Cl 1.182 to 3.994), difficult cannulation (OR 5.110 95% Cl 2.731 to 9.560), pancreatic cannulation (OR 5.692 95% Cl 0.994 to 32.602) and postprocedure residual stone (OR 2.252 95% Cl 1.403 to 3.614) were found to be associated with PEP. The successful procedure (OR 0.378 95% Cl 0.204 to 0.699) had a protective effect on PEP. Choledocholithiasis indication (OR 3.594 95% Cl 1.444 to 8.942) and small papilla (OR 2.042 95% Cl 1.170 to 3.562) were associated with the development of PSB. Choledochal stenosis, periampullary-diverticulum, oral anticoagulant, and oral antiaggregant use were not associated with the development of PSB. Of the patients with post-ERCP perforation, 85.7% had difficult cannulation, 57.1% had precut sphincterotomy, and 28.6% had periampullary-diverticulum. CONCLUSION Female sex, biliary stricture, precut sphincterotomy, difficult cannulation, pancreatic cannulation, and postoperative residual stone were associated with PEP. Choledocholithiasis indication and the presence of small papilla were associated with PSB.
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Affiliation(s)
| | - Hüseyin Aykut
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Emin Pala
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Süleyman Sayar
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Ebru Tarikçi Kiliç
- Health Sciences University Umraniye Training and Research Hospital, Department of Anesthesiology, Istanbul, Turkey
| | - Gupse Adali
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Resul Kahraman
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Oğuzhan Öztürk
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
| | - Kamil Özdil
- Health Sciences University Umraniye Training and Research Hospital, Department of Gastroenterology
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Zorzetti N, Lauro A, Cervellera M, Panarese A, Khouzam S, Marino IR, Sorrenti S, D'Andrea V, Tonini V. Debris-Filled Duodenal Diverticulum and Lemmel's Syndrome. Dig Dis Sci 2022; 67:2805-2808. [PMID: 35650417 DOI: 10.1007/s10620-022-07571-z] [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] [Accepted: 05/02/2022] [Indexed: 02/08/2023]
Abstract
We report a case of a 73-year-old woman affected by Lemmel's syndrome, a rare type of obstructive jaundice caused by a periampullary duodenal diverticulum. The patient was admitted to the Emergency Department for pneumonia associated with mild epigastric pain and vomiting. While hospitalized for antibiotic treatment, the appearance of jaundice led us to discover a periampullary duodenal diverticulum by endoscopy and CT scan. The jaundice was successfully managed endoscopically with removal of food debris from the diverticulum.
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Affiliation(s)
- Noemi Zorzetti
- Department of General Surgery, "A. Costa" Hospital - Porretta Terme, Bologna, Italy.
- Department of Surgical Sciences, La Sapienza University, Rome, Italy.
| | - A Lauro
- Department of Surgical Sciences, La Sapienza University, Rome, Italy
| | - M Cervellera
- Department of General Surgery, "Santissima Annunziata" Hospital, Taranto, Italy
| | - A Panarese
- Department of General Surgery, "Santissima Annunziata" Hospital, Taranto, Italy
| | - S Khouzam
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - S Sorrenti
- Department of Surgical Sciences, La Sapienza University, Rome, Italy
| | - V D'Andrea
- Department of Surgical Sciences, La Sapienza University, Rome, Italy
| | - V Tonini
- Department of General Surgery, "Santissima Annunziata" Hospital, Taranto, Italy
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
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Titanium Clip-dental Floss Traction-assisting Endoscopy in Patients With Difficulty in Cannulation Into the Duodenal Peridiverticular Papilla. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2022; 32:462-465. [PMID: 35797640 DOI: 10.1097/sle.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/04/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess titanium clip-dental floss traction-assisting endoscopy in patients with difficulty in cannulation into the papilla located at the lower, left or right side of the periampullary diverticulum. MATERIALS AND METHODS Sixty-eight patients who had difficulty in cannulation into the papilla located at the lower, left, or right side of the periampullary diverticulum upon endoscopic retrograde cholangiopancreatography (ERCP) were recruited at Taizhou Hospital from July 2016 to June 2020. A random number table was used to divide the patients into an intervention (with titanium clip-dental floss traction) group and a control group (n=34 in each group). Patients in both groups underwent ERCP. The cannulation time, cannulation success rate, incidence of postprocedural complications after ERCP, hospitalization time, and hospitalization expenses in the 2 groups were compared. RESULT The cannulation time was 15.3±4.1 minutes in the intervention group, which was less than that in the control group (25.7±6.5 min). The cannulation success rate was 77±12.1% in the intervention group, which was higher than that in the control group (43±16.7%). Postprocedural complications occurred in 2 patients in the intervention group and 6 patients in the control group, with no significant differences. The hospitalization time and expenses were 3.8±2.6 days and 11.1±6 thousand yuan in the intervention group, respectively, and 6.1±3.7 days and 18.2±8 thousand yuan in the control group, respectively. The differences were statistically significant (P<0.05). CONCLUSION Titanium clip-dental floss traction-assisting endoscopy achieved excellent efficacy in patients with difficulty in cannulation into the papilla located at the lower, left or right side of the periampullary diverticulum. The cannulation success rate was improved after treatment, with good safety and prognosis.
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12
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Probert S, Cai W, Islam F, Ballanamada Appaiah NN, Salih A. Bouveret Syndrome: A Rare Case and Review of the Literature. Cureus 2022; 14:e24768. [PMID: 35686250 PMCID: PMC9170448 DOI: 10.7759/cureus.24768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Bouveret syndrome is a subtype of gallstone ileus, wherein a calculus becomes entrapped in the duodenum via a cholecystocolic fistula, leading to gastric outlet obstruction. Due to the non-specific symptoms the patients present with, a diagnosis is reliant on computed tomography (CT), magnetic resonance imaging (MRI) or direct endoscopic visualisation. We report a case of Bouveret syndrome and review current literature, outlining the aetiopathogenesis and management strategies of this condition.
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Khoury T, Sbeit W. Peri-ampullary diverticulum was associated with a higher rate of acute cholangitis among patients with choledocholithiasis. Surg Endosc 2022; 36:2936-2941. [PMID: 34101011 DOI: 10.1007/s00464-021-08586-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce. AIMS We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis. METHODS We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. RESULTS Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4 years, respectively (P < 0.0001). The rate of PAD was significantly higher in group A as compared to group B (35.2% vs. 19%, P = 0.0002). However, the rate of smoking, chronic liver diseases, hemolytic anemia, and post-cholecystectomy status were not different between the groups (P = 0.3, P = 0.3, P = 0.2, and P = 0.3), respectively. On univariate analysis, age (OR 1.05, P < 0.0001) and PAD (OR 2.32, P = 0.0006) were significantly associated with acute cholangitis. On multivariate logistic regression analysis, the effects of age and PAD were preserved (OR 1.05, 95% CI 1.03-1.07, P < 0.0001 and OR 1.64, 95% CI 1.02-2.72, P = 0.049), respectively. CONCLUSION PAD showed a significant association with the development of acute cholangitis among patients with choledocholithiasis. Identification of gallbladder and biliary stones in patients with PAD is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications.
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Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Faculty of Medicine in the Galilee, Galilee Medical Center, Bar-Ilan University, Safed, Israel.
| | - Wisam Sbeit
- Department of Gastroenterology, Faculty of Medicine in the Galilee, Galilee Medical Center, Bar-Ilan University, Safed, Israel
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Zhu KX, Yue P, Wang HP, Meng WB, Liu JK, Zhang L, Zhu XL, Zhang H, Miao L, Wang ZF, Zhou WC, Suzuki A, Tanaka K, Li X. Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto. World J Gastrointest Surg 2022; 14:132-142. [PMID: 35317545 PMCID: PMC8908344 DOI: 10.4240/wjgs.v14.i2.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/24/2021] [Accepted: 01/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.
AIM To compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.
METHODS Patients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.
RESULTS A total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.
CONCLUSION Many clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.
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Affiliation(s)
- Ke-Xiang Zhu
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Ping Yue
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hai-Ping Wang
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Bo Meng
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jian-Kang Liu
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02451, United States
| | - Lei Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiao-Liang Zhu
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Long Miao
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Zheng-Feng Wang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Ce Zhou
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Azumi Suzuki
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Kiyohito Tanaka
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto 602-8026, Japan
| | - Xun Li
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
- Key Laboratory of Biological Therapy and Regenerative Medicine Transformation Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
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Shankar U, Bhandari P, Panchal A, Weeks D, Wu H, Chen F, Maheshwari N, Bansal R, Walfish A, Baum J, Jamidar PA, Aron J. Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study. BMC Gastroenterol 2022; 22:52. [PMID: 35130860 PMCID: PMC8822858 DOI: 10.1186/s12876-022-02120-4] [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: 09/28/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.
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Affiliation(s)
- Uday Shankar
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA. .,Digestive Disease Center, Trinity Health of New England and St. Mary's Hospital, 133 Scovill Street, Suite 101, Waterbury, CT, 06706, USA.
| | - Priyanka Bhandari
- Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Ankur Panchal
- Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - David Weeks
- Department of Radiology, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Helen Wu
- Connecticut Convergence Institute, Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, 06312, USA
| | - Fufei Chen
- Connecticut Convergence Institute, University of Connecticut Health Center, Farmington, CT, 06312, USA
| | - Narinder Maheshwari
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Raghav Bansal
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Aaron Walfish
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Joel Baum
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Priya A Jamidar
- Division of Digestive Diseases and Advanced Endoscopy, Yale University School of Medicine, New Haven, CT, USA
| | - Joshua Aron
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
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Goenka MK, Rodge GA, Shah BB, Afzalpurkar S. Difficult Biliary Cannulation for Intradiverticular Papilla: Forceps Technique Revisited. Surg J (N Y) 2021; 7:e191-e194. [PMID: 34395870 PMCID: PMC8354361 DOI: 10.1055/s-0041-1731442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 04/15/2021] [Indexed: 10/25/2022] Open
Abstract
Periampullary diverticula (PAD) have been encountered in 5.9 to 18.5% of patients during all the endoscopic retrograde cholangiopancreatography (ERCP). Cannulation in the presence of PAD can sometimes be difficult, time consuming, and often requires a higher level of endoscopic skills. Several techniques have been reported to facilitate and increase the chances of successful bile duct cannulation in the presence of PAD. The two-devices in one-channel method has been sparingly used. It involves the simultaneous use of a biopsy forceps and another instrument, either a cannula or sphincterotome through the same working channel. We successfully performed ERCP in three cases, where bile duct cannulation was performed in the setting of intradiverticular papilla using two-devices in one-channel method. We feel that the two-devices in one-channel method can be very useful and positioned higher up in the algorithm for successful cannulation in patients with PAD.
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Affiliation(s)
- Mahesh Kumar Goenka
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kadapara, Phool Bagan, Kankurgachi, Kolkata, West Bengal, India
| | - Gajanan Ashokrao Rodge
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kadapara, Phool Bagan, Kankurgachi, Kolkata, West Bengal, India
| | - Bhavik Bharat Shah
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kadapara, Phool Bagan, Kankurgachi, Kolkata, West Bengal, India
| | - Shivaraj Afzalpurkar
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kadapara, Phool Bagan, Kankurgachi, Kolkata, West Bengal, India
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17
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Sunnapwar A, Nagar A, Katre R, Khanna L, Sayana HP. Imaging of Ampullary and Periampullary Conditions. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1726663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractThe ampulla of Vater is formed by the union of the pancreatic duct and the common bile duct and is also known as hepatopancreatic ampulla or hepatopancreatic duct. The ampulla is surrounded by a muscular valve known as the sphincter of Oddi, which controls the flow of bile and pancreatic juices into the duodenum in response to food. The ampulla is also an important embryological landmark as it marks the anatomical transition from foregut to the midgut. Because of this, it is a watershed zone where the blood supply changes from the celiac axis to the superior mesenteric artery. Radiologic evaluation of the ampulla and the periampullary region is challenging because it requires an understanding of the embryology, the normal appearance, and different anatomic variants. Also, a wide variety of pathologies can occur in this region. The purpose of this review is to present the normal anatomy of the ampulla and the periampullary region on different imaging modalities and to summarize the imaging features of the common variants, and benign and malignant ampullary and periampullary conditions. Understanding of the normal anatomical appearance and variants along with the knowledge of common pathologic conditions affecting the ampulla and periampullary conditions can help radiologists in making accurate diagnosis resulting in optimum patient care.
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Affiliation(s)
- Abhijit Sunnapwar
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Arpit Nagar
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Rashmi Katre
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Lokesh Khanna
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Hari Prasad Sayana
- Department of Gastroenterology, University of Texas Health San Antonio, San Antonio, Texas, United States
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Bakula B, Romic I, Sever M, Halle ZB. Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:375-377. [PMID: 33371697 DOI: 10.17235/reed.2020.7516/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.
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Affiliation(s)
| | - Ivan Romic
- Surgery, University Hospital Center Zagreb
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19
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Liu Y, Liu W, Hong J, Li G, Chen Y, Xie Y, Zhou X. Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study. Surg Laparosc Endosc Percutan Tech 2021; 31:533-538. [PMID: 33605680 DOI: 10.1097/sle.0000000000000924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists. MATERIALS AND METHODS Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests. RESULTS The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications. CONCLUSIONS Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.
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Affiliation(s)
- Yang Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Wei Liu
- Department of Gastroenterology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong Province, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Guohua Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Youxiang Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Yong Xie
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Xiaojiang Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
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Lee FC, Hattar L, Wesson D, Whitfield Van Buren K, Wilsey M, Fishman DS. Post-Surgical Abnormalities of the Duodenum Leading to Pancreaticobiliary Disease in Children. JPGN REPORTS 2021; 2:e036. [PMID: 37206947 PMCID: PMC10191589 DOI: 10.1097/pg9.0000000000000036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/02/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Frances C. Lee
- From the Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX
| | - Lana Hattar
- From the Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX
| | - David Wesson
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX
| | - Kristin Whitfield Van Buren
- From the Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX
| | - Michael Wilsey
- Department of Pediatric Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Douglas S. Fishman
- From the Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX
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21
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Complications increase in which type of duodenal diverticulum? A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.813042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Yilmaz E, Kostek O, Hereklioglu S, Goktas M, Tuncbilek N. Assessment of Duodenal Diverticula: Computed Tomography Findings. Curr Med Imaging 2020; 15:948-955. [PMID: 32008522 DOI: 10.2174/1573405614666180904123526] [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: 01/03/2018] [Revised: 07/29/2018] [Accepted: 08/07/2018] [Indexed: 11/22/2022]
Abstract
AIMS To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT). MATERIALS AND METHODS Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively. RESULTS DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected. CONCLUSION Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications.
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Affiliation(s)
- Erdem Yilmaz
- Department of Radiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Osman Kostek
- Department of Medical Oncology, School of Medicine, Trakya University, Edirne, Turkey
| | - Savas Hereklioglu
- Department of Radiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Muhammet Goktas
- Department of Radiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Nermin Tuncbilek
- Department of Radiology, School of Medicine, Trakya University, Edirne, Turkey
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Chen Q, Yang M, Liao GQ, Zhao YE, Yue DY, Yuan Y, Cheng B, Qin H. Precautionary Measures: Performing ERCP on a Patient With Juxtapapillary Duodenal Diverticula (JPDD)-Related Biliary Stone After COVID-19 Lockdown Restriction Lifted in Wuhan, China. Front Med (Lausanne) 2020; 7:564. [PMID: 33015107 PMCID: PMC7500472 DOI: 10.3389/fmed.2020.00564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
On April 8, 2020, after nearly 3 months of battling against the outbreak of COVID-19, Wuhan, where the pandemic began, began easing lockdown restrictions. However, given that asymptomatic carriers could continue to lead to transmission of COVID-19 during the very early stages, the endoscopists have taken precautions and conduct risk assessments to perform endoscopic intervention in this transition stage. Here, we have reported an urgent ERCP in a patient with acute pancreatitis secondary to JPDD-related biliary stone. Based on our experiences, the objective is to provide practical suggestions for the safe resumption of ERCP procedures in the setting of the COVID-19 pandemic with specific focus on patient risk assessment, personal protection equipment (PPE), and dress code modalities, all of which have been implemented in our hospital to reduce the risk of viral transmission.
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Affiliation(s)
- Qian Chen
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Min Yang
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Guang-Quan Liao
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Yu-Er Zhao
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Dao-Yuan Yue
- The Department of Laboratory Services at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Yuan
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Cheng
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Hua Qin
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
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Yanagaki M, Shiba H, Hagiwara S, Hoshino M, Sakuda H, Furukawa Y, Yanaga K. A successfully treated case of Lemmel syndrome with pancreaticobiliary maljunction: A case report. Int J Surg Case Rep 2020; 72:560-563. [PMID: 32698288 PMCID: PMC7327874 DOI: 10.1016/j.ijscr.2020.06.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/14/2020] [Accepted: 06/14/2020] [Indexed: 12/07/2022] Open
Abstract
Lemmel syndrome is a rare condition that leads to cholangitis and/or pancreatitis due to intraduodenal diverticulum. Surgery is considered for the treatment of severe or repeated symptoms in patients with this condition. We herein report a successfully diagnosed and treated case of Lemmel syndrome with pancreaticobiliary maljunction. Background Lemmel syndrome is a rare condition that leads to cholangitis and/or pancreatitis due to intraduodenal diverticulum. Surgery is considered for the treatment of severe or repeated symptoms in patients with this condition. Case presentation An 81-year-old woman was admitted to our hospital, complaining of general fatigue, BT 38.8 degree, and right hypochondoralgia. Her hepatobiliary enzyme levels were elevated, and enhanced abdominal computed tomography revealed dilation of the common bile duct and intraduodenal diverticulum. After restarting oral intake, her symptoms were exacerbated. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed pancreaticobiliary maljunction and parapapillary diverticulum. Under a diagnosis of Lemmel syndrome with pancreaticobiliary maljunction complicated by acute pancreatitis and cholangitis, we performed extrahepatic bile duct resection with cholecystectomy and papilloplasty. Her postoperative course was uneventful, and the patient was discharged 20 days after surgery. She remains well at 5 months after surgery. Conclusion We herein report a successfully diagnosed and treated case of Lemmel syndrome with pancreaticobiliary maljunction.
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Affiliation(s)
- Mitsuru Yanagaki
- Department of Digestive Surgery, AOI Universal Hospital, 2-9-1, Tamachi, Kawasaki-ku, Kawasaki-city, Kanagawa, 210-0822, Japan.
| | - Hiroaki Shiba
- Department of Hepato-Biliary-pancreatic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Shin Hagiwara
- Department of Cardiovascular Surgery, AOI Universal Hospital, 2-9-1, Tamachi, Kawasaki-ku, Kawasaki-city, Kanagawa, 210-0822, Japan.
| | - Masato Hoshino
- Department of Digestive Surgery, AOI Universal Hospital, 2-9-1, Tamachi, Kawasaki-ku, Kawasaki-city, Kanagawa, 210-0822, Japan.
| | - Hitoshi Sakuda
- Department of Cardiovascular Surgery, AOI Universal Hospital, 2-9-1, Tamachi, Kawasaki-ku, Kawasaki-city, Kanagawa, 210-0822, Japan.
| | - Yoshiyuki Furukawa
- Department of Digestive Surgery, AOI Universal Hospital, 2-9-1, Tamachi, Kawasaki-ku, Kawasaki-city, Kanagawa, 210-0822, Japan.
| | - Katsuhiko Yanaga
- Department of Hepato-Biliary-pancreatic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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25
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The influence of periampullary diverticula on ERCP for treatment of common bile duct stones. Sci Rep 2020; 10:11477. [PMID: 32651446 PMCID: PMC7351729 DOI: 10.1038/s41598-020-68471-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.
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26
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Alzerwi NA. Recurrent ascending cholangitis with acute pancreatitis and pancreatic atrophy caused by a juxtapapillary duodenal diverticulum: A case report and literature review. Medicine (Baltimore) 2020; 99:e21111. [PMID: 32629744 PMCID: PMC7337422 DOI: 10.1097/md.0000000000021111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Intermittent combined pancreaticobiliary obstruction may lead to multiple episodes of ascending cholangitis and pancreatitis, usually due to choledocholithiasis or periampullary mass. However, one of the rare causes is periampullary or juxtapapillary duodenal diverticulum. Although duodenal diverticula are relatively common in the general population, the overwhelming majority are asymptomatic. Duodenal diverticula can cause combined pancreaticobiliary obstruction through multiple mechanisms such as stasis-induced primary choledocholithiasis, stasis-induced intradiverticular enterolith, or longstanding diverticulitis, causing stenosing fibrosing papillitis or a combination of more than one of these mechanisms. Herein, I report a case of Lemmel syndrome due to a combination of multiple mechanisms and review the available literature on the epidemiology, pathogenesis, clinical presentation, diagnostic work-up, and management of juxtapapillary duodenal diverticulum. PATIENT CONCERNS Multiple episodes of abdominal pain, jaundice, anorexia, fever, and significant unintentional weight loss. DIAGNOSES AND INTERVENTIONS Primary choledocholithiasis, recurrent ascending cholangitis, recurrent acute pancreatitis, and pancreatic atrophy due to giant juxtapapillary duodenal diverticulum, with unsuccessful endoscopic retrograde cholangiopancreatography that was completely resolved after open transduodenal sphincteroplasty and septoplasty, transampullary and transcystic common bile duct exploration and stone extraction, and duodenal diverticular inversion. OUTCOME Complete resolution of combined pancreaticobiliary obstruction without recurrence for 2 years after surgery. LESSONS Surgeons should be aware of such rare syndromes to avoid misdiagnosis and delayed or inappropriate management. Furthermore, they should understand the different available operative options for cases that are refractory to endoscopic approach.
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27
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Mu P, Yue P, Li F, Lin Y, Liu Y, Meng W, Zhou W, Li X. Does periampullary diverticulum affect ERCP cannulation and post-procedure complications? an up-to-date meta-analysis. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:193-204. [PMID: 32343231 DOI: 10.5152/tjg.2020.19058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Research conclusions differ on the impact of periampullary diverticulum (PAD) on endoscopic retrograde cholangiopancreatography (ERCP). An up-to-date meta-analysis evaluated the role of PAD in ERCP, especially in terms of cannulation failure and early complications. A comprehensive literature search was performed. All statistical analyses were carried out with the Review Manager 5.3 software. Horizontal lines represented a 95% confidence interval (CI) and the area of each square in forest plots. Twenty-six studies including 23 826 patients with or without PAD who underwent ERCP were evaluated. PAD was associated with an increase in the overall cannulation failure rate (RR=1.46, 95% CI: 1.27-1.67; p<.00001), but in the subgroup of studies performed post-2000, PAD was irrelevant to cannulation failure (RR=1.16, 95% CI: 0.96-1.41; p=0.12). In overall analyses, PAD was also associated with a high risk of ERCP-related pancreatitis (RR=1.32, 95% CI: 1.10-1.59; p=0.003), perforation (RR=1.73, 95% CI: 1.06-2.82; p=0.030), and bleeding (RR=1.48, 95% CI: 1.13-1.93; p=0.005). The presence of PAD increased the overall cannulation failure rate, but not the rate post-2000. PAD also affected the occurrence of early pancreatitis, perforation, and bleeding.
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Affiliation(s)
- Peilei Mu
- The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu, China; Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China;Peilei Mu and Ping Yue contributed equally to this work
| | - Ping Yue
- The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu, China; Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China;Peilei Mu and Ping Yue contributed equally to this work
| | - Fangwei Li
- Department of Social Medicine and Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Yanyan Lin
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, NO.1 DongGang West Road, LanZhou, China;Hepatopancreatobiliary Surgery Institute of Gansu Province, Clinical Medical College Cancer Center of Lanzhou University, NO.1 DongGang West Road, LanZhou, China
| | - Ying Liu
- Department of Foreign Languages, Lanzhou University, Lanzhou, China
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu, China;Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China;Gansu Province Key Laboratory Biotherapy and Regenerative Medicine, Lanzhou, Gansu, China
| | - Wence Zhou
- The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu, China;The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Xun Li
- The First Clinical Medical School of Lanzhou University, Lanzhou, Gansu, China;The Fifth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Rangan V, Lamont JT. Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts. Curr Gastroenterol Rep 2020; 22:4. [PMID: 31940112 DOI: 10.1007/s11894-019-0741-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Small bowel diverticulosis is a well-known clinical entity whose diagnosis and management has evolved in recent years. This review covers pathophysiology, incidence, and prevalence, and it also provides an update on modern diagnosis and management. Meckel's diverticula are covered elsewhere in this volume. RECENT FINDINGS CT scan and MRI have largely supplanted barium follow-through for diagnosis. No intervention is needed in asymptomatic individuals. Endoscopic management is playing an increasing role for both bleeding and resection of intraduodenal diverticula, but surgical intervention remains the only definitive intervention for other complications like diverticulitis and small bowel obstruction. Small bowel diverticulosis is an uncommon condition which is associated with numerous possible complications. While endoscopy is playing an increasingly large role in management, surgical resection remains the treatment of choice for most complications. A high index of suspicion is needed in order to diagnose this entity.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA.
| | - J Thomas Lamont
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
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29
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Khan A, Karanth V, Khan A, Rodrigues G. Duodenal diverticulitis masquerading as acute cholecystitis: A lesson learnt. SURGICAL PRACTICE 2019. [DOI: 10.1111/1744-1633.12394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Amena Khan
- Department of General SurgeryKasturba Medical College, Manipal Academy of Higher Education Manipal India
| | - Veena Karanth
- Department of General SurgeryKasturba Medical College, Manipal Academy of Higher Education Manipal India
| | - Afroz Khan
- Department of General SurgeryKasturba Medical College, Manipal Academy of Higher Education Manipal India
| | - Gabriel Rodrigues
- Department of General SurgeryKasturba Medical College, Manipal Academy of Higher Education Manipal India
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30
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Xu XD, Xu CF, Qian JQ, Dai JJ, Sun ZX. Endoscopic papillary large balloon dilation with minor sphincterotomy for periampullary diverticular papilla. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:935-940. [PMID: 31718197 DOI: 10.17235/reed.2019.6179/2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background To observe the outcome of endoscopic papillary large balloon dilation (EPLBD) with minor sphincterotomy (mEST) for periampullary diverticular papilla related to stone removal. Methods Patients with confirmed periampullary diverticulum (PAD) during stone removal from May 2016 to April 2018 were reviewed retrospectively. The Chi-square test with Yates correction or Fisher's exact test was used for the analysis of categorical data and a normality test was applied for continuous data. Results A total of 154 consecutive patients (89 males and 65 females, aged 51-87 years) with confirmed PAD during stone removal were included in the study. Cases were divided into the conventional EST group (n = 79) and the mEST plus EPLBD group (n = 75). The number of patients with an initial treatment success was greater in the EPLBD+mEST group compared with the EST group (96% vs 86.1%, p=0.03) and the procedure time for EPLBD+mEST was shorter than that for EST alone (46.1±13.7 min vs 53.3±11.6 min, p=0.01). The rate of complications in the EPLBD+mEST group was lower than in the EST group (17.3% vs 32.9%, p=0.04). When PAD was >15 mm, the initial success rate was higher (92.6% vs 73.9%, p=0.04) and the rate of overall complications was lower (14.8% vs 41.7%, p=0.03) in the EPLBD+mEST group than those in the EST group. Although, this was similar when PAD was <15 mm. Conclusion EPLBD+mEST might be safer and more effective than conventional EST alone for stone removal in the presence of PAD.
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Affiliation(s)
- Xiao-Dan Xu
- Digestive Department, Changshu Affiliated Hospital of Soochow University, China
| | - Chun-Fang Xu
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University, China
| | - Jian-Qing Qian
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, China
| | - Jian-Jun Dai
- Department of Gastroenterology, Changshu Affiliated Hospital of Soochow University, China
| | - Zhen-Xing Sun
- Department of Gastroenterology, Ao Yang Hospital of Zhang Jia Gang,, China
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Deng F, Zhou M, Liu PP, Hong JB, Li GH, Zhou XJ, Chen YX. Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography: A large sample sized retrospective study. World J Clin Cases 2019; 7:1028-1037. [PMID: 31123675 PMCID: PMC6511924 DOI: 10.12998/wjcc.v7.i9.1028] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/15/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.
AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.
METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors, common bile duct (CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and Kaplan-Meier analysisly.
RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance (≥ 3 times) recurrence rates were 19.5% and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years (odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy (OR = 2.458; P < 0.01), endoscopic papillary balloon dilation (OR = 5.679; P = 0.000), endoscopic sphincterotomy (OR = 3.463; P = 0.000), CBD stent implantation (OR = 5.780; P = 0.000), multiple ERCP procedures (≥2; OR = 2.75; P = 0.000), stones in the intrahepatic bile duct (OR = 2.308; P = 0.000), periampullary diverticula (OR = 1.627; P < 0.01), choledocholithiasis diameter ≥ 10 mm (OR = 1.599; P < 0.01), bile duct-duodenal fistula (OR = 2.69; P < 0.05), combined biliary tract infections (OR = 1.057; P < 0.01), and no preoperative antibiotic use (OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.
CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.
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Affiliation(s)
- Feng Deng
- The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Mi Zhou
- Medical College of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Ping-Ping Liu
- Department of Gastroenterology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou 341000, Jiangxi Province, China
| | - Jun-Bo Hong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Guo-Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Xiao-Jiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
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Jayaraj M, Mohan BP, Dhindsa BS, Mashiana HS, Radhakrishnan G, Dhir V, Trindade AJ, Adler DG. Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis. Dig Dis Sci 2019; 64:1364-1376. [PMID: 30293190 DOI: 10.1007/s10620-018-5314-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/29/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Periampullary diverticulum (PAD) is most often asymptomatically found in elderly population. ERCP in the presence of PAD is technically challenging since the location and orientation of the ampulla could be altered. Various studies have reported differing results on the technical success and safety outcomes of ERCP in the presence of PAD. We aimed at a meta-analysis of such studies to assess the technical success and the occurrence of complications during ERCP in patients with PAD. METHODS We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2017). The search was done in accordance with PRISMA guidelines to identify studies. Studies that reported on the ERCP outcomes based on the presence of PAD were included. Both prospective and retrospective studies, manuscripts and abstracts were included. Only articles in English literature were included. The primary analysis focused on the overall technical success of ERCP in the presence of PAD, and the secondary analysis was to estimate the risk of occurrence of complications. RESULTS Our search resulted in 16 studies that were included for final analysis. These 16 studies reported on 2794 patients, who had PAD, and the control group included 13,032 patients, who did not have a PAD during ERCP. Our meta-analysis of this data showed an Odd's ratio estimate of having a successful ERCP procedure in patients with PAD to be 0.51 [95% C.I. (0.35-0.72)] when compared to patients without it. This was statistically significant, with a p value 0.00. Considerable heterogeneity was noted among the studies. The heterogeneity proportion was quantified at 74.6% based on I2 statistic. The secondary outcomes measured were complications. We analyzed the pooled Post-ERCP Pancreatitis (PEP), cholangitis, perforation, and bleeding. Only those studies that had the data for these complications in both the study and the control groups were selected. PEP: The pooled Odd's estimate of having PEP was 1.28, [95% C.I (0.88-1.87)] from 12 studies reporting on 1863 patients with PAD in comparison with 7803 patients without it. The risk of PEP occurrence tended to be more in the group without PAD, though it was not statistically significant, with a p value 0.20. There was some heterogeneity observed between the studies, with the quantification I2 statistic being 28.6%. Our analysis shows that having PAD does not put a patient at increased risk for PEP. Bleeding: The pooled Odds estimate was 1.69, 95% C.I. 0.88-3.25 from nine studies reporting on 1816 patients with PAD in comparison with 5327 patients without it. This was not statistically significant, p value 0.11. Considerable heterogeneity was noted, with I2 being 55.7%. The risk of having a bleed was noted to be more in control group, and having PAD did not put patients at increased risk for bleeding during an ERCP procedure. Perforation: Patients with PAD undergoing ERCP were not at increased risk for perforation. Seven studies reported on this complication. This was noted in seven patients out of 1245 in study group, and 19 patients out of 4912 in control group. The pooled Odd's estimate was 1.24, 95% C.I. 0.54-2.87. There was no statistical significance, p value 0.61. No heterogeneity was noted among the studies included in this analysis. Cholangitis: Only four studies reported on this complication. In a total of 778 patients in study group, four had cholangitis and eight had this complication out of 3886 patients in the control group. The pooled Odd's was 2.12, 95% C.I. 0.61-7.33. There was no statistical significance, p value 0.24. No heterogeneity was noted. CONCLUSION ERCP is technically feasible and increasingly successful when performed by experts in the presence of PAD. The risk of complications such as PEP, bleeding, perforation and cholangitis does not differ between ERCP done in patients with and without PAD.
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Affiliation(s)
- Mahendran Jayaraj
- Division of Gastroenterology, University of Nevada Las Vegas (UNLV) School of Medicine, Las Vegas, NV, USA
| | | | - Banreet S Dhindsa
- Department of Internal Medicine, University of Nevada Las Vegas (UNLV) School of Medicine, Las Vegas, NV, USA
| | - Harmeet S Mashiana
- Department of Internal Medicine, University of Nevada Las Vegas (UNLV) School of Medicine, Las Vegas, NV, USA
| | | | - Vinay Dhir
- Department of Gastroenterology and Endoscopy, S L Raheja Hospital- A Fortis Associate, Mahim, Mumbai, India
| | - Arvind J Trindade
- Long Island Jewish Medical Center, Northwell Hofstra University, Hempstead, NY, USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, 30 N 1900E 4R118, Salt Lake City, UT, 84132, USA.
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Köksal AŞ, Eminler AT, Parlak E. Biliary endoscopic sphincterotomy: Techniques and complications. World J Clin Cases 2018; 6:1073-1086. [PMID: 30613665 PMCID: PMC6306628 DOI: 10.12998/wjcc.v6.i16.1073] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/20/2018] [Accepted: 11/26/2018] [Indexed: 02/05/2023] Open
Abstract
Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.
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Affiliation(s)
- Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University, School of Medicine, Ankara 41000, Turkey
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Wijarnpreecha K, Panjawatanan P, Manatsathit W, Cheungpasitporn W, Pungpapong S, Lukens FJ, Ungprasert P. Association Between Juxtapapillary Duodenal Diverticula and Risk of Choledocholithiasis: a Systematic Review and Meta-analysis. J Gastrointest Surg 2018; 22:2167-2176. [PMID: 30022443 DOI: 10.1007/s11605-018-3865-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND/OBJECTIVES Studies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk. METHODS A literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. RESULTS Of 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84-2.86). The statistical heterogeneity was moderate with an I2 of 60%. CONCLUSIONS A significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.
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Affiliation(s)
- Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | | | - Wuttiporn Manatsathit
- Department of Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Wisit Cheungpasitporn
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Surakit Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Tobin R, Barry N, Foley NM, Cooke F. A giant duodenal diverticulum causing Lemmel syndrome. J Surg Case Rep 2018; 2018:rjy263. [PMID: 30349662 PMCID: PMC6189375 DOI: 10.1093/jscr/rjy263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/02/2018] [Accepted: 09/15/2018] [Indexed: 11/18/2022] Open
Abstract
An 80-year-old female, with a known periampullary giant duodenal diverticulum, presented to the emergency department with general deterioration. While not clinically icteric, her laboratory investigations revealed an obstructive jaundice. MRCP demonstrated mild distension of the gallbladder with several calculi. There was intra- and extra-hepatic biliary dilatation to the level of the ampulla. A giant fluid and air filled periampullary duodenal diverticulum measuring ~8 cm in the long axis was noted. The CBD was dilated to the level of this diverticulum and the cause of the patient’s biliary dilatation and obstruction. A rare pancreaticobiliary complication of duodenal diverticula is Lemmel syndrome. Lemmel syndrome is defined as an obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intra-pancreatic portion of the common bile duct with resultant dilatation of the extra- and intra-hepatic bile ducts. Recognition of this condition is important, as delayed diagnosis can result in unnecessary further investigations.
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Affiliation(s)
- Roseanne Tobin
- School of Medicine, University College Cork, College Road, Cork, Ireland
| | - Niamh Barry
- School of Medicine, University College Cork, College Road, Cork, Ireland
| | - Niamh M Foley
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, Ireland
| | - Fiachra Cooke
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, Ireland
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Bruno M, Ribaldone DG, Fasulo R, Gaia S, Marietti M, Risso A, Stradella D, Strona S, Saracco GM, De Angelis C. Is there a link between periampullary diverticula and biliopancreatic disease? An EUS approach to answer the question. Dig Liver Dis 2018; 50:925-930. [PMID: 30145052 DOI: 10.1016/j.dld.2018.07.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/26/2018] [Accepted: 07/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many studies, almost all in an Endoscopic Retrograde Cholangiopancreatography (ERCP) setting, have been conducted to establish if a link exists between periampullary diverticula (PADs) and biliopancreatic diseases but the issue is still debated. AIMS The objective was to clarify the link between PADs and biliopancreatic disease, for the first time using Endoscopic Ultrasound (EUS). METHODS We retrospectively reviewed our database seeking patients scheduled for EUS with an indication that entailed the exploration of the second duodenum. For each patient with a PAD enrolled in the study, 6 controls were randomly selected. RESULTS 2475 patients met the inclusion criteria. Among them, 185 subjects with a PAD were found (prevalence 7.5%), 1110 subjects served as controls. Patients with a PAD had more frequently a history of cholangitis (8.1 vs 2.2%; OR 3.99, p < 0.001), a higher prevalence of common bile duct (CBD) dilation (44.3 vs 28.2%; OR 2, p < 0.0001) and a higher prevalence of CBD stones (34.1 vs 19.6%; OR 2.1, p < 0.0001). No differences were found about history of jaundice, acute/recurrent pancreatitis or EUS signs of chronic pancreatitis. CONCLUSION Whereas PADs were linked with history of cholangitis, CBD stones and dilation, no association was found with pancreatic diseases.
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Affiliation(s)
- Mauro Bruno
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Roberta Fasulo
- Department of Gastroenterology, San Giovanni Bosco Hospital, Turin, Italy
| | - Silvia Gaia
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Milena Marietti
- Division of Gastroenterology, Chivasso Hospital, Turin, Italy
| | - Alessandro Risso
- Department of Gastroenterology and Digestive Endoscopy, Santa Croce e Carle Hospital, Cuneo, Italy
| | | | - Silvia Strona
- Division of Gastroenterology, Chivasso Hospital, Turin, Italy
| | - Giorgio Maria Saracco
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy
| | - Claudio De Angelis
- Department of General and Specialist Medicine, Gastroenterologia-U, Città della Salute e della Scienza di Torino, Turin, Italy
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The presence of periampullary diverticulum increased the complications of endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2018; 30:1009-1012. [PMID: 29864066 DOI: 10.1097/meg.0000000000001172] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of needle-knife fistulotomy technique in patient with periampullary diverticula (PAD) for biliary duct cannulation may lead to risk of complications. The present study aimed to investigate the association between PAD and the complications of endoscopic retrograde cholangiopancreatography (ERCP), unsuccessful cannulation rates and to determine the rates of cannulation complications using sphincterotomy and needle-knife fistulotomy. MATERIALS AND METHODS The ERCP procedures were held in Gastroenterology Endoscopy Unit between September 2015 and October 2016 and were retrospectively evaluated. The patients were divided into two groups, a PAD group and a non-PAD group. These groups were compared regarding demographic characteristics, ERCP complications and mortality. RESULTS A total of 827 patients fulfilling the criteria for ERCP were enrolled in the study. Of 827 patients, 164 had PAD and 663 did not have PAD (non-PAD). The success rate of cannulation was 98.8% in patients with PAD and 98.6% in patients without PAD. There was no statistical difference of cannulation types with sphincterotomy and with needle-knife fistulotomy between the two groups. Mean baseline number of guide wire cannulation attempts was 1.96±0.20 in PAD group. No complications were observed in PAD patients treated with needle-knife fistulotomy. ERCP-related complications rates (bleeding, pancreatitis, and perforation) were higher in the PAD group (P=0.007). CONCLUSION In conclusion, there is a strong association between PAD and higher rates of cannulation complications, independent of cannulation technique. In certain situations, and in the hands of experienced endoscopists, needle-knife fistulotomy might be a feasible option for successful biliary cannulation in certain patients with PAD.
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Itoi T, Ryozawa S, Katanuma A, Okabe Y, Kato H, Horaguchi J, Tsuchiya T, Gotoda T, Fujita N, Yasuda K, Igarashi Y, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation. Dig Endosc 2018; 30:293-309. [PMID: 29411902 DOI: 10.1111/den.13029] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironori Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Takuji Gotoda
- 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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Mandai K, Uno K, Ueda Y, Okada Y, Yasuda K. Outcomes of a Physician-Controlled Wire-Guided Cannulation of the Bile Duct Using a Novel Sphincterotome: A Single-Center, Prospective Study. Gastroenterology Res 2018; 11:36-40. [PMID: 29511404 PMCID: PMC5827900 DOI: 10.14740/gr974w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/08/2018] [Indexed: 02/03/2023] Open
Abstract
Background Efficacy of a physician-controlled wire-guided cannulation of the bile duct has been reported. This study aimed to evaluate a novel sphincterotome with a short tip and a short wire, which can be bowed compactly compared to conventional sphincterotomes. Methods This was a single-arm, single-center, prospective study. We enrolled patients with choledocholithiasis and/or obstructive jaundice and/or cholangitis for whom endoscopic sphincterotomy was planned. The main outcome measurement was the proportion of successful selective bile duct cannulation by physician-controlled wire-guided cannulation within 10 min. Results The study cohort consisted of 40 patients. The proportion of successful selective bile duct cannulation within 10 min was 72.5% (n = 29). The proportion of post-endoscopic retrograde cholangiopancreatography pancreatitis was 2.5% (mild, n = 1) and the proportion of hemorrhage was 2.5% (moderate, n = 1). Conclusions Although physician-controlled wire-guided cannulation using a novel sphincterotome with a short tip and a short wire was not superior to wire-guided cannulation using conventional sphincterotomes reported in a previous study, it remains a safe and efficacious alternative in terms of successful biliary cannulation.
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Affiliation(s)
- Koichiro Mandai
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Koji Uno
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Yuki Ueda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Yusuke Okada
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
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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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Cannulation in patients with large periampullary diverticulum using SpyBite miniforceps. Clin Exp Hepatol 2018; 4:41-42. [PMID: 29594197 PMCID: PMC5865906 DOI: 10.5114/ceh.2018.73370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/20/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction Cannulation is difficult in patients with periampullary diverticulum (PAD). The described success rate varies from 61% to 95.4%. Material and methods Four cases with PAD in which, despite repeated attempts, we were unable to locate the papilla and cannulate. To overcome this difficulty, we used SpyBite forceps (Boston Scientific) to pull out the papillary orifice and then perform the cannulation using a sphincterotome introduced through the same working channel. Results This method reduced the time required for cannulation. In all four of our cases, we had 100% success in cannulation. Conclusions Use of SpyBite miniforceps in difficult cannulations in patients with PAD is useful and has an excellent success rate.
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Chen QF, Tang ZH, Yu XY, Liu ZJ, Li GH, Zhou XJ, Chen YX, Zhou XD. Impact of periampullary diverticula on technical success and complications of endoscopic retrograde cholangiopancreatography. Shijie Huaren Xiaohua Zazhi 2017; 25:1597-1604. [DOI: 10.11569/wcjd.v25.i17.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the association of periampullary diverticula (PAD) with pancreaticobiliary diseases as well as the impact of PAD on the technical success and complications of endoscopic retrograde cholangiopancreatography (ERCP).
METHODS A total of 1455 consecutive patients who underwent ERCP from January 2016 to December 2016 at The First Affiliated Hospital of Nanchang University were analyzed retrospectively. The patients were divided into a PAD group (n = 293) and a non-PAD group (n = 1162) according to the presence or absence of PAD. The rate of pancreaticobiliary diseases was analyzed and compared between the PAD group and non-PAD group, and the technical success rate of ERCP and the incidence of postoperative complications were also compared.
RESULTS The rate of PAD increased with age (P < 0.05). The incidence rates of suppurative cholangitis and acute pancreatitis (AP) and carcinoma of the pancreatic head in patients with PAD were significantly higher than those in patients without (P < 0.05). The rates of postoperative complications, such as hemorrhage, perforation, post-ERCP pancreatitis (PEP) and hyperamylasemia, were significantly higher in patients with PAD (P < 0.05). No significant differences was observed in the success rate of ERCP (P > 0.05).
CONCLUSION PAD is associated with an increased rate of pancreaticobiliary diseases as well as the occurrence of postoperative complications of ERCP. However, the presence of PAD dose not affect the technical success rate of ERCP.
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Number of Endoscopic Retrograde Cholangiopancreatography Procedures Required for Short Biliary Cannulation Time. Gastroenterol Res Pract 2017; 2017:1515260. [PMID: 28487727 PMCID: PMC5405567 DOI: 10.1155/2017/1515260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 02/04/2023] Open
Abstract
Background. Several previous studies assessed the competence in endoscopic retrograde cholangiopancreatography (ERCP) using the bile duct cannulation success rate. However, the cannulation time is also important, because a long cannulation time was reported to be a risk factor for post-ERCP pancreatitis. Aim. To determine the number of ERCP procedures required for short cannulation time of the bile duct. Methods. We retrospectively analyzed 605 ERCP procedures performed for bile duct cannulation in patients with native papilla at our institution between March 2012 and December 2015. The successful procedures were divided into 2 groups: group L and group S (cannulation time > 15 minutes and ≤15 minutes, resp.). An analysis of the relationship among the biliary cannulation time, ERCP experience, and other factors was then conducted. Results. Multivariate analysis showed that the ERCP experience of ≤300 procedures (odds ratio, 2.080; 95% confidence interval, 1.337–3.142; P = 0.001) and malignant biliary stricture due to pancreatic cancer (odds ratio, 1.912; 95% confidence interval, 1.072–3.412; P = 0.028) were found to be significantly associated with a cannulation time of >15 minutes. Conclusions. Our findings suggested that an ERCP experience of ≤300 procedures and malignant biliary stricture due to pancreatic cancer were associated with prolonged biliary cannulation time.
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Abstract
Lemmel syndrome occurs when a duodenal diverticulum causes obstructive jaundice due to a mechanical obstruction of the common bile duct. Additional pathophysiologic processes may also contribute to the development of Lemmel syndrome. These include duodenal diverticula causing dysfunction of the sphincter of Oddi as well as compression of the common bile duct by duodenal diverticula. It is uncommon for duodenal diverticulum to become inflamed. We report the case of a 25-year-old female presenting with unintentional weight loss and fatigue. Since her initial labs were concerning for possible infection with hepatobiliary abnormalities, a contrast-enhanced CT was obtained. This study revealed a large periampullary diverticulum with mucosal enhancement and fat stranding consistent with diverticulitis.
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Affiliation(s)
- Keyur Desai
- Department of Radiology, Truman Medical Center
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Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2017; 29:105-111. [PMID: 27606949 DOI: 10.1097/meg.0000000000000744] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Periampullary diverticulum (PAD) is frequently encountered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate the association of PAD with pancreaticobiliary diseases as well as the impact of PAD on the technical success of ERCP and different methods of bile duct stone extraction. PATIENTS AND METHODS A total of 1489 cases of patients with PAD were identified from 6390 patients who underwent ERCP. These patients were compared with 1500 controls without PAD in terms of biliary stone formation, technical success, and complications of ERCP. RESULTS Patients with PAD had increased prevalence of bile duct stones, gallstones, and cholangitis (P<0.01). Successful cannulation rates were similar in the PAD and the control group (98.59 vs. 99.07%, P=0.225). The incidence of complications did not differ between the PAD and the control group. Successful stone removal rate of endoscopic sphincterotomy (EST) was lower in the PAD group than in the control group (83.53 vs. 94.31%, P=0.005). In patients with PAD, the rate of successful stone removal was lower in the EST group than in the endoscopic papillary balloon dilation (EPBD) and EPBD combined with limited EST (ESBD) group. The rates of complications were similar among different treatments (EST, EPBD, or ESBD) in patients with PAD. CONCLUSION PAD is associated with bile duct stones, gallstones, and cholangitis. In addition, PAD should not be considered a barrier to a successful cannulation. Moreover, EST is less effective than EPBD and ESBD in patients with PAD, whereas EST, EPBD, and ESBD are equally safe in patients with PAD.
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The Impact of Duodenal Diverticuli and the Execution of Endoscopic Retrograde Cholangiopancreaticography. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2016; 2016:5026289. [PMID: 27882342 PMCID: PMC5110878 DOI: 10.1155/2016/5026289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/16/2016] [Indexed: 01/15/2023]
Abstract
Introduction. Duodenal diverticuli alter the anatomy of the papillary region and can make an ERCP difficult. Aim. To study the outcome of ERCP in cases of duodenal diverticuli. Patients and Methods. Consecutive ERCPs in a period of 24 years were included. Endoscopy reports were studied for presence of diverticuli. Success of the procedure and findings were noted. Clinical records were searched for clinical presentation of the patient. Patients without duodenal diverticuli were used as comparison. Results. 2795 procedures were done in 2092 patients. Of these, 211 (10%) had diverticuli. Diverticuli occurred significantly more often in women (p < 0.001). ERCP was significantly more often inconclusive in cases of a diverticulum, 12.8% versus 6.3%, p < 0.001. In cases of a successful ERCP, patients with diverticuli showed more often no abnormalities in the bile duct, 26% versus 17%, p < 0.001. In 64% of cases, the reason for ERCP was cholestasis. There was no significant difference in presence of stones or cholangitis. Biliary pancreatitis was seen more often in patients without diverticuli, 4.4% versus 1.4%, p = 0.04. This was also the case for malignancies, 18.5% versus 6.6%, p < 0.001. Conclusion. It is concluded that duodenal diverticuli can be responsible for cholestasis. Presence of a diverticulum in the duodenum makes the ERCP procedure more complex.
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Örmeci N, Deda X, Kalkan Ç, Tüzün AE, Karakaya F, Dökmeci A, Bahar DK, Özkan H, İdilman R, Çınar K. Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma. Euroasian J Hepatogastroenterol 2016; 6:31-34. [PMID: 29201721 PMCID: PMC5578555 DOI: 10.5005/jp-journals-10018-1162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/19/2016] [Indexed: 01/15/2023] Open
Abstract
Introduction Periampullary diverticula (PD) is caused by extraluminal pouching of duodenal mucosa. Using a very common endoscopic procedure to diagnose or treat gastrointestinal disorders, we encountered duodenal diverticulum. Materials and methods This is a retrospective, single-center study. Three thousand and sixteen patients on whom endoscopic retrograde cholangiopancreatography (ERCP) was performed at Ankara University Medical School, Department of Gastroenterology, from June 2009 to June 2014 were included to the study. Results Hundred and thirty patients (males 65, females 65) among the 3,016 had PD. Two hundred and sixty patients without diverticulum were randomly chosen from the 3,016 patients, as a control group [121 (47%) females, 139 (53%) males]. There was no statistical difference between the two groups. The mean age of the patients with PD was 69.9 years, while the mean age was 62.3 years for patients without PD (p < 0.001). Incidence for PD was 4.6%. The papilla of Vater was located in the inter-diverticular area (Type 1) in 9 patients (8.3%), at the edge of the diverticulum (Type 2) in 31 patients (28.4%), and at a distance of 2 to 3 cm from the papilla (Type 3) in 69 patients (63.3%). Discussion Although numerically more common bile duct stones occurred in patients with PD compared to those without PD, there was no statistical difference between the two groups. The rate of pancreato-biliary carcinomas was higher in patients without diverticulum. Cannulation was successful in both groups at the rate of 97.6 and 92% respectively, but cannulation failed more often in patients without PD. Duodenal perforation occurred in one patient with PD. Bleeding after sphincterotomy occurred in two patients without PD. How to cite this article Örmeci N, Deda X, Kalkan Ç, Tüzün AE, Karakaya F, Dökmeci A, Bahar DK, Özkan H, İdilman R, Çınar K. Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(1):31-34.
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Affiliation(s)
- Necati Örmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Xheni Deda
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Çağdaş Kalkan
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Emrehan Tüzün
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Fatih Karakaya
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Abdulkadir Dökmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - D Kadir Bahar
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Hasan Özkan
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ramazan İdilman
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Kubilay Çınar
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
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Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center. Gastroenterol Res Pract 2016; 2016:9381759. [PMID: 27143965 PMCID: PMC4837272 DOI: 10.1155/2016/9381759] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/08/2016] [Indexed: 12/12/2022] Open
Abstract
Aims. We here investigated the association of different types of periampullary diverticula (PAD) with pancreaticobiliary disease and with technical success of endoscopic retrograde cholangiopancreatography (ERCP). Methods. A total of 850 consecutive patients who underwent their first ERCP were entered into a database. Of these patients, 161 patients (18.9%) had PAD and the age- and sex-matched control group comprised 483 patients. Results. PAD was correlated with common bile duct (CBD) stones (59.6% versus 35.0% in controls; P = 0.008) and negatively correlated with periampullary malignancy (6.8% versus 21.5% in controls; P = 0.004). The acute pancreatitis was more frequent (62.5%) in patients with PAD type 1 followed by PAD type 2 (28.9%, P = 0.017) and type 3 (28.0%, P = 0.006). No significant differences were observed in successful cannulation rate and post-ERCP complications among the 3 types of PAD. Type 1 PAD patients had less recurrence of CBD stones than did the patients who had type 2 or type 3 PAD (53.8% versus 85.7%; P = 0.043). Conclusions. PAD, especially type 1 PAD, is associated with an increased acute pancreatitis as well as occurrence and recurrence of CBD stones. PAD during an ERCP should not be considered as an obstacle to a successful cannulation.
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Altonbary AY, Bahgat MH. Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation. World J Gastrointest Endosc 2016; 8:282-287. [PMID: 27014423 PMCID: PMC4804185 DOI: 10.4253/wjge.v8.i6.282] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/05/2016] [Accepted: 01/29/2016] [Indexed: 02/05/2023] Open
Abstract
Periampullary diverticulum (PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD is usually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography (ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD, suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.
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Kim TH, Kim JH, Seo DW, Lee DK, Reddy ND, Rerknimitr R, Ratanachu-Ek T, Khor CJL, Itoi T, Yasuda I, Isayama H, Lau JYW, Wang HP, Chan HH, Hu B, Kozarek RA, Baron TH. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc 2016; 83:37-47. [PMID: 26232360 DOI: 10.1016/j.gie.2015.06.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/11/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Tae Hyeon Kim
- Department of Gastroenterology, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nageshwar D Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Christopher J L Khor
- Department of Gastroenterology and Hepatology, National University Health System, Tan Tock Seng Hospital, Singapore
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - James Y W Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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