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Adachi A, Yoshida M, Hori Y, Kato A, Kachi K, Sahashi H, Toyohara T, Kuno K, Kito Y, Kataoka H. Innovative use of a 3-Fr microcatheter for precision guidewire placement with digital single-operator cholangioscopy for pancreaticobiliary drainage (with video). Sci Rep 2024; 14:30647. [PMID: 39730389 DOI: 10.1038/s41598-024-75692-8] [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: 02/16/2024] [Accepted: 10/08/2024] [Indexed: 12/29/2024] Open
Abstract
Biliary and pancreatic tract stenosis are hallmark symptoms in pancreaticobiliary diseases, transcending malignancy. Endoscopic techniques are pivotal for biliary/pancreatic drainage; however, challenging scenarios arise when attempting to pass a guidewire (GW) through obstruction. Cholangioscopy-assisted GW placement has proven valuable, but challenges persist in its execution, particularly in maneuvering the GW through cholangioscopy. Therefore, we explored the integration of a 3-Fr microcatheter into cholangioscopy with the aim of enhancing direct visualization and offering a super-selective approach. When GW manipulation under a digital single-operator cholangioscope (D-SOC) guidance was still unsuccessful in a resistant obstruction, the 3-Fr microcatheter was introduced. This technique was performed in 42 individuals for 37 biliary and 5 pancreatic duct drainages, among which there were 19 malignant, 18 benign, and 4 anastomotic obstructions. In all patients, contrast-filled cholangiography in the target area couldn't be achieved at the pre-microcatheter insertion stage due to obstruction. The technical success rate was 85.7% overall, 89.5% in malignant strictures, 84.2% in benign strictures, and 75.0% in anastomotic obstructions, resulting in a clinical success rate of 78.6%. The use of a 3-Fr microcatheter appears effective for endoscopic drainage performed for obstruction. This technique could pave the way for improved outcomes in patients with pancreaticobiliary diseases.
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Affiliation(s)
- Akihisa Adachi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Michihiro Yoshida
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan.
| | - Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Akihisa Kato
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Kenta Kachi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Hidenori Sahashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Tadashi Toyohara
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Kayoko Kuno
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Yusuke Kito
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku Nagoya, Nagoya, Aichi, 467-8601, Japan
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Alonso Lárraga JO, Jiménez-Gutiérrez JM, Meneses-Mayo M, Hernández-Guerrero A, Serrano-Arévalo ML, Villegas-González LF. Acceptable number of cholangioscopy-guided biopsies for diagnosing perihilar cholangiocarcinoma. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 39559864 DOI: 10.17235/reed.2024.10719/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
INTRODUCTION Diagnosing perihilar cholangiocarcinoma can be challenging. Previous studies suggest that the sensitivity of taking three cholangioscopy-guided biopsies is approximately 70%. We hypothesized that obtaining four or more biopsies might improve the sensitivity for diagnosing perihilar cholangiocarcinoma. OBJECTIVE To determine the acceptable number of cholangioscopy-guided biopsies to improve sensitivity for diagnosing perihilar cholangiocarcinoma. METHODS This retrospective study analyzed clinical records of adults with perihilar stenosis who underwent cholangioscopy-guided biopsies. Patients with gallbladder cancer or metastatic bile duct obstruction were excluded. Data were grouped based on the number of biopsies taken: Group A (1 to 3 biopsies), Group B (4 to 6 biopsies), and Group C (7 to 10 biopsies). Results from each group were compared against a composite standard, including clinical follow-up and/or biopsies performed by alternative methods. RESULTS The group that underwent 4 to 6 biopsies had a sensitivity of 77.4%, while the group with 7 to 10 had a sensitivity of 70.8%. The group with 1 to 3 biopsies had a sensitivity of 34.5%. Statistically significant differences were observed between the groups, with comparisons showing improved sensitivity in the 4 to 6 biopsy group versus the 1 to 3 biopsy group (χ² = 14.42, P = 0.0001), and the 7 to 10 biopsy group versus the 1 to 3 biopsy group (χ² = 6.56, P = 0.010). CONCLUSIONS Performing 4 to 6 cholangioscopy-guided biopsies significantly improves sensitivity for diagnosing perihilar cholangiocarcinoma compared to 1 to 3 biopsies. Further studies are needed to validate these findings.
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Affiliation(s)
| | | | - Marcos Meneses-Mayo
- Facultad de Ciencias de la Salud, Universidad Anáhuac México. Centro de Investigación en Ciencias de la Salud , México
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Büringer K, Schempf U, Fusco S, Wichmann D, Stüker D, Götz M, Malek NP, Werner CR. Feasibility, safety and efficacy of endoscopic single-operator cholangioscopy: a retrospective single-center study. Therap Adv Gastroenterol 2024; 17:17562848241288111. [PMID: 39431174 PMCID: PMC11487541 DOI: 10.1177/17562848241288111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 09/13/2024] [Indexed: 10/22/2024] Open
Abstract
Background Endoscopic retrograde cholangiopancreaticography (ERCP) is the standard endoscopic procedure for the diagnosis and treatment of diseases of the pancreas and bile ducts. Cholangioscopy provides direct visualization of the bile ducts. It offers the possibility of more detailed diagnostic and therapeutic indications. Today, cholangioscopy is often performed as a single-operator (SOC) procedure. Objectives We were interested in the clinical efficacy of our SOC procedure in comparison with published studies, and performed this retrospective data analysis of all our consecutive patients from 2016 to 2022 to analyze the feasibility, safety, and efficacy of SOC. Design and Methods A retrospective single-center analysis of patients undergoing SOC at a tertiary center from 2016 to 2022 (N = 196) was performed. Demographic data, indication for SOC, exam-specific data, efficacy, and complications were included. Sensitivity and specificity for diagnosing indeterminate biliary strictures were calculated. Results The most common indications for SOC were indeterminate biliary strictures (n = 117; 60%), treatment of biliary stones (n = 45; 23%), and other indications (n = 34; 17%), for example, foreign body removal or intraoperative SOC. In 97% of the SOC (n = 191), the procedure was technically successful. The diagnostic or therapeutic goal was achieved in 91% of SOC (n = 173). In the subgroup where the SOC result was confirmed by subsequent surgery (n = 93), sensitivity was 86%, specificity 99%, and SOC treatment of stones was successful in 89%. Complications occurred in (20%; n = 37). The majority of these patients (n = 18; 10%) had minor bleeding requiring no intervention. Conclusion SOC is an effective and safe procedure that should be the standard of care when primary diagnostic and/or therapeutic ERCP has failed. The sensitivity and specificity for determining the dignity of biliary strictures and the efficacy for the treatment of difficult-to-treat stones are reproducibly very high.
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Affiliation(s)
- Karsten Büringer
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious Diseases, University Hospital Tübingen, Otfried-Müller-Str. 10, Tübingen D-72076, Germany
| | - Ulrike Schempf
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
| | - Stefano Fusco
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
| | - Dörte Wichmann
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
| | - Dietmar Stüker
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Tubingen, Germany
| | - Martin Götz
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
- Medizinische Klinik IV, Gastroenterologie/Onkologie, Kliniken Böblingen, Böblingen, Germany
| | - Nisar P. Malek
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
| | - Christoph R. Werner
- Department of Gastroenterology, Hepatology, Gastrointestinal Oncology, Geriatrics and Infectious diseases, University Hospital Tübingen, Tubingen, Germany
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Sakamoto Y, Takeda Y, Yamashita T, Seki Y, Kawahara S, Hirai T, Suto N, Shimosaka T, Hamamoto W, Koda H, Onoyama T, Matsumoto K, Yashima K, Isomoto H, Yamaguchi N. Comparative Study of Endoscopic Treatment for Intrahepatic and Common Bile Duct Stones Using Peroral Cholangioscopy. J Clin Med 2024; 13:5422. [PMID: 39336909 PMCID: PMC11432575 DOI: 10.3390/jcm13185422] [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: 08/08/2024] [Revised: 09/04/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Objectives: Although peroral cholangioscopy has improved the endoscopic treatment of difficult stones, the treatment of intrahepatic stones remains challenging. The incidence of cholangitis is high when peroral cholangioscopy is used to treat intrahepatic stones. This study aimed to investigate the efficacy and safety of endoscopic treatment with peroral cholangioscopy for intrahepatic and common bile duct stones. Methods: Patients aged ≥20 years, who underwent endoscopic treatment with peroral cholangioscopy for intrahepatic or common bile duct stones at Tottori University Hospital from January 2016 to December 2022, were retrospectively evaluated to determine the efficacy and safety of the treatment. Results: Overall, 70 patients were included in this study: 22 in the intrahepatic stone group and 48 in the common bile duct stone group. Stones were smaller (8 vs. 17.5 mm, p < 0.001) and more numerous (p = 0.016) in the intrahepatic stone group than in the common bile duct stone group. Although the common bile duct stone group exhibited a higher rate of complete stone clearance in the first session, no significant differences were observed in the final results. The intrahepatic stone group had a higher incidence of cholangitis (36% vs. 8%, p = 0.007); however, all cases were mild. Conclusions: Endoscopic treatment with peroral cholangioscopy for intrahepatic stones may be associated with a higher incidence of cholangitis than that for common bile duct stones. Since saline irrigation may contribute to the development of cholangitis, it is important to be aware of intraductal bile duct pressure when performing peroral cholangioscopy.
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Affiliation(s)
- Yuri Sakamoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Yohei Takeda
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Taro Yamashita
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Yuta Seki
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Shiho Kawahara
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Takayuki Hirai
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Noriyuki Suto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Takuya Shimosaka
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Wataru Hamamoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Hiroki Koda
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Takumi Onoyama
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Kazuya Matsumoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Kazuo Yashima
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan; (Y.S.)
| | - Naoyuki Yamaguchi
- Department of Endoscopy, Nagasaki University Hospital, Nagasaki 852-8501, Japan
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Huang S, Liang Y, Li Y, Pan L, Wang B, Liu Y, Shi R, Feng Y. Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis. Sci Rep 2024; 14:18830. [PMID: 39138255 PMCID: PMC11322515 DOI: 10.1038/s41598-024-69943-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
Radiation-free one-stage bedside endoscopic stone removal and biliary drainage for severe acute cholangitis (SAC) caused by choledocholithiasis in intensive care unit (ICU) has not been reported. Herein, we introduce our preliminary experience of such intervention. Radiation-free bedside digital cholangioscope-assisted one-stage endoscopic stone removal and biliary drainage was performed in an urgent manner. Data on clinical outcomes and follow-up from thirty patients were retrospectively analyzed. Time interval was 7.6 ± 4.7 (2-18) h between ICU admission and endoscopic intervention, and was 35.5 ± 14.5 (5-48) h between the seizure and endoscopic intervention. A 100% technical success was achieved. Except for one mild pancreatitis, no other complication occurred. Patients showed good responses to endoscopic interventions, which were reflected by ameliorated disease severities and laboratory findings. Time lengths of ICU stay and total in-hospital stay were 8.7 ± 4.9 (2-23) days and 14.5 ± 7.4 (5-39) days, respectively. In-hospital mortality occurred in three patients. According to a 6-month follow-up, two patients died of pneumonia and acute myocardial infarction. No SAC and/or biliary stone residual occurred. The current intervention demonstrated favorable results compared to traditional endoscopic retrograde cholangiopancreatography. Our study provides a novel bedside endoscopic intervention method for SAC caused by choledocholithiasis.
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Affiliation(s)
- Shuaijing Huang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yan Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yuanyuan Li
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Liang Pan
- Department of Gastroenterology, Changzhou Jintan First People's Hospital Affiliated to Jiangsu University, 500 Jintan Avenue, Jintan, 210036, Jiangsu, China.
| | - Bin Wang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Gastroenterology, The Affiliated Changshu Hospital of Nantong University, Changshu No. 2 People's Hospital, 18 Taishan Road, Changshu, 215500, China
| | - Yang Liu
- Department of Gastroenterology, Nanjing Pukou People's Hospital, 166 Shanghe Road, Nanjing, 210031, Jiangsu, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yadong Feng
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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Sánchez-Cerna V, Araujo-Almeyda G, Aliaga-Ramos J, Reyes-Mugruza T, Celedonio-Campos W. Percutaneous cholangioscopy utilizing SpyGlass Discover for difficult-to-treat choledocholithiasis in an altered anatomy: A case report. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:451-453. [PMID: 38906756 DOI: 10.1016/j.rgmxen.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/04/2024] [Indexed: 06/23/2024]
Affiliation(s)
- V Sánchez-Cerna
- Área de Gastroenterología, CIRE Intervencionista, Lima, Peru; Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima, Peru.
| | - G Araujo-Almeyda
- Área de Radiología Intervencionista y vascular, CIRE Intervencionista, Lima, Peru
| | - J Aliaga-Ramos
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima, Peru
| | - T Reyes-Mugruza
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima, Peru
| | - W Celedonio-Campos
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima, Peru
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Ashat M, Berei J, El-Abiad R, Khashab MA. Benign Biliary Strictures: A Comprehensive Review. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2024; 35:513-522. [PMID: 39128126 PMCID: PMC11363390 DOI: 10.5152/tjg.2024.24044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/21/2024] [Indexed: 08/13/2024]
Abstract
Benign biliary strictures (BBS) ensue from inflammatory conditions (e.g., chronic pancreatitis) or post surgery (e.g., cholecystectomy and liver transplant). High-quality cross-sectional imaging studies such as computed tomography or magnetic resonance cholangiopancre atography are essential in the diagnosis and planning of therapeutic interventions and in ruling out malignancy. Endoscopic retrograde cholangiopancreatography with dilation and stenting is the mainstay treatment for BBS, while surgery is reserved for failed endoscopy or refractory cases.
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Affiliation(s)
- Munish Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Joseph Berei
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Rami El-Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Sacco M, Gesualdo M, Staiano MT, Dall'Amico E, Caronna S, Dibitetto S, Canalis C, Caneglias A, Mediati F, Stasio RC, Gaia S, Saracco GM, Bruno M, De Angelis CG. Direct Single-Operator Cholangioscopy and Intraductal Ultrasonography in Patients with Indeterminate Biliary Strictures: A Single Center Experience. Diagnostics (Basel) 2024; 14:1316. [PMID: 39001208 PMCID: PMC11240807 DOI: 10.3390/diagnostics14131316] [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: 05/14/2024] [Revised: 06/16/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024] Open
Abstract
The evaluation of biliary strictures poses a challenge due to the low sensitivity of standard diagnostic approaches, but the advent of direct single-operator cholangioscopy (DSOC) has revolutionized this paradigm. Our study aimed to assess the diagnostic performance of DSOC and DSOC-targeted biopsies, intraductal ultrasound (IDUS), and standard brush cytology in patients with indeterminate biliary strictures (IBS). We reviewed patients who underwent advanced diagnostic evaluation for IBS at our endoscopy unit from January 2018 to December 2022, all of whom had previously undergone at least one endoscopic attempt to characterize the biliary stricture. Final diagnoses were established based on surgical pathology and/or clinical and radiological follow-up spanning at least 12 months. A total of 57 patients, with a mean age of 67.2 ± 10.0 years, were included, with a mean follow-up of 18.2 ± 18.1 months. The majority of IBS were located in the distal common bile duct (45.6%), with malignancy confirmed in 35 patients (61.4%). DSOC and IDUS demonstrated significantly higher accuracies (89.5% and 82.7%, respectively) compared to standard cytology (61.5%, p < 0.05). Both DSOC visualization and IDUS exhibited optimal diagnostic yields in differentiating IBS with an acceptable safety profile.
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Affiliation(s)
- Marco Sacco
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Marcantonio Gesualdo
- Endoscopy Unit, Gastroenterology Department, Section of Gastroenterology II, National Institute of Research IRCCS "Saverio De Bellis", 70013 Castellana Grotte, Italy
| | - Maria Teresa Staiano
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Eleonora Dall'Amico
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Stefania Caronna
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Simone Dibitetto
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Chiara Canalis
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Alessandro Caneglias
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Federica Mediati
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Rosa Claudia Stasio
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Silvia Gaia
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Giorgio Maria Saracco
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Mauro Bruno
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Claudio Giovanni De Angelis
- Endoscopy Unit, Gastroenterology Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
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9
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Sánchez-Cerna V, Araujo-Almeyda G, Aliaga-Ramos J, Reyes-Mugruza T, Celedonio-Campos W. Colangioscopia percutánea utilizando SpyGlass Discover para el manejo de coledocolitiasis difícil en anatomía alterada: reporte de caso. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2024. [DOI: 10.1016/j.rgmx.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
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10
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Fugazza A, Colombo M, Kahaleh M, Muthusamy VR, Benjamin B, Laleman W, Barbera C, Fabbri C, Nieto J, Al-Lehibi A, Ramchandani M, Tyberg A, Shahid H, Sarkar A, Ehrlich D, Sherman S, Binda C, Spadaccini M, Iannone A, Khalaf K, Reddy N, Anderloni A, Repici A. The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope: A multicenter retrospective international study. Hepatobiliary Pancreat Dis Int 2024; 23:71-76. [PMID: 37100688 DOI: 10.1016/j.hbpd.2023.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Duodenoscope-related multidrug-resistant organism (MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography (ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. METHODS This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score (1 to 10) on performance rating of the single-use duodenoscope, and adverse event (AE) rate. RESULTS A total of 66 patients (26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47 (71.2%) grade 3 and 19 (28.8%) grade 4. The technical success rate was 98.5% (65/66). Procedural duration was 64 (interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66 (1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients (6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis (PEP), 1 cholangitis and 1 bleeding. CONCLUSIONS Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Via Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Michel Kahaleh
- Gastroenterology, Rutgers Robert Wood Johnson; New Brunswick, New Jersey, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles School of Medicine at UCLA, Los Angeles, California, USA
| | - Bick Benjamin
- Division of Digestive and Liver Disorders; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Carmelo Barbera
- U.O.C. di Gastroenterologia ed Endoscopia Digestiva, Ospedale Giuseppe Mazzini, ASL Teramo, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida, USA
| | - Abed Al-Lehibi
- Department of Gastroenterology and Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Amy Tyberg
- Gastroenterology, Rutgers Robert Wood Johnson; New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Gastroenterology, Rutgers Robert Wood Johnson; New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Gastroenterology, Rutgers Robert Wood Johnson; New Brunswick, New Jersey, USA
| | - Dean Ehrlich
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles School of Medicine at UCLA, Los Angeles, California, USA
| | - Stuart Sherman
- Division of Digestive and Liver Disorders; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Via Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | | | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Via Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Via Manzoni 56, 20089, Rozzano, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
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11
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Xiong Z, Wang K, Zhang H, Fang Y, Li F, Huang J. Improved fluoroscopy-guided biopsies in the diagnosis of indeterminate biliary strictures: a multi-center retrospective study. Sci Rep 2023; 13:13152. [PMID: 37573370 PMCID: PMC10423265 DOI: 10.1038/s41598-023-39438-2] [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: 10/07/2022] [Accepted: 07/25/2023] [Indexed: 08/14/2023] Open
Abstract
To evaluate the diagnostic accuracy of improved fluoroscopy-guided biopsies for indeterminate biliary strictures (IBDS). A multi-center retrospective study was performed. Patients with IBDS who underwent digital single-operator cholangioscopy (DSOC) and improved fluoroscopy-guided biopsies procedures were included. The individual sensitivity, specificity, and accuracy were analyzed. A total of 67 patients were enrolled in this multi-center retrospective study. The DSOC and improved fluoroscopy-guided biopsies procedures were successfully performed in all cases (100%). The sensitivity, specificity, and accuracy values were 83.3%, 89.5%, and 85.1% for DSOC visual impression; 95.8%, 94.7%, and 95.5% for improved fluoroscopy-guided biopsies procedures, respectively. The sensitivity and accuracy of improved fluoroscopy-guided biopsies were significantly higher compared with DSOC visual impression. Four patients (6.0%, 4/67) occurred adverse events after the procedures. Improved fluoroscopy-guided biopsies had a high diagnostic accuracy of IBDS diagnosis.
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Affiliation(s)
- Zhe Xiong
- Department of Gastroenterology, Changzhou No.2 People's Hospital, Changzhou, China
- Graduate School of Dalian Medical University, Dalian, China
| | - Kuangjing Wang
- Department of Gastroenterology, The People's Hospital of Ma Anshan, Ma Anshan, China
| | - Huahui Zhang
- Department of Gastroenterology, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Ying Fang
- Department of Gastroenterology, Changzhou No.2 People's Hospital, Changzhou, China
- Graduate School of Dalian Medical University, Dalian, China
| | - Fengdong Li
- Department of Gastroenterology, Changzhou No.2 People's Hospital, Changzhou, China
| | - Jin Huang
- Department of Gastroenterology, Changzhou No.2 People's Hospital, Changzhou, China.
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12
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Chiang CH, Chen KC, Devereaux B, Chung CS, Kuo KC, Lin CC, Lin CK, Wang HP, Chen KH. Precise mapping of hilar cholangiocarcinoma with a skip lesion by SpyGlass cholangioscopy: A case report. World J Gastrointest Surg 2023; 15:965-971. [PMID: 37342860 PMCID: PMC10277946 DOI: 10.4240/wjgs.v15.i5.965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/07/2023] [Accepted: 04/07/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Cholangiocarcinoma (CC) is a very aggressive cancer with a poor prognosis. As surgery is the only curative therapy, preoperative evaluation of the tumor extent is essential for surgical planning. Although high-quality image modalities such as computed tomography and magnetic resonance imaging have been used extensively in preoperative evaluation, the accuracy is low. To obtain precise localization of tumor spread arising from the hilar region preoperatively, the development of an acceptable imaging modality is still an unmet need.
CASE SUMMARY A 52-year-old female presented to our emergency department with jaundice, abdominal pain, and fever. Initially, she was treated for cholangitis. Endoscopic retrograde cholangiopancreatography with the cholangiogram showed long segment filling defect in the common hepatic duct with dilatation of bilateral intrahepatic ducts. Transpapillary biopsy was performed, and the pathology suggested intraductal papillary neoplasm with high-grade dysplasia. After treatment of cholangitis, contrasted-enhanced computed tomography revealed a hilar lesion with undetermined Bismuth-Corlette classification. SpyGlass cholangioscopy showed that the lesion involved the confluence of the common hepatic duct with one skip lesion in the posterior branch of the right intrahepatic duct, which was not detected by previous image modalities. The surgical plan was modified from extended left hepatectomy to extended right hepatectomy. The final diagnosis was hilar CC, pT2aN0M0. The patient has remained disease-free for more than 3 years.
CONCLUSION SpyGlass cholangioscopy may have a role in precision localization of hilar CC to provide surgeons with more information before the operation.
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Affiliation(s)
- Cheng-Han Chiang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Xin-Tai General Hospital, New Taipei 242063, Taiwan
| | - Kuan-Chih Chen
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Herston 4029, Queensland, Australia
| | - Chen-Shuan Chung
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Kuei-Chang Kuo
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Chien Chu Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Cheng-Kuan Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 10002, Taiwan
| | - Kuo-Hsin Chen
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei 22060, Taiwan
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Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc 2023; 97:268-278.e1. [PMID: 36007584 DOI: 10.1016/j.gie.2022.08.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/04/2022] [Accepted: 08/13/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Accurately diagnosing malignant biliary strictures (MBSs) as benign or malignant remains challenging. It has been suggested that direct visualization and interpretation of cholangioscopy images provide greater accuracy for stricture classification than current sampling techniques (ie, brush cytology and forceps biopsy sampling) using ERCP. We aimed to develop a convolutional neural network (CNN) model capable of accurate stricture classification and real-time evaluation based solely on cholangioscopy image analysis. METHODS Consecutive patients with cholangioscopy examinations from 2012 to 2021 were reviewed. A CNN was developed and tested using cholangioscopy images with direct expert annotations. The CNN was then applied to a multicenter, reserved test set of cholangioscopy videos. CNN performance was then directly compared with that of ERCP sampling techniques. Occlusion block heatmap analyses were used to evaluate and rank cholangioscopy features associated with MBSs. RESULTS One hundred fifty-four patients with available cholangioscopy examinations were included in the study. The final image database comprised 2,388,439 still images. The CNN demonstrated good performance when tasked with mimicking expert annotations of high-quality malignant images (area under the receiver-operating characteristic curve, .941). Overall accuracy of CNN-based video analysis (.906) was significantly greater than that of brush cytology (.625, P = .04) or forceps biopsy sampling (.609, P = .03). Occlusion block heatmap analysis demonstrated that the most frequent image feature for an MBS was the presence of frond-like mucosa/papillary projections. CONCLUSIONS This study demonstrates that a CNN developed using cholangioscopy data alone has greater accuracy for biliary stricture classification than traditional ERCP-based sampling techniques.
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14
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Sánchez-Ocaña R, Foruny Olcina JR, Vila Costas J, Gallego Rojo F, Jiménez Pérez J, Domínguez-Muñoz E, González Huix F, Pons Beltrán V, Gornals Soler J, Sánchez Hernández E, Gómez Oliva C, Dolz Abadía C, Aparicio Tormo JR. SEED Consensus Document on SpyGlass-DS. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:69-79. [PMID: 36179947 DOI: 10.1016/j.gastrohep.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/07/2022] [Accepted: 08/26/2022] [Indexed: 01/18/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.
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Affiliation(s)
- Ramón Sánchez-Ocaña
- Servicio de Medicina Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José Ramón Foruny Olcina
- Unidad de Endoscopia, Servicio de Medicina Digestiva, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Vila Costas
- Unidad de Endoscopia, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | | | - Javier Jiménez Pérez
- Unidad de Endoscopia, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - Enrique Domínguez-Muñoz
- Servicio de Gastroenterología, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | | | - Vicente Pons Beltrán
- Endoscopia Digestiva, Hospital Universitari i Politecnic La Fe, Valencia, España
| | - Joan Gornals Soler
- Endoscopia Digestiva, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | | | | | - Carlos Dolz Abadía
- Aparato Digestivo, Hospital Universitario Son Llàtzer, Palma de Mallorca, España
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15
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Kastelijn JB, Didden P, Bogte A, Moons LMG, Vleggaar FP. Digital single-operator cholangioscopy to guide selective cannulation of complex biliary strictures. Surg Endosc 2022; 36:9476-9480. [PMID: 36261641 PMCID: PMC9652227 DOI: 10.1007/s00464-022-09665-1] [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] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Selective cannulation and stenting of complex, tight, and/or angulated biliary strictures under endoscopic retrograde cholangiopancreaticography (ERCP) can be challenging. Digital single-operator cholangioscopy (SOC) may facilitate guidewire advancement through the stricture with endoscopic visual guidance. We aimed to describe a case series on clinical outcomes of this technique for selective cannulation, when used after failed conventional ERCP attempts. METHODS Consecutive patients who underwent therapeutic digital SOC for selective cannulation of biliary strictures after failed conventional ERCP were retrospectively included. RESULTS Ten patients with a malignant (n = 6) or benign (n = 4) biliary stricture were included. Digital SOC-assisted selective guidewire insertion and stent placement across the biliary stricture were technically successful in five (50%) patients. Bilirubin levels improved in all patients with technical success. One (10%) patient developed a post-ERCP pancreatitis. CONCLUSIONS Technically successful cannulation of biliary strictures with digital SOC was achieved in half of patients in whom cannulation with conventional ERCP failed, sparing them more invasive interventions. Stricture opacification during the failed ERCP was seen in all technically successful SOCs.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Sakamoto Y, Takeda Y, Seki Y, Kawahara S, Shimosaka T, Hamamoto W, Koda H, Yamashita T, Onoyama T, Matsumoto K, Yashima K, Isomoto H. The Usefulness of Peroral Cholangioscopy for Intrahepatic Stones. J Clin Med 2022; 11:6425. [PMID: 36362652 PMCID: PMC9654474 DOI: 10.3390/jcm11216425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/13/2022] [Accepted: 10/28/2022] [Indexed: 06/03/2024] Open
Abstract
Peroral cholangioscopy (POCS) is believed to be effective in treating intrahepatic stones; however, reports on its efficacy are few. We reviewed the results of intrahepatic stones treated with fluoroscopic guidance or POCS. This study included 26 patients who underwent endoscopic treatment for intrahepatic stones at our institution between January 2017 and December 2021. We retrospectively evaluated the procedure time and adverse events in the first session and the rate of complete stone removal. Complete stone removal was achieved in 92% (24/26); POCS was required in 16 of 26 (62%) procedures and the complete stone removal was achieved in 15 of 16 (94%) of these procedures. The POCS group had a significantly longer procedure time than the fluoroscopy group. Cholangitis incidence was high; however, no difference was noted between patients with and without POCS, and all cases were mild and treated conservatively. Endoscopic treatment for intrahepatic stones may lead to an increase in the incidence of cholangitis, requires specialized devices such as a cholangioscope, and should be performed in an established institution by experienced staff. POCS is useful for intrahepatic stones formed upstream of the stenosis and intrahepatic stones piled in the bile duct.
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Affiliation(s)
| | - Yohei Takeda
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Nishi-cho 36-1, Yonago 683-8504, Japan
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Utility of Digital Single-operator Video Cholangioscopy for the Endoscopic Management of Biliary Complications After Liver Transplantation-A Single-center Experience. Transplantation 2022; 107:925-932. [PMID: 36525550 DOI: 10.1097/tp.0000000000004388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Liver transplant recipients (LTRs) frequently develop biliary complications, and endoscopy is crucial for their subsequent management. Recently, single-operator video cholangioscopy (SOVC) with digital imaging quality was introduced. This study evaluated the utility of digital SOVC for the management of biliary complications in LTRs. METHODS This observational study retrospectively analyzed all LTRs undergoing digital SOVC between 2015 and 2019 at a tertiary referral center. Endpoints included the assessment of biliary strictures, performance of selective guidewire passage across biliary strictures, and diagnosis and treatment of biliary stone disease. RESULTS In total, 79 digital SOVCs performed in 50 LTRs were identified. Fifty-eight percent of the procedures were performed for biliary stricture assessment, and using visual signs or guided biopsies, SOVC excluded malignancy in all cases (100%). Of all the examinations, 29.1% (23/79) were performed solely because of a previous failure of conventional endoscopic methods to pass a guidewire across a biliary stricture. Using SOVC, guidewire passage was successfully performed in 73.9% of these examinations, enabling subsequent endoscopic therapy. Furthermore, biliary stones were found in 16.5% (13/79) of the examinations. In 38.5% of these cases, standard fluoroscopy failed to detect stones, which were only visualized using digital SOVC. Biliary stone treatment was successful in 92% (12/13) of the examinations. Complications occurred in 11.4% of all SOVCs. No procedure-associated mortalities were observed. CONCLUSIONS Digital SOVC is effective and safe for the endoscopic management of biliary complications in LTRs and offers unique diagnostic and therapeutic opportunities that strongly impact the clinical course in selected cases.
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Digital single-operator cholangioscopy in diagnostic and therapeutic bilio-pancreatic diseases: A prospective, multicenter study. Dig Liver Dis 2022; 54:1243-1249. [PMID: 35597763 DOI: 10.1016/j.dld.2022.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Digital single-operator cholangioscopy (D-SOC) is an endoscopic procedure that is increasingly used for the management of bilio-pancreatic diseases. We aimed to investigate the efficacy and safety of D-SOC for diagnostic and therapeutic indications. METHODS This is a multicenter, prospective study(January 2016-June 2019) across eighteen tertiary centers. The primary outcome was procedural success of D-SOC. Secondary outcomes were: D-SOC visual assessment and diagnostic yield of SpyBite biopsy in cases of biliary strictures, stone clearance rate in cases of difficult biliary stones, rate of adverse events(AEs) for all indications. RESULTS D-SOC was performed in 369 patients (201(54,5%) diagnostic and 168(45,5%)therapeutic). Overall, procedural success rate was achieved in 360(97,6%) patients. The sensitivity, specificity, PPV, NPV and accuracy in biliary strictures were: 88,5%, 77,3%, 83,3%, 84,1% and 83,6% for D-SOC visual impression; 80,2%, 92,6%, 95,1%, 72,5% and 84,7% for the SpyBite biopsy, respectively. For difficult biliary stones, complete duct clearance was obtained in 92,1% patients (82,1% in a single session). Overall, AEs occurred in 37(10%) cases.The grade of AEs was mild or moderate for all cases, except one which was fatal. CONCLUSION D-SOC is effective for diagnostic and therapeutic indications.Most of the AEs were minor and managed conservatively, even though a fatal event has happened that is not negligible and should be considered before using D-SOC.
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Bokemeyer A, Lenze F, Stoica V, Sensoy TS, Kabar I, Schmidt H, Ullerich H. Digital single-operator video cholangioscopy improves endoscopic management in patients with primary sclerosing cholangitis-a retrospective observational study. World J Gastroenterol 2022; 28:2201-2213. [PMID: 35721887 PMCID: PMC9157616 DOI: 10.3748/wjg.v28.i20.2201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) are at a high risk of developing cholestatic liver disease and biliary cancer, and endoscopy is crucial for the complex management of these patients.
AIM To clarify the utility of recently introduced digital single-operator video cholangioscopy (SOVC) for the endoscopic management of PSC patients.
METHODS In this observational study, all patients with a history of PSC and in whom digital SOVC (using the SpyGlass DS System) was performed between 2015 and 2019 were included and retrospectively analysed. Examinations were performed at a tertiary referral centre in Germany. In total, 46 SOVCs performed in 38 patients with a history of PSC were identified. The primary endpoint was the evaluation of dominant biliary strictures using digital SOVC, and the secondary endpoints were the performance of selective guidewire passage across biliary strictures and the diagnosis and treatment of biliary stone disease in PSC patients.
RESULTS The 22 of 38 patients had a dominant biliary stricture (57.9%). In 4 of these 22 patients, a cholangiocellular carcinoma was diagnosed within the stricture (18.2%). Diagnostic evaluation of dominant biliary strictures using optical signs showed a sensitivity of 75% and a specificity of 94.4% to detect malignant strictures, whereas SOVC-guided biopsies to gain tissue for histopathological analysis showed a sensitivity of 50% and a specificity of 100%. In 13% of examinations, SOVC was helpful for guidewire passage across biliary strictures that could not be passed by conventional methods (technical success rate 100%). Biliary stone disease was observed in 17.4% of examinations; of these, in 37.5% of examinations, biliary stones could only be visualized by SOVC and not by standard fluoroscopy. Biliary stone treatment was successful in all cases (100%); 25% required SOVC-assisted electrohydraulic lithotripsy. Complications, such as postinterventional cholangitis and pancreatitis, occurred in 13% of examinations; however, no procedure-associated mortality occurred.
CONCLUSION Digital SOVC is effective and safe for the endoscopic management of PSC patients and may be regularly considered an additive tool for the complex endoscopic management of these patients.
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Affiliation(s)
- Arne Bokemeyer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Frank Lenze
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Viorelia Stoica
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Timur Selcuk Sensoy
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Iyad Kabar
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen 45147, Germany
| | - Hansjoerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster 48149, Germany
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Inchingolo R, Acquafredda F, Posa A, Nunes TF, Spiliopoulos S, Panzera F, Praticò CA. Endobiliary biopsy. World J Gastrointest Endosc 2022; 14:291-301. [PMID: 35719901 PMCID: PMC9157693 DOI: 10.4253/wjge.v14.i5.291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/22/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
The differential diagnosis between benign and malignant biliary strictures is challenging and requires a multidisciplinary approach with the use of serum biomarkers, imaging techniques, and several modalities of endoscopic or percutaneous tissue sampling. The diagnosis of biliary strictures consists of laboratory markers, and invasive and non-invasive imaging examinations such as computed tomography (CT), contrast-enhanced magnetic resonance cholangiopancreatography, and endoscopic ultrasonography (EUS). Nevertheless, invasive imaging modalities combined with tissue sampling are usually required to confirm the diagnosis of suspected malignant biliary strictures, while pathological diagnosis is mandatory to decide the optimal therapeutic strategy. Although EUS-guided fine-needle aspiration biopsy is currently the standard procedure for tissue sampling of solid pancreatic mass lesions, its diagnostic value in intraductal infiltrating type of cholangiocarcinoma remains limited. Moreover, the "endobiliary approach" using novel slim biopsy forceps, transpapillary and percutaneous cholangioscopy, and intraductal ultrasound-guided biopsy, is gaining ground on traditional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography endobiliary forceps biopsy. This review focuses on the available endobiliary techniques currently used to perform biliary strictures biopsy, comparing the diagnostic performance of endoscopic and percutaneous approaches.
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Affiliation(s)
- Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Fabrizio Acquafredda
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Alessandro Posa
- Department of Radiology, Policlinico Universitario “A. Gemelli“, Rome 00186, Italy
| | - Thiago Franchi Nunes
- Interventional Radiology Unit, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Francesco Panzera
- Interventional Gastroenterology Unit, Madonna Delle Grazie Hospital, Matera 75100, Italy
| | - Carlos Alberto Praticò
- Unité d’Endoscopie Digestive, Hôpital Privé “Armand Brillard” 3/5 avenue Watteau, Nogent-sur-Marne 94130, France
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21
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Fukuhara S, Iwasaki E, Kayashima A, Machida Y, Tamagawa H, Kawasaki S, Horibe M, Hori S, Abe Y, Kitago M, Ogata H, Kanai T. Endoscopic Diagnosis of Biliary Stricture Combined with Digital Cholangioscope: A Case Series. Healthcare (Basel) 2021; 10:healthcare10010012. [PMID: 35052176 PMCID: PMC8775675 DOI: 10.3390/healthcare10010012] [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] [Received: 11/13/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022] Open
Abstract
The endoscopic diagnosis of biliary tract lesions is applied as a non-invasive method; however, its diagnostic accuracy is not yet high. Moreover, digital cholangioscopy is used for directly visualizing the inside of the bile duct, resulting in a more precise biopsy. We present the case series of the outcomes of diagnosis using digital cholangioscopy in patients who underwent cholangioscopy for the evaluation of biliary stenosis in our department between January 2014 and March 2021. The controls were those who underwent a biopsy for biliary stenosis with conventional endoscopic retrograde cholangiopancreatography (ERCP). Background data for each case were collected, and the clinical outcomes by biopsy were evaluated, focusing on the accuracy of the diagnosis. Cholangioscopy was performed in 15 cases, while a conventional biopsy by ERCP was performed in 172 cases. Nine of 15 cases (60.0%) were diagnosed with cholangiocarcinoma. The number of specimens obtained through conventional ERCP and cholangioscopy was 2.5 ± 1.3 and 3.3 ± 1.5, respectively (p = 0.043). The diagnostic accuracy of conventional ERCP and cholangioscopy were 65.7% (113 of 172 cases) and 100%, respectively, which was significantly higher in the group with cholangioscopy. Digital cholangioscopy is useful when the diagnosis of the biliary stricture using the conventional ERCP method is difficult.
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Affiliation(s)
- Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.F.); (H.O.)
- National Hospital Organization Tokyo Medical Center, Division of Gastroenterology and Hepatology, Tokyo 152-8902, Japan;
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
- Correspondence: ; Tel.: +81-3-5363-3790
| | - Atsuto Kayashima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Hiroki Tamagawa
- National Hospital Organization Tokyo Medical Center, Division of Gastroenterology and Hepatology, Tokyo 152-8902, Japan;
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.H.); (Y.A.); (M.K.)
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.F.); (H.O.)
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; (A.K.); (Y.M.); (S.K.); (M.H.); (T.K.)
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22
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Lee T, Teng TZJ, Shelat VG. Choledochoscopy: An update. World J Gastrointest Endosc 2021; 13:571-592. [PMID: 35070020 PMCID: PMC8716986 DOI: 10.4253/wjge.v13.i12.571] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/23/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.
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Affiliation(s)
- Tsinrong Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Thomas Zheng Jie Teng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Vishal G Shelat
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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23
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Feng Y, Xu W, Liu Y, Sun X, Liang Y, Bu C, Li Y, Zhang Y, Zhang J, Shi R. Digital Cholangioscopy-assisted Nonradiation Endoscopic Retrograde Cholangiopancreatography for Retrieval of Common Bile Duct Stone. Surg Laparosc Endosc Percutan Tech 2021; 32:203-208. [PMID: 34653113 DOI: 10.1097/sle.0000000000001015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of nonradiation endoscopic retrograde cholangiopancreatography (NR-ERCP) for choledocholithiasis is still limited. Hereby, we introduced our experience of digital cholangioscopy (DCS)-assisted NR-ERCP for retrieval of common bile duct stones. METHODS Altogether, data of 132 patients who underwent DCS-assisted NR-ERCP for choledocholithiasis were collected. Procedure details, complications, and short-term follow-up were reviewed and analyzed and were compared with those of conventional endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Routine stone extraction and laser lithotripsy were planned in 116 and 16 patients, respectively. Biliary access was successfully achieved by standard biliary cannulation and by advanced techniques in 99 and 33 patients, respectively. Complete stone removal was achieved in a single session in all patients. Routine stone extraction was performed in 117 patients, and laser lithotripsy was applied in 15 patients, among whom 14 patients with planned lithotripsy and 1 unexpected impacted stone found during the procedure. Unexpected right localized intrahepatic stones and purulent cholecystitis were found in 1 and 3 patients, respectively. Three mild and 1 moderate pancreatitis, 5 cases of hyperamylasemia, and 2 cases of leukocytosis occurred as complications. Short-term follow-up revealed no stone residual. Procedure details, technical success, and complications were not statistically different than conventional ERCP. CONCLUSIONS DCS-assisted NR-ERCP is technically feasible, efficient, and safe for retrieval of common bile duct stones. This novel method is superior to conventional ERCP on detecting unexpected concomitant biliary diseases.
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Affiliation(s)
- Yadong Feng
- Department of Gastroenterology, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu Province, China
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24
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Weigand K, Küchle M, Zuber-Jerger I, Müller M, Kandulski A. Diagnostic Accuracy and Therapeutic Efficacy of Digital Single-Operator Cholangioscopy for Biliary Lesions and Stenosis. Digestion 2021; 102:776-782. [PMID: 33631748 DOI: 10.1159/000513713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Digital single-operator cholangioscopy (dSOC) has revolutionized bile duct visualization. Interventions like electrohydraulic or laser lithotripsy, inspection of suspicious areas, and targeted biopsies have become possible quick and easy. One main indication for dSOC remains the evaluation of indeterminate biliary strictures. OBJECTIVE AND METHODS We analyzed 180 consecutive dSOCs procedures performed in a high-volume tertiary center to evaluate sensitivity, specificity as well as positive and negative predictive values (PPV and NPV) for indeterminate strictures. Furthermore, technical success and complications were analyzed. RESULTS In 92-97%, the region of interest was reached and successfully visualized. In 83-100%, targeted biopsies were obtained from the suspicious area. Only the distal bile duct was less successful with only 84 and 62%, respectively. In general, dSOC procedures were safe. Cholangitis was the main complication. Regarding the diagnostic accuracy of dSOC of indeterminate biliary strictures, we found a sensitivity of 0.87 and specificity of 0.88, over all. Within the whole cohort, the investigators' assessment directly after dSOC had a PPV of 0.63 and a NPV of 0.97. In patients with biliary lesions or stenosis suspicious for malignancy, the dSOC-based visual diagnosis revealed a very high diagnostic accuracy with sensitivity and specificity of 1.0 (95% CI 0.86-1.0) and 0.76 (95% CI 0.56-0.9) with a PPV of 0.77 (95% CI 0.59-0.9) and a high NPV of 1.0 (95% CI 0.85-1.0). CONCLUSIONS Our study demonstrates that dSOC has a high diagnostic accuracy as well as a favorable safety profile. Therefore, dSOC should be discussed as standard of care during endoscopic retrograde cholangiography for indeterminate biliary lesions.
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Affiliation(s)
- Kilian Weigand
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany,
| | - Merlin Küchle
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Ina Zuber-Jerger
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Arne Kandulski
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
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25
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Radiation-free digital cholangioscopy-guided laser lithotripsy for large common bile duct stones: feasibility and technical notes. Surg Endosc 2021; 35:6390-6395. [PMID: 34387747 DOI: 10.1007/s00464-021-08688-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/07/2021] [Indexed: 12/24/2022]
Abstract
AIMS Although endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones is facilitated by digital cholangioscopy-guided lithotripsy, it is performed by fluoroscopy guidance. Here, we report our experience of non-radiation ERCP for large CBD stones using digital cholangioscopy-guided laser lithotripsy. METHODS Sixteen patients with large CBD stones underwent non-radiation digital cholangioscopy-guided laser lithotripsy and lithotomy. Data relevant to procedure details, adverse events, and short-term follow-up were analyzed. RESULTS Biliary access was achieved in all patients using standard guidewire-assisted cannulation, double-guidewire technique, and transpancreatic precut in twelve, two, and two patients, respectively. Balloons of 10 mm, 8 mm, and 6 mm in diameter were applied for EPBD in 8, 2, and 6 patients, respectively. Complete stone removal in one session was achieved in all patients. One round of laser lithotripsy was needed for stone ≤ 25 mm, and three-to-five rounds were needed for stones > 25 mm or multiple stones. One or two clips were used for endoscopic clipping. The time lengths of biliary access, digital cholangioscopy-assisted laser lithotripsy and stone extraction, and whole procedure were 3.5 ± 3.2 (0.5-12) minutes, 52.5 ± 30.6 (45-97) minutes, and 76 ± 23.3 (58-106) minutes, respectively. Asymptomatic hyperleukocytose, hyperamylasemia, and mild pancreatitis were present in 1, 2, and 1 patient(s), respectively. No other complications occurred. No cholangitis or recurrent CBD stones were observed. CONCLUSION Non-radiation digital cholangioscopy-guided laser lithotripsy is technically feasible and can be safely performed for endoscopic management of large CBD stones.
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26
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Hao J, Huang X. The Status and Development of Oral Choledochoscopy Diagnosis and Treatment of Biliary Tract Diseases. Int J Gen Med 2021; 14:4269-4277. [PMID: 34393506 PMCID: PMC8360357 DOI: 10.2147/ijgm.s317484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022] Open
Abstract
Choledochoscopy technology has realized the direct observation of bile duct lesions, and can be loaded with a variety of special accessories to perform the corresponding diagnosis and treatment operations, and has become an important means for the diagnosis of unexplained bile duct stricture and treatment of refractory bile duct stones. With the further enhancement of the imaging quality and operability, the clinical application of choledochoscopy has gradually expanded to the precise positioning of cholangiocarcinoma before surgical resection, the drainage of the gallbladder through the nipple, the removal of the displaced bile duct stent and other fields. This paper briefly reviewed the historical evolution of choledochoscopy and reviewed the latest clinical advances of oral choledochoscopy in the diagnosis and treatment of biliary tract diseases.
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Affiliation(s)
- Jinyong Hao
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
| | - Xiaojun Huang
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
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27
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Oh CH, Dong SH. Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy. Korean J Intern Med 2021; 36:235-246. [PMID: 32972127 PMCID: PMC7969058 DOI: 10.3904/kjim.2020.425] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/16/2022] Open
Abstract
The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
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28
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Martins FP, Seleti SMR, Contini ML, DE Paulo GA, Ferrari AP. IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT? ARQUIVOS DE GASTROENTEROLOGIA 2021; 57:347-353. [PMID: 33237212 DOI: 10.1590/s0004-2803.202000000-67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 07/31/2020] [Indexed: 02/11/2025]
Abstract
BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.
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Laquière AE, Privat J, Fumex F, Grandval P, Lecomte L, Curel L, Belle A, Trottier-Tellier F, Urena-Campos R, Penaranda G, Boustière C, Napoléon B. Performance of digital single-operator cholangiopancreatoscope for biliopancreatic diseases in real life: results from a prospective multicenter study. Scand J Gastroenterol 2020; 55:1381-1388. [PMID: 33095075 DOI: 10.1080/00365521.2020.1832143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases. MATERIALS AND METHODS Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications. RESULTS From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64-82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The 'POCP visual impression' of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. 'POCP-guided samples histological analysis' showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1-9.6) and 9.0 (8.8-10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7-9.6) and 9.0 (7.9-9.7). Only three 30-day minor complications occurred without any major complications. CONCLUSIONS POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).
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Affiliation(s)
- Arthur E Laquière
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Jocelyn Privat
- Department of Hepatogastroenterology, Centre Hospitalier Vichy, Vichy, France
| | - Fabien Fumex
- Department of Hepatogastroenterology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Philippe Grandval
- Digestive Endoscopy and Gastroenterology Department, AP-HM Hôpital de la Timone, Marseille, France
| | - Laurence Lecomte
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Laurence Curel
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Arthur Belle
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Félix Trottier-Tellier
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Romina Urena-Campos
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | | | - Christian Boustière
- Departments of Hepatogastroenterology and Clinical Research, Hôpital Saint Joseph, Marseille, France
| | - Bertrand Napoléon
- Department of Hepatogastroenterology, Hôpital Privé Jean Mermoz, Lyon, France
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Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part I: Classification, diagnosis and staging. Dig Liver Dis 2020; 52:1282-1293. [PMID: 32893173 DOI: 10.1016/j.dld.2020.06.045] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/11/2022]
Abstract
Cholangiocarcinoma (CCA) is the second most common primary liver cancer, characterized by a poor prognosis and resistance to chemotherapeutics. The progressive increase in CCA incidence and mortality registered worldwide in the last two decades and the need to clarify various aspects of clinical management have prompted the Italian Association for the Study of the Liver (AISF) to commission the drafting of dedicated guidelines in collaboration with a group of Italian scientific societies. These guidelines have been formulated in accordance with the Italian National Institute of Health indications and developed by following the GRADE method and related advancements.
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31
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Wen LJ, Chen JH, Xu HJ, Yu Q, Liu K. Efficacy and Safety of Digital Single-Operator Cholangioscopy in the Diagnosis of Indeterminate Biliary Strictures by Targeted Biopsies: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:E666. [PMID: 32887436 PMCID: PMC7555631 DOI: 10.3390/diagnostics10090666] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Biliary strictures are frequently encountered in clinical practice. The determination of their nature is often difficult. This study aims to systematically evaluate the efficacy and safety of the second generation of digital single-operator cholangioscopy (SpyGlass DS, DSOC) in indeterminate biliary strictures (IBDS) through biopsies. METHODS All relative studies published in Medline, the Cochrane Library, Web of Science, and EMBASE were included. The diagnostic tests for IBDS were compared to the surgical histology, autopsy, or long-term clinical follow-up. The methodological quality of the included studies was evaluated by the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS-2). RESULTS A total of 11 studies, which involved 356 patients diagnosed through biopsies, were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.74 (95% CI: 0.67-0.80), 0.98 (95% CI: 0.95-1.00), 10.52 (95% CI: 5.45-20.32), 0.31 (95% CI: 0.23-0.41), and 65.18 (95% CI: 26.79-158.61), respectively. The area under the curve (AUC) was 0.9479, and the pooled adverse event rate was 7%. The sensitivity and specificity in the heterogeneity analysis were I2 = 48.1% and I2 = 25.4%, respectively. CONCLUSION SpyGlass DS is a safe and effective technique for IBDS. However, future randomized trials are needed to determine optimal number of biopsies.
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Affiliation(s)
- Li-Jia Wen
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Jun-Hong Chen
- College of Clinical Medicine, Jilin University, Changchun 130021, China;
| | - Hong-Ji Xu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
| | - Qiong Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun 130021, China;
| | - Kai Liu
- Department of Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, China; (L.-J.W.); (H.-J.X.)
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Furnari M, Telese A, Hann A, Lisotti A, Boškoski I, Eusebi LH. New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review. Curr Drug Metab 2020; 21:850-865. [PMID: 32703127 DOI: 10.2174/1389200221666200722145727] [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: 02/28/2020] [Revised: 05/04/2020] [Accepted: 06/02/2020] [Indexed: 12/07/2022]
Abstract
Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.
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Affiliation(s)
- Manuele Furnari
- Department of Internal Medicine, Gastroenterology Unit, Policlinico IRCCS "San Martino", University of Genoa, Genoa, Italy
| | - Andrea Telese
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alexander Hann
- Interventional and Experimental Endoscopy (InExEn), Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
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Galetti F, Moura DTHD, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGHD. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2020; 33:e1491. [PMID: 32609255 PMCID: PMC7325696 DOI: 10.1590/0102-672020190001e1491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. AIM To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. METHODS Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. RESULTS Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). CONCLUSIONS For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
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Affiliation(s)
- Facundo Galetti
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil.,Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Igor Braga Ribeiro
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Mateus Pereira Funari
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Martin Coronel
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Amit H Sachde
- Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Vitor Ottoboni Brunaldi
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tomazo Prince Franzini
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Robles-Medranda C, Soria-Alcívar M, Oleas R, Baquerizo-Burgos J, Puga-Tejada M, Valero M, Pitanga-Lukashok H. Digital per-oral cholangioscopy to diagnose and manage biliary duct disorders: a single-center retrospective study. Endosc Int Open 2020; 8:E796-E804. [PMID: 32490166 PMCID: PMC7247902 DOI: 10.1055/a-1153-8950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Digital, per-oral cholangioscopy (POCS) allows diagnosis of biliary ducts disorders and treatment for complicated stones. We aimed to determine the diagnostic accuracy of digital POCS systems for stricture lesions and the factors precluding complete biliary stone clearance. Patients and methods We performed a retrospective analysis of a prospective database of 265 consecutive patients referred for POCS between December 2016 and July 2018. We first analyzed the diagnostic accuracy of digital POCS for malignant and benign stricture lesions in 147 patients. Then, we analyzed the factors associated with complete or partial biliary stone clearance achieved with electrohydraulic lithotripsy (EHL) delivered via POCS in 118 patients. Results In the diagnostic group, digital POCS achieved 91 % visual-impression sensitivity, 99 % specificity, 99 % positive and 91 % negative predictive values, and 63.64 positive and 0.09 negative likelihood ratios for malignancy diagnosis. In the therapeutic group, complete biliary stone clearance was achieved by EHL in 94.9 % patients; the mean stone size was 20 mm (10-40 mm). In multivariable analyses, a stone size > 20 mm (OR: 1.020, P < 0.001) and the number of stones ≥ 3 (OR: 1.276, P < 001) was associated with partial biliary stone clearance. Adverse events were reported in 3.3 % patients; no deaths were reported 30 days after the procedure. Conclusions Digital POCS has excellent diagnostic efficacy for biliary lesions. EHL via POCS is effective for complicated biliary stone clearance. Stone size (> 20 mm) and the number of stones (≥ 3) are associated with partial biliary stone clearance.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Miguel Soria-Alcívar
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Manuel Valero
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
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Fung BM, Fejleh MP, Tejaswi S, Tabibian JH. Cholangioscopy and its Role in Primary Sclerosing Cholangitis. EUROPEAN MEDICAL JOURNAL. HEPATOLOGY 2020; 8:42-53. [PMID: 32714560 PMCID: PMC7380688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterised by chronic inflammation and fibro-obliteration of the intrahepatic and/or extrahepatic bile ducts. It is associated with numerous hepatobiliary complications including an increased risk of malignancy (in particular, cholangiocarcinoma) and biliary tract stone formation. The evaluation of biliary strictures in patients with PSC is especially challenging, with imaging and endoscopic methods having only modest sensitivity for the diagnosis of cholangiocarcinoma, and treatment of biliary strictures poses a similarly significant clinical challenge. In recent years, peroral cholangioscopy has evolved technologically and increased in popularity as an endoscopic tool that can provide direct intraductal visualisation and facilitate therapeutic manipulation of the biliary tract. However, the indications for and effectiveness of its use in patients with PSC remain uncertain, with only a few studies performed on this small but important subset of patients. In this review, the authors discuss the available data regarding the use of peroral cholangioscopy in patients with PSC, with a focus on its use in the evaluation and management of biliary strictures and stones.
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Affiliation(s)
- Brian M. Fung
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - M. Phillip Fejleh
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sooraj Tejaswi
- Division of Gastroenterology & Hepatology, University of California, UC Davis Health, Sacramento, California, USA
| | - James H. Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
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Bokemeyer A, Gerges C, Lang D, Bettenworth D, Kabar I, Schmidt H, Neuhaus H, Ullerich H, Lenze F, Beyna T. Digital single-operator video cholangioscopy in treating refractory biliary stones: a multicenter observational study. Surg Endosc 2020; 34:1914-1922. [PMID: 31309312 DOI: 10.1007/s00464-019-06962-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Standard endoscopic treatment might fail to treat biliary stone disease. Here, we investigated the efficacy and safety of recently introduced digital single-operator video cholangioscopy (SOVC) for the treatment of difficult biliary stones. METHODS Digital SOVC procedures, performed in two tertiary referral centers between 2015 and 2018, were retrospectively analyzed. Only patients with a previous failure of endoscopic standard treatment and a SOVC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone removal rate per procedure and per patient. RESULTS In total, 75 examinations with a digital SOVC-assisted biliary stone treatment, performed in 60 patients, were identified. Biliary stones were mainly located extrahepatic (64%) and less frequently intrahepatic (36%). The median stone size was 20 mm (interquartile range [IQR]: 10-25 mm) and the median stone number was 1 (IQR: 1-2). Digital SOVC-based treatment of biliary stone disease was successful in 95% of patients and 15% needed at least two treatment sessions. Evaluated per procedure, a complete stone removal was accomplished in 67% of all examinations (including initial and repeated procedures), while an incomplete stone removal was observed in 33% of cases. The per procedure analyzes revealed that the success rates for a complete stone removal were similar between LL and EHL (66% vs. 68%; p = 0.87). Complications, such as postinterventional cholangitis and pancreatitis occurred in 16% of examinations; however, except from one case, all were mild or moderate and no procedure-associated mortality occurred. CONCLUSIONS Digital SOVC-assisted biliary stone treatment is highly effective even in cases with difficult biliary stones and might be considered the new standard of care for these patients. Furthermore, mild up to moderate complications were intermittently observed which might document the complexity of our included cases.
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Affiliation(s)
- Arne Bokemeyer
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Christian Gerges
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Diana Lang
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Dominik Bettenworth
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Iyad Kabar
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Hartmut Schmidt
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Hansjoerg Ullerich
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Frank Lenze
- Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Torsten Beyna
- Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.
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Efficacy of digital single-operator cholangioscopy in the visual interpretation of indeterminate biliary strictures: a systematic review and meta-analysis. Surg Endosc 2020; 34:3321-3329. [PMID: 32342216 DOI: 10.1007/s00464-020-07583-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/18/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Indeterminate biliary strictures remain a significant diagnostic challenge. Digital single-operator cholangioscopy (D-SOC) incorporates digital imaging which enables higher resolution for better visualization and diagnosis of biliary pathology. We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to determine the efficacy of D-SOC in the visual interpretation of indeterminate biliary strictures. MATERIAL AND METHODS Electronic searches were performed using Medline (PubMed), EMBASE, and Cochrane Library. All D-SOC studies that reported the diagnostic performance in visual interpretation of indeterminate biliary strictures and biliary malignancies were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 was used to evaluate the quality of the included studies. All data were extracted and pooled to construct a 2 × 2 table. The visual interpretation of D-SOC was compared to resected surgical specimens or clinical follow-up in the included patients. Pooled sensitivity, specificity, positive predictive value, negative predictive value, prevalence, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and diagnostic odds ratio (OR) were calculated. The summarized receiver operating characteristic (SROC) curve corresponding with the area under the curve (AUC) was also analyzed. RESULTS The search yielded 465 citations. Of these, only six studies with a total of 283 procedures met inclusion criteria and were included in the meta-analysis. The overall pooled sensitivity and specificity of D-SOC in the visual interpretation of biliary malignancies was 94% (95% CI 89-97) and 95% (95%CI 90-98), respectively, while +LR, -LR, diagnostic OR, and AUC were 15.20 (95%CI 5.21-44.33), 0.08 (95%CI 0.04-0.14), 308.83 (95%CI 106.46-872.82), and 0.983, respectively. The heterogeneity among 6 included studies was moderate for specificity (I2 = 0.51) and low for sensitivity (I2 = 0.17) and diagnostic OR (I2 = 0.00). CONCLUSION D-SOC is associated with high sensitivity and specificity in the visual interpretation of indeterminate biliary strictures and malignancies. D-SOC should be considered routinely in the diagnostic workup of indeterminate biliary lesions.
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Bang JY, Navaneethan U, Hasan M, Sutton B, Hawes R, Varadarajulu S. Optimizing Outcomes of Single-Operator Cholangioscopy-Guided Biopsies Based on a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:441-448.e1. [PMID: 31351135 DOI: 10.1016/j.cgh.2019.07.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/18/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although single-operator cholangioscopy is considered to be the most sensitive method for tissue acquisition in patients with indeterminate bile duct strictures (IBDS), methods are needed to optimize the specimen collection and processing techniques. We aimed to determine the optimal method for specimen processing and identify the number of biopsies required to establish a definitive diagnosis. METHODS Patients with IBDS were randomly assigned to groups that underwent specimen processing using the onsite (n = 32) or offsite (n = 30) method. The primary outcome was to compare operating characteristics of onsite vs offsite specimen processing techniques. The secondary outcome was number of biopsies needed to establish definitive diagnosis. A final diagnosis was established at surgery or after a minimum clinical follow-up period of 18 months RESULTS: The final diagnosis was benign disease in 33 patients and malignancy in 29 patients. There were no significant differences between the offsite and onsite groups in diagnostic accuracy (90% vs 87.5%; P=.99), sensitivity (76.9% vs 75%; P=.99), specificity (100% vs 100%; P=.99), positive predictive value (100% vs 100%; P=.99), or negative predictive value (85% vs 80%; P=.99). Although diagnoses were established by analysis of a median of 1 biopsy in the onsite cohort (interquartile range, 1-1.5), the diagnostic accuracy was identical (90%) in each group, regardless of whether 3 or 4 biopsies were collected from each patient in the offsite cohort. CONCLUSIONS In a prospective comparative study, we found that centers without onsite cytopathology support that analyze 3 single-operator cholangioscopy-guided biopsies of a biliary stricture and process the specimens offsite make the correct diagnosis for 90% of cases. ClinicalTrials.gov, Number: NCT01815619.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | | | - Muhammad Hasan
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida.
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Ishida Y, Itoi T, Okabe Y. Current Status and Future Perspective in Cholangiopancreatoscopy. ACTA ACUST UNITED AC 2019; 17:327-341. [DOI: 10.1007/s11938-019-00238-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Parsa N, Khashab MA. The Role of Peroral Cholangioscopy in Evaluating Indeterminate Biliary Strictures. Clin Endosc 2019; 52:556-564. [PMID: 31309767 PMCID: PMC6900308 DOI: 10.5946/ce.2019.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/20/2019] [Indexed: 12/11/2022] Open
Abstract
Biliary strictures are considered indeterminate when the initial radiologic evaluation and endoscopic retrograde cholangiopancreatography with brush cytology and/or forceps biopsy do not reveal diagnostic findings. Evaluation of these strictures is challenging and often requires a multidisciplinary approach and multiple procedures. Peroral cholangioscopy allows direct visualization of these lesions and targeted tissue acquisition using miniature biopsy forceps. In the past decade, there have been significant improvements in the field of cholangioscopy. These advances have allowed higher-quality image acquisition, easy setup, operation by a single operator, easy maneuverability, and excellent targeted tissue sampling performance. However, the interpretation of cholangioscopic visual findings remains challenging. In this review, we discuss the role of peroral cholangioscopy in the evaluation of indeterminate biliary strictures.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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Prat F, Leblanc S, Foissac F, Ponchon T, Laugier R, Bichard P, Maire F, Coumaros D, Charachon A, Vedrenne B, Boytchev I, Chaussade S, Kaddour N, Laquière A, Gaujoux S. Impact of peroral cholangioscopy on the management of indeterminate biliary conditions: a multicentre prospective trial. Frontline Gastroenterol 2019; 10:236-243. [PMID: 31281624 PMCID: PMC6583565 DOI: 10.1136/flgastro-2018-100985] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/10/2018] [Accepted: 10/18/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy (SOC) can help diagnose biliopancreatic conditions. The impact of SOC on patient outcome has never been specifically addressed. PATIENTS AND METHODS Consecutive patients bearing indeterminate biliary strictures (IDBS), or primary sclerosing cholangitis (PSC) with suspected cholangiocarcinoma, were included. Patients with IDBS had at least one previous inconclusive endoscopic retrograde cholangio pancreatography (ERCP) + cytology. Primary endpoint was the difference in adequacy of management planned before and after SOC with regard to final diagnosis obtained after surgery or 24 months follow-up. DESIGN Prospective open-label multicentre trial. RESULTS 61 patients were included (IDBS: 48; PSC: 13); 70.5% had a benign lesion (IDBS 66.7%, PSC 84.6%). The management adequacy rate was significantly higher after SOC than before SOC overall (p<10-5), in IDBS (p<0.001) and PSC (p<0.05) patients. SOC induced changes in the management of the majority of patients in all groups (60.3%). The overall sensitivity of combined visual impression and biopsy ranged from 52% to 63.6% depending on investigator or independent expert rating (κ 0.92-0.96), whereas specificity, positive and negative predictive values of SOC were, respectively, 100%, 100% and 83.6%. Patient management observed at the end of follow-up was consistent with that anticipated after SOC in 88.5% overall. CONCLUSION Despite a moderate sensitivity for the diagnosis of malignancy, SOC has a dramatic impact on the management of patients with IDBS and PSC with suspected carcinoma. Cholangioscopy might be implemented in the workup of selected patients with challenging diagnosis, when a significant impact on outcome (essentially resection vs conservative management) is to be expected.
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Affiliation(s)
- Frederic Prat
- Department of Gastroenterology, Assistance Publique Hopitaux de Paris, Paris-Descartes University, Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology, Assistance Publique Hopitaux de Paris, Paris-Descartes University, Paris, France
| | | | | | - René Laugier
- Gastroenterology, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Philippe Bichard
- Digestive Endoscopy Unit, Centre Hospitalier Universitaire de Grenoble, Grenoble, France,Service de Gastro-entérologie et Hépatologie, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | | | | | | | - Bruno Vedrenne
- Groupe Hospitalier de la Region de Mulhouse et Sud Alsace, Mulhouse, France
| | | | | | | | - Arthur Laquière
- Gastroenterology and Endoscopy Unit, Hopital st joseph, Marseille, France
| | - Sèbastien Gaujoux
- Department of Surgery, Assistance Publique - Hopitaux de Paris, Paris, France
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Indications for Single-Operator Cholangioscopy and Pancreatoscopy: an Expert Review. ACTA ACUST UNITED AC 2019; 17:408-419. [DOI: 10.1007/s11938-019-00237-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Karagyozov P, Boeva I, Tishkov I. Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders. World J Gastrointest Endosc 2019; 11:31-40. [PMID: 30705730 PMCID: PMC6354115 DOI: 10.4253/wjge.v11.i1.31] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/11/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023] Open
Abstract
Due to the need for improvement in the diagnosis and minimally invasive therapy of the bile duct disorders new technologies for cholangioscopy have been recently developed. Per-oral cholangioscopy has become an important diagnostic and therapeutic tool leading to avoidance of aggressive and unnecessary surgery in many clinical scenarios. This paper focuses on the newly developed SpyGlass DS technology, its advantages, and the technique of single-operator cholangioscopy (SOC), biliary indications and possible adverse events. We also review the available literature; discuss the limitations and future expectations. Digital SOC (D-SOC) is a useful technique, which provides endoscopic imaging of the biliary tree, optical diagnosis, biopsy under direct vision and therapeutic interventions. The implementations are diagnostic and therapeutic. Diagnostic indications are indeterminate biliary strictures, unclear filling defects, staging of cholangiocarcinoma, staging of ampullary tumors (extension into the common bile duct), unclear bile duct dilation, exploring cystic lesions of the biliary tree, unexplained hemobilia, posttransplant biliary complications. Therapeutic indications are lithotripsy of difficult stones, retrieval of migrated stents, foreign body removal, guide wire placement, transpapillary gallbladder drainage and endoscopic tumor ablative therapy. Most studied and established indications are the diagnosis of indeterminate biliary stricture and intraductal lithotripsy of difficult stones. The adverse events are not different and more common compared to those of Endoscopic retrograde cholangiopancreatography (ERCP) alone. D-SOC is a safe and effective procedure, adjunct to the standard ERCP and the newly available digital technology overcomes many of the limitations of the previous generations of cholangioscopes.
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Affiliation(s)
- Petko Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
| | - Irina Boeva
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
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Ofosu A, Ramai D, Sunkara T, Adler DG. The emerging role of non-radiation endoscopic management of biliary tract disorders. Ann Gastroenterol 2018; 31:561-565. [PMID: 30174392 PMCID: PMC6102463 DOI: 10.20524/aog.2018.0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic technique into a therapeutic-centered modality for managing biliary disorders. Despite its many therapeutic benefits, radiation exposure from ERCP fluoroscopy is of concern and should be minimized as much as possible. Although the use of personal equipment offers significant protection against radiation, attention has been given to the development of non-radiation-based ERCP techniques. To this end, digital cholangioscopy and endoscopic ultrasound-assisted ERCP have emerged as alternatives to standard ERCP. Both techniques have sufficient feasibility and potential diagnostic accuracy to eliminate the need for fluoroscopy. Here we discuss the advances in non-radiation ERCP techniques and their role in the management of biliary stones.
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Affiliation(s)
- Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Daryl Ramai, Tagore Sunkara), USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Daryl Ramai, Tagore Sunkara), USA
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu, Daryl Ramai, Tagore Sunkara), USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Douglas G. Adler), USA
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Digital single-operator cholangioscopy: a useful tool for selective guidewire placements across complex biliary strictures. Surg Endosc 2018; 33:731-737. [PMID: 30006839 DOI: 10.1007/s00464-018-6334-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 07/06/2018] [Indexed: 12/16/2022]
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