Safety of same-day endoscopic ultrasound and endoscopic retrograde cholangiopancreatography under conscious sedation

AIM: To assess the tolerability and safety of same-day tandem procedures, endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation. METHODS: A retrospective review was conducted at Loma Linda University Medical Center, a tertiary-care center. All 54 patients who underwent EUS followed by ERCP (group A) from 2004 to 2006 were included in the study. A second group of 56 patients who underwent EUS only (group B), and a third group of 53 patients who...     

Role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in isolated pancreatic metastasis from lung cancer

A case is reported of a 50-year-old woman with a history of small-cell lung cancer admitted with pancreatic head lesions, discovered during investigation for obstructive jaundice. Endoscopic ultrasound assisted fine needle aspiration of the pancreatic mass was consistent with small cell carcinoma, presenting as an isolated metastasis from the previously diagnosed lung cancer. Endoscopic retrograde cholangiopancrea- tography (ERCP) showed extrinsic compression and a bile duct stricture, requiring sphincterotomy and stent insertion. This case highlights that acute pancreatitis and biliary obstruction can occur as a manifestation of small cell lung cancer metastasizing to the pancreas. EUS is a safe, low risk and rapid diagnostic tool in such cases, and ERCP with stenting offers a safe and effective treatment option.     

High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

AIM To examine whether high-flow nasal oxygen(HFNO) availability influences the use of general anesthesia(GA) in patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasound(EUS) and associated outcomes.METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras(era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era(era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3(P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3(P 0.001) but not between eras 1 and 2(P = 0.028) or 1 and 3(P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation(P ≤ 0.007) as was the anesthesia-only time(P ≤ 0.001).CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.     

Propofol vs traditional sedative agents for endoscopic retrograde cholangiopancreatography: a meta-analysis

AIM:To investigate the efficacy and safety of propofol sedation for endoscopic retrograde cholangiopancreatography(ERCP).METHODS:Databases including PubMed,Embase,and the Cochrane Central Register of Controlled Trials updated as of October 2010 were searched.Main outcome measures were ERCP procedure duration,recovery time,incidence of hypotension and hypoxia.RESULTS:Six trials with a total of 663 patients were included.The pooled mean difference in ERCP procedure duration between the propofol and traditiona...     

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy must be performed by a highly experienced endoscopist.The challenges are accessing the afferent limb in different types of reconstruction,cannulating a papilla with a reverse orientation,and performing therapeutic interventions with uncommon endoscopic accessories.The development of endoscopic techniques has led to higher success rates in this group of patients.Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction;however,these success rate is lower in long-limb reconstruction.ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length;however,it must be performed by a highly experienced and skilled endoscopist.Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography,but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy.Laparoscopic-assisted ERCP has an almost 100%success rate in longlimb reconstruction because of the use of a conventional side-view duodenoscope,which is compatible with standard accessories.This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy.This review focuses on the advantages,disadvantages,and outcomes of various procedures that are suitable in different situations and reconstruction types.Emerging new techniques and their outcomes are also discussed.     

治疗性ERCP在85岁以上高龄患者中的应用价值评价

目的 评价治疗性ERCP在85岁以上高龄老年人的安全性和有效性.方法 回顾性分析2004年至2009年间85岁以上ERCP患者（A组,52例）的临床资料,并与同期70～84岁ERCP患者（B组,329例）做比较.结果 A组患者伴发症（52/52）明显高于B组（255/329）,P〈0.05;对于胆总管结石者,需要多次取清结石者A组（19/52）明显多于B组（65/329）,P〈0.05;并发症发生率分别为（4/52）和（16/329）,P〉0.05;术后死亡率分别为（1/52）和（2/329）,P〉0.05.结论 治疗性ERCP对于85岁以上高龄老年人是安全有效的,但需严格掌握手术适应证.     

ERCP结合EPT对胆囊切除术后患者诊治价值的探讨

目的 回顾性研究逆行性胰胆管造影（ERCP）结合乳头肌切开术（EPT）对胆囊切除术后患者的诊治价值。方法 170例胆囊切除术后症状再发或反复发作患者,接受ERCP检查和EPT等治疗,诊断结果与B超作对照。同时动态观察内镜下介入诊治术后临床表现的改变。不良反应及血清淀粉酶的变化及高淀粉酶血症的分布情况。结果 经ERCP结合EPT等术后患者临床症状显著改善;与B超对照ERCP对胆囊切除术后胆总管残余结石的诊断率显著提高（P＜0．001）,对胆总管扩张程度的诊断价值显著优于B超（P＜0．05）,并能发现许多B超检查不能发现的胆胰病变;术后主要不良反应表现为出血、高淀粉酶血症,ERCP结合EPT等治疗组高淀粉酶的发生率显著高于单纯ERCP操作组（P＜0．01）。经积极地处理后短期内出血控制,血清淀粉酶多在3日内转为正常。结论 对胆囊切除术后患者,ECRP结合EPT不失为一项非常有价值、安全的诊治措施。     

内镜逆行胰胆管造影对Mirizzi综合征的诊断价值

目的 探讨内镜逆行胰胆管造影（ＥＲＣＰ）对Ｍｉｒｉｚｚｉ综合征的诊断价值,提高对该病的术前诊断率。方法 对３０例Ｍｉｒｉｚｚｉ综合征的临床特征,实验室检查、十二指肠镜下特点及ＥＲＣＰ的Ｘ线表现进行分析,并与Ｂ超、ＣＴ检查棹比较。结果 Ｍｉｒｉｚｚｉ综合征病史较长,ＥＲＣＰ的典型表现为肝总管可风级完整的充盈缺损,缺损以上的肝总管及肝内胆管轻至重度扩张。并胆囊萎缩及胆囊结石。ＥＲＣＰ确诊率为８６．６７     

Retrieval-balloon-assisted enterography in post-pancreaticoduodenectomy endoscopic retrograde cholangiopancreatography

This case reports an application of conventional duodenoscope in a post pancreaticoduodenectomy patient with the help of retrieval balloon assisted enterography. The 56-year-old woman had pancreaticoduodenectomy with Child reconstruction 9 mo ago because of pancreatic adenocarcinoma and now there are recurrent enlarged lymph nodes in the anastomotic stoma of hepaticojejunostomy. Considering the patient’s late-stage cancer, a plastic stent was then successfully placed there to drainage. The main challenge in this case was the extremely long afferent loop and blind cannulation through the anastomotic stoma of hepaticojejunostomy. Retrieval balloon assisted enterography is very helpful for duodenoscope going through the reconstructed intestinal tract and for the cannulation. After two weeks, the patient remained free of painful symptoms and free of fever. Liver function improved well. Four months after the placement of stent, the patient died of cachexia without jaundice, fever and abdominal pain according to her daughter’s statement.     

磁共振胰胆管造影术与内镜逆行胰胆管造影术的对照研究

目的 通过磁共振胰胆管造影术（ＭＲＣＰ）与内镜逆行胰胆管造影术（ＥＲＣＰ）的对照研究,评价ＭＲＣＰ对胰胆系疾病的诊断价值。方法 ４０例疑有胰胆系疾病的患者进行了ＭＲＣＰ及ＥＲＣＰ检查,两者结果作对照研究。结果 本组资料中ＭＲＣＰ对胰胆系疾病总的诊断价值为敏感度８９．１％、特异度１００％、准确度９０％,ＥＲＣＰ总的诊断价值为敏感度８４．２％、特异度１００％、准确度８５％,两者统计学上无显著性差异。结     

Efficacy and safety of a patient-positioning device(EZ-FIX)for endoscopic retrograde cholangiopancreatography

AIM: To assess the efficacy and safety of a patientpositioning device(EZ-FIX) for endoscopic retrograde cholangiopancreatography(ERCP).METHODS: A total of 105 patients were randomized to the EZ-FIX(n = 53) or non-EZ-FIX(n = 52) group in this prospective study. Midazolam and propofol,titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision.Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients.RESULTS: There was no significant difference in the rate of hypoxia, but there was a statistical trend(EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%,P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group(89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025).In addition, the EZ-FIX group had a shorter mean recovery time(11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX.FIX group than in the nonEZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively(P = 0.856).Procedure-related complications did not differ by group(11.32% vs 13.46%, respectively, P = 0.735).CONCLUSION: Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.     

Endoscopic retrograde cholangiopancreatography training in the United Kingdom: A critical review

Endoscopic retrograde cholangiopancreatography training used to be in virtually all district general hospitals, resulting in a large number of trainees with an inadequate case load and achieving poor levels of skill. Training is now restricted to a small number of trai nees working in approved units. Continuous audit of outcomes and the appointment of a training lead in the unit are essential. Use of the global rating scale helps clinicians advise hospital administration on the prior it ies for a quality training program.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Risk factors of recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography

Background: The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP) have not been well studied. The aim of this study was to explore the risk factors of recurrent choledocholithiasis. Methods: We carried out a retrospective analysis of data collected between January 1, 2010 and January 1, 2020. Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therape...     

Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.     

A phantom gallbladder on endoscopic retrograde cholangiopancreatography

Various complications have been related to laparoscopic cholecystectomy but most occur shortly after the procedure. In this report, we present a case with very late complications in which an abscess developed within the gallbladder fossa 6 years after laparoscopic cholecystectomy. The abscess resolved after treatment with CT-guided extrahepatic aspiration. However, 4 years later, an endoscopic retrograde cholangiopancreatography （ERCP） performed for choledocholithiasis demonstrated a “gallbladder” which communicated with the common bile duct via a patent cystic duct. This unique case indicates that a cystic duct stump may communicate with the gallbladder fossa many years following cholecystectomy.     

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy.METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations.RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.     

Advances in endoscopic retrograde cholangiopancreatography cannulation

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.     

磁共振胰胆管成像与内镜逆行胰胆管造影术对梗阻性黄疸的诊断价值

目的：评价磁共振胰胆管成像（MRCP）与经内镜胰胆管造影（ERCP）对梗阻性黄疸的诊断价值。方法：对32例梗阻性黄疸患者先后进行MRCP与ERCP检查，所有诊断均经手术或病理证实。结果：MRCP与ERCP对梗阻的定位准确率分别为90.6％（29/32）及82.8％（24/29），两者差异无统计学意义（P=0.5960），合并两者检查的准确率为96.9％（31/32），与单项MRCP(P=0.3010)、ERCP(P=0.0643)准确率差异无显著性意义。MRCP与ERCP对梗阻的定性诊断准确性分别为75.0％（24/32）及72.4（21/29），两者间差异无显著意义（P=0.9503），合并两者检查的准确率为93.8％（30/32），高于MRCP(P=0.0387)或ERCP(P=0.0245)单项检查。结论：MRCP与ERCP都是有效、安全的诊断梗阻性黄疸的方法，MRCP与ERCP相结合诊断准确率可进一步提高。