Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.     

Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Acute Coronary Syndrome

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is considered a high-risk procedure in patients with previous acute coronary syndrome (ACS); however, clinical studies are rare in the literature. The aim of this study was to investigate the safety and efficacy of ERCP in patients with previous ACS.

Methods

We retrospectively reviewed the medical records of patients with previous ACS who underwent ERCP between January 2007 and August 2012. The clinical characteristics, ERCP diagnoses, treatment results, and complications were analyzed.

Results

Fifty patients underwent ERCP an average of 41.6 months after ACS. The most common indication for ERCP was calculous cholangitis. After deep biliary cannulation, endoscopic sphincterotomy, biliary stone removal and endoscopic biliary drainage were successfully performed. Immediate postsphincterotomy bleeding occurred in seven patients, which was successfully controlled using endoscopic therapy. Elevation of cardiac troponin I levels were observed in three patients (6%) before ERCP, and all of these patients were diagnosed with pancreatobiliary disease combined with recurrent ACS, which was treated with coronary artery stent insertion (n=2) and balloon angioplasty (n=1).

Conclusions

Therapeutic ERCP is effective and safe in patients with previous ACS. Cardiac troponin I elevation should be considered a warning sign for recurrent ACS in patients who undergo ERCP.     

Findings and Risk Factors of Early Mortality of Endoscopic Retrograde Cholangiopancreatography in Different Cohorts of Elderly Patients

OBJECTIVES: To analyze experience of endoscopic retrograde cholangiopancreatography (ERCP) in patients with of different age cohorts and discuss the risk factors of early mortality after ERCP.
DESIGN: Retrospective study.
SETTING: Tertiary care medical center.
PARTICIPANTS: Two hundred sixty-four patients with pancreatobiliary diseases divided into cohorts according to decades as young-old (YO, 65–74, n=143), old-old (OO, 75–84, n=88), and very-old (VO, ≥85, n=33).
MEASUREMENTS: The indications, results, and complications of ERCP in these three groups were demonstrated and compared.
RESULTS: Three hundred three ERCP procedures were performed. The leading indication for ERCP was common bile duct (CBD) obstruction or dilation. Diabetes mellitus was significantly more prevalent in the YO group (39.2%) than in the other two groups (OO, 15.9%; VO, 24.2%; P =.001). The most common finding of ERCP was CBD dilatation. There was no difference in incidence of malignant diseases between the three groups. Acute pancreatitis was the most frequently identified post-ERCP complication. There was no significant difference in early mortality between the three cohorts. Patients with malignancy had higher early mortality than those with benign disease (71.4% vs 11.2%; P =.001).
CONCLUSION: The findings and incidences of complication of ERCP in different elderly cohorts were similar. Underlying malignancy seemed to bear some relation to early mortality after the ERCP procedure.     

Endoscopic Retrograde Cholangiopancreatography with Single-Balloon Enteroscopy Is Feasible in Patients with a Prior Roux-en-Y Anastomosis

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65–91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.     

ERCP联合胆汁肿瘤标志物测定对可疑胰胆管疾病的诊断价值研究

目的探讨胆汁肿瘤标志物测定在ERCP对可疑胰胆管疾病诊断中的辅助作用。方法对经B超、MRCP、生化、血清肿瘤标志物等常规检查未能明确诊断的可疑胰胆管疾病患者,进行ERCP检查或对症治疗,同时行胆汁肿瘤标志物测定,选取29例明确诊断的病例分为良性和恶性组,比较2组在生化、肿瘤标志物上的差别,同时评估和比较B超、EUS、MRCP、ERCP、ERCP＋胆汁肿瘤标志物对可疑胰胆管疾病的诊断价值。结果生化、血清癌胚抗原（CEA）、血清CA19-9、胆汁CA19—9,在2组间差异无统计学意义,而胆汁CEA在恶性组中平均值高于良性组,且差异有统计学意义（P〈0．001）,ERCP联合胆汁CEA测定对可疑胰胆管疾病诊断准确率为69．0％（20／29）,高于单纯的B超6．9％（2／29）、EUS60．0％（6／10）、MRCP37．9％（11／D）和ERCP41．4％（12／29）。结论ERCP联合胆汁的CEA测定能进一步提高可疑胰胆管疾病诊断的准确性,对良恶性疾病的鉴别诊断有着辅助作用。     

Efficacy and Safety of Percutaneous Transhepatic Cholangioscopy with the Spyglass DS Direct Visualization System in Patients with Surgically Altered Anatomy: A Pilot Study

Background/AimsPercutaneous transhepatic cholangioscopy (PTCS) is used for the diagnosis and treatment of biliary diseases in patients with failed endoscopic retrograde cholangiopancreatography, particularly those with surgically altered anatomy. However, few studies are available on the clinical use of Spyglass DS direct visualization system (SpyDS)-assisted PTCS. This study aimed to assess the efficacy and safety of SpyDS-assisted PTCS in patients with surgically altered anatomy, particularly those with a Roux-en-Y reconstruction.MethodsThirteen patients (six women, median age 71.4 years [range, 53 to 83 years]) with surgically altered anatomy (four Roux-en-Y choledochojejunostomies, seven Roux-en-Y hepaticojejunostomies, and two Roux-en-Y esophagojejunostomies) who underwent SpyDS-assisted PTCS between January 2019 and August 2020 were included and the data was acquired by retrospectively reviewing electronic medical record.ResultsA total of 19 SpyDS-assisted PTCS procedures were performed in the 13 patients eight had bile-duct stones, and five had biliary strictures. All SpyDS-assisted PTCS procedures were successfully performed. The total procedure time was 42.42±18.0 minutes (mean±standard deviation). Bile duct clearance was achieved in all bile duct stone cases after a median of 2 (range, 1 to 3) procedures. In the five biliary stricture cases, the results of SpyBite forceps-guided targeted biopsy were consistent with adenocarcinoma (100% accuracy). The median hospitalization duration was 20 days (range, 14 to 30 days). No procedure-related morbidity or mortality occurred.ConclusionsSpyDS-assisted PTCS may be a safe, feasible, and effective procedure for the diagnosis and treatment of biliary diseases in patients with surgically altered anatomy, particularly in those with the Roux-en-Y reconstruction requiring a percutaneous approach. However, our findings need to be validated in further studies.     

Comparison of Mometasone Furoate Dry Powder Inhaler and Fluticasone Propionate Dry Powder Inhaler in Patients with Moderate to Severe Persistent Asthma Requiring High-Dose Inhaled Corticosteroid Therapy: Findings from a Noninferiority Trial

Background. Inhaled corticosteroids (ICSs) are one of the suggested first-line therapies for patients with persistent asthma of moderate severity. Methods: The efficacy and safety of mometasone furoate (MF) 400 μg twice daily (BID) and fluticasone propionate (FP) 500 μ g BID administered for 12 weeks via dry powder inhaler (DPI) were compared in a noninferiority trial, in adults with moderate-to-severe persistent asthma. The primary variable was the change from baseline in am peak expiratory flow rate (PEFR). pm PEFR, forced expiratory volume in 1 second (FEV₁), asthma symptoms, rescue medication use, response to therapy, exacerbation rates, and adverse events were also assessed. Results. The lower bound of 95% CIs for treatment differences in the primary variable ranged from 2.6% to 5.6% throughout the 12-week study and were within the prespecified noninferiority range. No significant between-group differences were observed in lung function, rescue medication use, response to therapy, exacerbation rates, or adverse events. At most of the weeks assessed, there were no between-group differences in asthma symptoms. Most adverse events were mild-to-moderate. Conclusion. MF-DPI 400 μ g BID was therapeutically equivalent to FP-DPI 500 μ g BID in patients with moderate-to-severe persistent asthma.