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.     

Impact of Scope Exchange from a Long Single Balloon Enteroscope to a Gastroscope during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy

Background/AimsEndoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is challenging to gastrointestinal endoscopists. The aim of this study was to evaluate the impact of scope exchange from a long single balloon enteroscope (SBE) to a gastroscope during SBE-assisted ERCP (SBE-ERCP) in patients with SAA.MethodsPatients who underwent SBE-ERCP between February 2019 and October 2020 were retrospectively identified. Intubation success, scope exchange success, cannulation success, and therapeutic success were analyzed along with complications.ResultsFifty-six patients with various SAAs underwent SBE-ERCP procedures, including Billroth II subtotal gastrectomy (B-II, n=13), pylorus-preserving pancreato-duodenectomy (PPPD, n=6), Roux-en-Y hepaticojejunostomy (REY HJ, n=4), and total gastrectomy with REY anastomosis (TG REY, n=33). Overall intubation, cannulation, and therapeutic success rates were 89.3%, 82.1%, and 82.1%, respectively. Therapeutic success rates did not differ significantly among the type of SAA. Successful scope exchange rate after successful intubation was significantly higher in native papilla (B-II and TG REY, 83.3%, 35/42) compared to bilioenteric anastomosis (PPPD and REY HJ, 0%, 0/8, p<0.001). Intubation success, scope exchange, and cannulation success were associated with therapeutic success (p<0.001). In multivariate analysis, successful scope exchange was the only factor related to cannulation success (p=0.02). The major complication rate was 1.8% (one perforation).ConclusionsSBE-ERCP is a safe and effective procedure to treat biliary problems in patients with SAA. Successful scope exchange may lead to higher therapeutic success by way of cannulation success.     

Triple-Tissue Sampling during Endoscopic Retrograde Cholangiopancreatography Increases the Overall Diagnostic Sensitivity for Cholangiocarcinoma

Background/Aims

There are several methods for obtaining tissue samples to diagnose malignant biliary strictures during endoscopic retrograde cholangiopancreatography (ERCP). However, each method has only limited sensitivity. This study aimed to evaluate the diagnostic accuracy of a combined triple-tissue sampling (TTS) method (on-site bile aspiration cytology, brush cytology, and forceps biopsy).

Methods

We retrospectively reviewed 168 patients with suspicious malignant biliary strictures who underwent double-tissue sampling (DTS; n=121) or TTS (n=47) via ERCP at our institution from 2004 to 2011.

Results

Among the 168 patients reviewed, 117 patients (69.6%) were eventually diagnosed with malignancies. The diagnostic sensitivity for cancer was significantly higher in the TTS group than the DTS group (85.0% vs 64.9%, respectively; p=0.022). Furthermore, the combination of brush cytology and forceps biopsy was superior to the other method combinations in the DTS group. With respect to cancer type (cholangiocarcinoma vs noncholangiocarcinoma), interestingly, the diagnostic sensitivity was higher for cholangiocarcinoma in the TTS group than the DTS group (100% vs 69.4%, respectively; p<0.001) but not for the non-cholangiocarcinoma patients (57.1% vs 57.1%, respectively).

Conclusions

TTS can provide an improved diagnostic accuracy in suspicious malignant biliary strictures, particularly for cholangiocarcinoma.     

Endoscopic Retrograde Cholangiopancreatography in Laparoscopic Cholecystectomy

Abstract: With the widespread use of laparoscopic cholecystectomy (LC), the role of pre- and postoperative endoscopic retrograde cholangiopancreatography (ERCP) and / or endoscopic sphincterotomy (ES) has become very important. Indications for ERCP with possible ES before LC include clinical suspicion of a common bile duct (CBD) stone alone, evidence of jaundice, recent cholangitis or pancreatitis that is probably due to a duct stone or dilated CBD. Local endoscopic and surgical expertise are important factors in deciding the approach to the pre-LC patients. The success rate of ductal clearance of stones by ES approaches 90 to 95% in expert hands. ERCP is very effective in the management of post-LC patients with symptoms, as well as in diagnosing and treating complications such as retained stones, ductal leaks and strictures.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.     

Analysis of Comparative Studies Using Different Contrast Agents for Endoscopic Retrograde Cholangiopancreatography

Abstract: Pancreatitis induced by ERCP ha been associated with numerous pathogenic factors such as a previous history of pancreatitis, acinarization, mechanical and thermal injury, medications, and lastly the type of contrast agent used. Conventional contrast agents are characterized by both ionicity and high osmolality. These traditional agents have demonstrated deleterious effects upon multiple organ systems. Newer contrast agents have been developed with properties of low osmolality and non-ionicity in efforts to their decrease potential toxic effects, This review analyzes the current literature regarding the role of different contrast agents in the incidence of ERCP related pancreatitis. Nine randomized, double-blind, prospective studies have been published comparing low and high osmolality contrast agents for ERCP. Although five studies have shown lower degrees of amylase/lipase elevation after ERCP for the low osmolality agents, only three studies demonstrated a statistically significant advantage for the reduction of clinical pancreatitis among the low osmolality agent groups. In addition, these studies also varied in terms of specific contrast agents used, inclusion and exclusion criteria, rates of acinarization, and definition of clinical pancreatitis. However, after combining all of the data from these studies, there was a statistically significant advantage in reducing ERCP induced pancreatitis for non-ionic, low osmolality agents (1.44%) compared with the ionic, high osmolality agents (7.39%) [p = 0.007] and the ionic, low osmolality agents (9.67%) [p = 0.0001]. There was no statistical difference between the ionic, high osmolality agents and the ionic, low osmolaltiy agents [p = 0.5481. This data seem to suggest that ionicity rather than osmolality may play a more significant role in the incidence of ERCP induced pancreatitis. The major disadvantage of the use of low osmolality, non-ionic agents is their relatively high cost. Overall, controversy remains about whether these newer agents should be utilized in all patients or be selectively used in only high risk patients. Presently, we utilize these agents routinely.     

Primary Leiomyosarcoma of the Liver: Diagnostic Efficacy of Endoscopic Retrograde Cholangiopancreatography

Abstract: A small primary leiomyosarcoma of the liver detected in a 58-year-old man is presented in this paper. In addition to the findings obtained by gray scale ultrasonogruphy and computed tomography, the possible diagnosis of this very rare tumor was suggested by endoscopic retrograde cholangiopancreatography (ERCP). The characteristic findings of leiomyosarcoma of the liver obtained by ERCP were skipping strictures at the intrahepatic bile ducts. The ERCP findings and diagnosis were verified bv pathological studies of the resected material. This appears to be the first report discussing the usefulness of ERCP in vnaking a diagnosis of primary leiomyosarcoma of the liver.     

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.     

静脉麻醉在内镜逆行胰胆管造影中的应用

背景：内镜逆行胰胆管造影（ERCP）是一种微创技术，但相当一部分患者仍对其操作过程难以耐受。目的：探讨静脉麻醉在ERCP中的镇静作用及其临床实用性。方法：57例接受ERCP诊治的患者分为两组：麻醉组25例，在咪达唑仑、异丙酚和芬太尼静脉麻醉下行ERCP；非麻醉组32例，ERCP术前予安定镇静。比较两组患者检查前后和操作过程中生命体征的变化，分别以操作过程评分和Ramsay镇静评分评价操作的难易程度和患者的镇静程度。结果：麻醉组与非麻醉组的ERCP成功率无显著差异。麻醉组的操作过程评分和Ramsay镇静评分均显著优于非麻醉组（P〈0．01）。两组术中心率和血压较术前有显著变化（P〈0．05）．但手术前后脉搏血氧饱和度（SpO2）的变化无统计学意义结论：静脉麻醉在ERCP操作中镇静效果显著．患者耐受性好，在治疗性ERCP中尤其有利于医师操作。     

Endoscopic papillary large balloon dilation in Billroth II gastrectomy patients with bile duct stones

Background and Aims: Patients with Billroth II (B‐II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B‐II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B‐II gastrectomy. Methods: Twenty‐six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B‐II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10–15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated. Results: In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1–3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation. Conclusions: Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B‐II gastrectomy.     

经内镜逆行胰胆管造影916例临床分析

目的探讨经内镜逆行胰胆管造影(ERCP)在诊断及治疗胰胆道疾病中的应用价值及安全性,寻找提高ERCP操作成功率以及防止或减少并发症发生率的有效措施。方法2003年1月~2005年7月,我院接受ERCP诊断及治疗的患者916例,记录并分析其操作过程及术后并发症的发生。结果在916例患者中,总操作成功率为94.7%,共有128例患者接受十二指肠乳头肌预切开术。术后严重并发症发生率为5.4%(50例),其中包括胰腺炎33例,胆管炎10例,消化道出血4例和消化道穿孔3例。另外,有297例患者出现术后高淀粉酶血症(占32.4%)。结论对于胰胆道疾病患者,诊断性和治疗性ERCP是安全有效的诊治措施,其术后并发症主要有胰腺炎、胆管炎、消化道出血、消化道穿孔和高淀粉酶血症。十二指肠乳头肌预切开术有助于提高ERCP选择性插管的成功率。     

Endoscopic Papillary Large Balloon Dilation for the Retrieval of Bile Duct Stones After Prior Billroth II Gastrectomy

Background/Aims:

Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.

Materials and Methods:

From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.

Results:

Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.

Conclusions:

EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.     

Large Balloon Anchor Technique for Endoscopic Retrograde Cholangiopancreatography Required for Esophagogastroduodenal Deformities

Objective It is difficult to insert a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatography in patients with esophagogastroduodenal deformities. To evaluate the efficacy and safety of using a large balloon anchor technique for cases in which inserting side-viewing duodenoscopes is difficult. Methods We retrospectively examined patients with endoscopic retrograde cholangiopancreatography who required the large balloon anchor technique between April 2016 and October 2020. Patients with deformed superior duodenal angles, esophagogastric junctions and pyloric rings and those having a shortened lesser curve were included. Results The balloon as an anchor was safely used to insert the duodenoscopes in 17 patients, and this procedure was performed 21 times. The procedure was successful 20 out of 21 times (95.2%), including 12 cases with duodenal deformities, 5 with shortening of the lesser curve, 2 after duodenal stent placement and 1 with a deformity of the esophagogastric junction. In the remaining patient, the first ERCP was successful, but the second was unsuccessful with duodenal deformities. There were no complications throughout the course of the study. Conclusion The large balloon anchor technique is a safe and useful technique for patients when inserting side-viewing duodenoscopes is difficult for various reasons.     

Risk Factors of Post Endoscopic Retrograde Cholangiopancreatography Bacteremia

Background/Aims

Bacteremia following endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication, but the risk factors for this condition have not yet been clearly determined. Thus, the aim of this study was to investigate the risk factors of post-ERCP bacteremia.

Methods

Among patients who underwent ERCP from June 2006 to May 2009, we selected patients without any signs of infection prior to the ERCP procedures. Of these patients, we further selected those who experienced bacteremia after ERCP as well as two-fold age and sex-matched controls who did not experience bacteremia after ERCP procedures. We compared clinical, laboratory and technical aspects between these two groups.

Results

There were 70 patients (3.1%) who developed bacteremia after ERCP. In the multivariate analysis, a history of previous liver transplantation, an elevated serum alkaline phosphatase level and an endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia (p=0.006, p=0.001, and p=0.004, respectively). The microbiologic analysis revealed the presence of gram-negative organisms in 80% of the cases, and 11 patients had infections with bacteria expressing extended spectrum β-lactamases. Pseudomonas infection was significantly more common in patients who received liver transplantation as compared to patients without transplantation (p=0.014).

Conclusions

A history of liver transplantation, elevated serum alkaline phosphatase levels and endoscopic retrograde biliary drainage procedure were independent risk factors of post-ERCP bacteremia and require additional attention in future studies.     

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.     

磁共振胰胆管造影术与经内镜逆行胰胆管造影术诊断阻塞性黄疸的价？…

目的：比较磁共振胰胆管造影术（ＭＲＣＰ）与经内镜逆行胰胆管造影术（ＥＲＣＰ）对阻塞性黄疸的诊断价值。方法：５５列阻塞性黄疸患者分别行ＭＲＣＰ和ＥＲＣＰ,其中１例行ＥＲＣＰ失败改行经皮肝胆管造影术（ＰＴＣ）。ＭＲＣＰ采用重Ｔ２加权及超快速自旋回波水成像技术进行,ＥＲＣＰ和ＰＴＣ按常规方法进行。结果：ＭＲＣＰ与ＥＲＣＰ（或ＰＴＣ）总的诊断准确率分别为９０．９％（５０／５５）和９８．２％（５４／５５）,     

Billroth Ⅱ式胃切除术后患者ERCP诊治

目的 总结BillrothⅡ式胃切除术后患者进行ERCP诊治的经验,对其手术操作的成功率、安全性和有效性进行评估.方法 回顾性分析2007年1月至2009年11月间,75例BillrothⅡ式术后因胆道疾患接受ERCP诊治患者的临床资料.结果 75例患者中,顺利进入空肠输入襻69例（92%）,其中选择性胆道插管成功68例,3例行诊断性胆道造影检查,65例为治疗性操作.后者中16例行EST＋取石＋鼻胆管引流术,19例行塑料支架胆管引流术,18例金属支架胆管引流术,12例内镜下球囊扩张术＋取石＋鼻胆管引流术.1例患者因空肠输入襻穿孔（1.3%）急诊行手术治疗,2例（2.6%）并发术后急性胰腺炎,经保守治疗痊愈,无出血相关并发症.结论 对于BillrothⅡ式术后患有胆道疾病的患者,进行ERCP诊治是安全、可行的.     

Difficult Biliary Cannulation from the Perspective of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Identifying the Optimal Timing for the Rescue Cannulation Technique

Background/AimsRecently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP).MethodsAn ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis.ResultsWe analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ²=49.857, p<0.001) and inadvertent PD manipulation (χ²=8.556, p=0.010) were decisive factors. PEP occurred in 3.9%, 11.8%, and 16.2% of patients with biliary cannulation duration lasting 3 to 5 minutes, >5 minutes, and >5 minutes with inadvertent PD manipulation, respectively.ConclusionsBiliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique. (Gut Liver 2021;15-465)