OUR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATICOGRAPHY EXPERIENCES: SINGLE CENTER, 688 PATIENTS

Introduction and Aim: Successful ERCP requires deep cannulation of the common bile duct and/or the main pancreatic duct through the major duodenal papilla (papilla of Vater). Complications have been reported in cases of selective biliary cannulation, but this diminishes in experienced hands. The aim of this topic is to evaluate the practices and results in our clinic on how to achieve successful cannulation and sphincterotomy at minimum risk for the patient. Methods: The results of 688 patients who underwent ERCP in the endoscopy unit of our clinic over a 6-year period (2015-2021) are evaluated. Demographic findings, co-morbidities, duration of the procedure, presence of periampullary diverticulum, difficult cannulation rate, stent use, complication rate and successful cannulation rates of the patients were evaluated. Results: 58.5% of the patients were female. Heart diseases were found in 44.6% of the patients, kidney diseases in 11.5%, lung diseases in 14.9%, central nervous system diseases in 7.8% and malignancy in 2.1%. The common bile duct diameter is 12.98 ± 3.44 mm, and the mean stone size is 8.70 ± 4.50 mm. Periampullary diverticulum was present in 110 (15.9%) of the patients, and stony gall bladder was present in 48.0% of the patients. Selective cannulation was performed in 77.9% and pre-cut sphincterotomy was performed in 18.2%. Periampullary malignancy was detected in 12.1% of patients, and stent was applied to 22.1% of patients. Failed in 3.1% of patients. Emergency laparotomy was performed in 4 patients (0.6%). Bleeding was found in 58 patients (8.5%), perforation in five patients (0.8%), pancreatitis in 25 patients (4.0%), and mortality in six patients (1.0%). Conclusions: Although endoscopic retrograde cholangiopancreatography is an effective diagnostic and therapeutic tool, it can lead to serious complications. ERCP indication should be put correctly, procedures should be done by experienced people. In experienced hands, the success rate is high even with anatomical variations and difficult stones.

Specifics of endoscopic retrograde cholangiopancreatographyin patients with altered anatomy of gastrointestinal tract (a literature review)

The aim of the work: analysis and integration of literature data regarding the technical and methodological implementation of endoscopic retrograde cholangiopancreatography in altered anatomy of the gastrointestinal tract after gastric resection. Results. World literature data convincingly indicate the need for a staged approach to performing endoscopic retrograde cho langiopancreatography in patients with altered anatomy of the gastrointestinal tract. Scientific works state that the main stages are detailed examination of a past surgical history in patients, careful selection of suitable endoscopic instruments, afferent limb intubation, papilla of Vater cannulation and papillary interventions. The article describes the existing endoscopic instruments, modern techniques and approaches, their advantages and disadvantages, and the influence of various factors on the success of their use in comparison with traditional techniques for various types of surgical reconstruction for each of the above stages. The length of the afferent limb is one of the main factors that affect the success rates of the procedure. Conclusions. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy is complex and faces a number of challenges. Thanks to the development of special instruments and techniques, it can be performed even in patients with a long Roux-en-Y limb, reaching therapeutic success rates close to those in patients with normal anatomy, but this requires extensive experience of an endoscopist. There are currently no clear recommendations for the use of a particular technique; therefore the choice of the optimal strategy depends on the type of surgical reconstruction, surgeon skill level and endoscopy center facilities.

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

An Interactive Automation for Human Biliary Tree Diagnosis Using Computer Vision

The biliary tree is a network of tubes that connects the liver to the gallbladder, an organ right beneath it. The bile duct is the major tube in the biliary tree. The dilatation of a bile duct is a key indicator for more major problems in the human body, such as stones and tumors, which are frequently caused by the pancreas or the papilla of vater. The detection of bile duct dilatation can be challenging for beginner or untrained medical personnel in many circumstances. Even professionals are unable to detect bile duct dilatation with the naked eye. This research presents a unique vision-based model for biliary tree initial diagnosis. To segment the biliary tree from the Magnetic Resonance Image, the framework used different image processing approaches (MRI). After the image’s region of interest was segmented, numerous calculations were performed on it to extract 10 features, including major and minor axes, bile duct area, biliary tree area, compactness, and some textural features (contrast, mean, variance and correlation). This study used a database of images from King Hussein Medical Center in Amman, Jordan, which included 200 MRI images, 100 normal cases, and 100 patients with dilated bile ducts. After the characteristics are extracted, various classifiers are used to determine the patients’ condition in terms of their health (normal or dilated). The findings demonstrate that the extracted features perform well with all classifiers in terms of accuracy and area under the curve. This study is unique in that it uses an automated approach to segment the biliary tree from MRI images, as well as scientifically correlating retrieved features with biliary tree status that has never been done before in the literature.

EUS-guided biliary interventions for benign diseases and unsuccessful ERCP – a prospective unicenter feasibility study on a large consecutive patient cohort

Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of biliary obstruction of any etiology. However, cannulation failure of the common bile duct (CBD) by ERCP occurs in 5–10%. Alternatives after a failed ERCP are re-ERCP by an expert endoscopist, percutaneous transhepatic cholangio drainage (PTCD), (balloon) enteroscopy-assisted ERCP, or surgery. Endoscopic ultrasonography-guided drainage of the bile ducts (EUS-BD) is becoming the standard of care in tertiary referral centers for cases of failed ERCP in patients with malignant obstruction of the CBD. In expert hands, EUS-guided biliary drainage has excellent technical/clinical success rates and lower complication rates compared to PTCD. Despite the successful performance of EUS-BD in malignant cases, its use in benign cases is limited. The aim of this study (design, systematic prospective clinical observational study on quality assurance in daily clinical practice) was to evaluate the efficacy and safety of EUS-BD in benign indications. Patients and methods Patients with cholestasis and failed ERCP were recruited from a prospective EUS-BD registry (2004–2020). One hundred and three patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal = 474). Indications of EUS-BDs included surgically altered anatomy (n = 65), atypical bile duct percutaneous transhepatic cholangio orifice at the duodenal junction from the longitudinal to the horizontal segment (n = 1), papilla of Vater not reached due to the gastric outlet/duodenal stenoses (n = 6), papilla that cannot be catheterized (n = 24), and proximal bile duct stenosis (n = 7). The primary endpoint was technical and clinical success. Secondary endpoints were procedure-related complications during the hospital stay. Results 103 patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal=474). Different transluminal access routes were used to reach the bile ducts: transgastric (n = 72/103); -duodenal (n = 16/103); -jejunal (n = 14/103); combined -duodenal and -gastric (n = 1/103). The technical success rate was 96 % (n = 99) for cholangiography. Drainage was not required in 2 patients; balloon dilatation including stone extraction was sufficient in 17 cases (16.5 %; no additional or prophylactic insertion of a drain). Transluminal drainage was achieved in n = 68/103 (66 %; even higher in patients with drain indication only) by placement of a plastic stent (n = 29), conventional biliary metal stents (n = 24), HotAXIOS stents (n = 5; Boston Scientific, Ratingen, Germany), Hanaro stents (n = 6; Olympus, Hamburg, Germany), HotAXIOS stents and plastic stents (n = 1), HotAXIOS stents and metal stents (n = 1) and metal stents and plastic stents (n = 2). Techniques for stone extraction alone (nSuccessful=17) or stent insertion (nTotal = 85; nSuccessful=85 – rate, 100 %) and final EUS-BD access pathway included: Rendezvous technique (n = 14/85; 16.5 %), antegrade internal drainage (n = 20/85; 23.5 %), choledochointestinostomy (n = 7/85; 8.2 %), antegrade internal and hepaticointestinostomy (n = 22/85; 25.9 %), hepaticointestinostomy (n = 21/85; 24.7 %), choledochointestinostomy and hepaticointestinostomy (n = 1/85; 1.2 %).The complication rate was 25 % (n = 26) – the spectrum comprised stent dislocation (n = 11), perforation (n = 1), pain (n = 2), hemorrhage (n = 6), biliary ascites/leakage (n = 3) and bilioma/liver abscess (n = 3; major complication rate, n = 12/68 – 17.6 %). Re-interventions were required in 19 patients (24 interventions in total). Discussion EUS-BD can be considered an elegant and safe alternative to PTCD or reoperation for failed ERCP to achieve the necessary drainage of the biliary system even in underlying benign diseases. An interventional EUS-based internal procedure can resolve cholestasis, avoid PTCD or reoperation, and thus improve quality of life. Due to the often complex (pathological and/or postoperative) anatomy, EUS-BD should only be performed in centers with interventional endoscopy/EUS experience including adequate abdominal surgery and interventional radiology expertise in the background. This enables adequately adapted therapeutic management in the event of challenging complications. It seems appropriate to conduct further studies with larger numbers of cases to systematize the approach and peri-interventional management and to successively develop specific equipment.

Snare-assisted precutting and dual-knife fistulotomy performed during difficult biliary cannulation in a patient with an ectopic papilla of Vater

Endoscopic retrograde cholangiopancreatography is widely used in the diagnosis and treatment of pancreatobiliary diseases; however, successful biliary cannulation is a prerequisite for this operation. We herein present a new method in a patient in whom cannulation was difficult. A 56-year-old man was admitted to the hospital with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed, and duodenoscopy revealed that the patient’s duodenal papilla was located at the initial part of the horizontal segment of the duodenum. Because of the ectopic location of the duodenal papilla, the guidewire could not be inserted into the biliary and pancreatic duct. Therefore, we performed a new method to resolve the problem of difficult cannulation. A polypectomy snare was used to excise the mucosa covering the surface of the intramural segment of the common bile duct, and a dual knife was used to form a fistula. A guidewire was then inserted through the stoma into the bile duct. After the procedure, the bile duct was successfully cannulated and the stones were removed. No complications occurred. This new method may be an alternative treatment to precutting for difficult biliary cannulation in patients with a protruded papilla of Vater.

Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography for the Treatment of Common Bile Duct Stones in Patients with Roux-en-Y Gastrectomy: Outcomes and Factors Affecting Complete Stone Extraction

Background: Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in patients with Roux-en-Y gastrectomy (RYG) remains technically challenging. Methods: Seventy-nine RYG patients (median 79 years old) underwent short-type double-balloon enteroscopy-assisted ERCP (sDBE-ERCP) for CBD stones at three referral hospitals from 2011–2020. We retrospectively investigated the treatment outcomes and potential factors affecting complete stone extraction. Results: The initial success rates of reaching the papilla of Vater, biliary cannulation, and biliary intervention, including complete stone extraction or biliary stent placement, were 92%, 81%, and 78%, respectively. Of 57 patients with attempted stone extraction, complete stone extraction was successful in 74% for the first session and ultimately in 88%. The adverse events rate was 5%. The multivariate analysis indicated that the largest CBD diameter ≥14 mm (odds ratio (OR), 0.04; 95% confidence interval (CI), 0.01–0.58; p = 0.018) and retroflex position (OR, 6.43; 95% CI, 1.12–36.81; p = 0.037) were independent predictive factors affecting complete stone extraction achievement. Conclusions: Therapeutic sDBE-ERCP for CBD stones in a relatively elderly RYG cohort, was effective and safe. A larger CBD diameter negatively affected complete stone extraction, but using the retroflex position may be useful for achieving complete stone clearance.