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.

JUST BECAUSE IT IS RARE DOESN’T MEAN IT IS IMPLAUSIBLE: LEMMEL’S SYNDROME A CASE SERIES

Lemmel’s syndrome is a rare pancreaticobiliary complication of duodenal diverticula. It occurs when a duodenal diverticulum causes obstructive jaundice due to a mechanical obstruction of the common bile duct. Other mechanisms like sphincter of Oddi dysfunction can also play a role in pathophysiology. We report three cases of Lemmel’s syndrome where liver biochemistry showed obstructive jaundice; but subsequent MRCP showed a massive periampullary diverticulum causing biliary obstruction. Early detection and intervention can prevent needless additional investigations and complications due to obstruction.

Effect of Periampullary Diverticulum on Biliary Flora and the Formation of Common Bile Duct Stone

Background: Bile duct stone is closely related to periampullary diverticulum, but it is not clear whether the formation of it was affected by the diverticulum through the biliary flora. To explore the diversity and correlation of biliary and intestinal flora in the patients with choledocholithiasis and the effects of periampullary diverticulum on the flora and bile duct stone. Methods: Bile and intestinal fluid were collected from patients with primary common bile duct stones, and then divided into diverticulum group and none- diverticulum group according to the presence or absence of paravertebral diverticula, DNA of these samples was extracted and a bacterial gene library was constructed, and related bioinformatics analysis was performed after high-throughput sequencing to obtain the bacterial components and community structure of the sample. Result: A total of 3001,613 valid sequences were obtained, with an average of 136436.95±3696.842 sequences, which were classified into 6021 ASV/OUT. Alpha diversity analysis showed that the species richness and diversity in the diverticulum group were lower than those in the nondiverticulum group. According to the species annotation results, the advantage bacterium group of the bile is Proteobacteria (BG 80.41%, Bg 70.95%), and advantage bacterium group of the intestinal fluid is Firmicutes and Proteobacteria (BG 89.39%, Bg 74.11%). A large proportion of Enterobacter was found in bile. Escherichia coli, Klebsiella, Streptococcus and other bacteria closely related to stone formation have been found. The proportion of E. coli in the diverticulum group was increased and due to the existence of the diverticulum Enterobacteria in the bile were increased and more complex. The bacteria that produce Betaglucuronidase are found to be increased in bile. Due to the influence of the periampullary diverticulum, the intestinal flora will be changed and then the biliary flora will also change. Conclusion: The existence of periampullary diverticulum will affect the biliary tract flora and lead to the increase of bacteria related to stone formation, which will affect the formation of choledocholithiasis and make it easier for choledocholithiasis to form.

Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography

Endoscopic ultrasound (EUS) was originally devised as a novel diagnostic technique to enable endoscopists to stage malignancies and acquire tissue. However, it rapidly advanced toward therapeutic applications and has provided gastroenterologists with the ability to effectively treat and manage advanced diseases in a minimally invasive manner. EUS-guided biliary drainage (EUS-BD) has gained considerable attention as an approach to provide relief in malignant and benign biliary obstruction for patients when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible. Such instances occur in those with surgically altered anatomy, gastroduodenal obstruction, periampullary diverticulum or prior transampullary duodenal stenting. While ERCP remains the gold standard, a multitude of studies are showing that EUS-BD can be used as an alternative modality even in patients who could successfully undergo ERCP. This review will shed light on recent EUS-guided advancements and techniques in malignant and benign biliary obstruction.