Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Retrospective analysis of complications related to endoscopic retrograde cholangio-pancreatography in patients with cirrhosis vs patients without cirrhosis

BACKGROUND There is minimal objective data regarding adverse events related to endoscopic retrograde cholangio-pancreatography(ERCP)in patients with cirrhosis compared to those without cirrhosis and even fewer data comparing complications among cirrhosis patients based on severity of cirrhosis.AIM To determine if patients with cirrhosis are at increased risk of adverse events related to ERCP:mainly pancreatitis,bleeding,perforation,cholangitis,and mortality;And to see if higher Child-Pugh(CP)score and Model for End-Stage Liver Disease(MELD)score are associated with higher post-ERCP complications.METHODS We performed a retrospective analysis of 692 patients who underwent ERCP and analyzed the impact of cirrhosis etiology,gender,type of sedation used during procedure,interventions performed,and co-morbidities on the rate of complications in cirrhosis patients as compared to non-cirrhosis patients.RESULTS Overall complications were higher in those with cirrhosis as compared to those without cirrhosis(P=0.015 at significance level of 0.05).CP class,especially CP class C,was shown to be associated with a significantly higher rate of ERCP complications as compared to CP class A and CP class B(P=0.010 at significance level of 0.05).CONCLUSION The results of our study reaffirm that liver cirrhosis has an impact on the occurrence of complications during ERCP.Our study shows that CP class seems to be more reliable as compared to MELD score in predicting complications of ERCP in cirrhosis patients.

Endoscopic management of biliary complications after liver transplantation: An evidence-based review

Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM:To investigate endoscopic ultrasound(EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.METHODS:Records of 111 patients seen at our institution from November 1999 to July 2011 with the postoperative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed.Records of patients who underwent preoperative EUS for diagnostic purposes were identified.The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results.In addition,the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome(recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded,compared and analyzed.RESULTS:Among 111 patients with benign ampullary and duodenal adenomas,47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions.In addition,computed tomography was performed in 18 patients,endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients.There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis(FAP)/other polyposis syndromes.In 38(81%,P < 0.05) patients,EUS reliably identified absence of submucosal and muscularis invasion.In 4 cases,EUS underestimated submucosal invasion that was proven by pathology.In the other 5 patients,EUS predicted muscularis invasion which could not be demonstrated in the resected specimen.EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90%(P < 0.05).Types of resection performed included endoscopic resection in 22 cases,partial duodenectomy in 9 cases,transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases.The main post-operative final pathological results included villous adenoma(n = 5),adenoma(n = 8),tubulovillous adenoma(n = 10),tubular adenoma(n = 20) and hyperplastic polyp(n = 2).Among the 47 patients who underwent resection,8(17%,5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma,intra-abdominal abscess,wound infection,delayed gastric emptying and prolonged ileus.After median followup of 20 mo there were 6 local recurrences(13%,median follow-up = 20 mo) 4 of which were in patients with FAP.CONCLUSION:EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas.These patients can safely undergo endoscopic or local resection.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.

Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation(EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography(ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis(PEP). However, as the efficacy of endoscopic papillary largeballoon dilatation(EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy(EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Laparo-endoscopic “Rendezvous” to treat cholecysto-choledocolithiasis: Effective,safe and simplifies the endoscopist’s work

AIM: To investigate our clinical experience with combined laparo-endoscopic Rendezvous (RV) for the treatment of patients affected by gallstones and common bile duct (CBD) stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized "tailored" RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire. RESULTS: The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases.CONCLUSION: Simultaneous RV carries higheffectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.

Endoscopic management of acute cholangitis in elderly patients

AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupⅠ, age < 60 years; group Ⅱ, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group Ⅱ compared to 120 of 123 in groupⅠ. High fever (fever ≥ 38.0℃) was more common in groupⅠ(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group Ⅱ. Biliopancreatic malignancy was a common cause of biliary obstruction in group Ⅱ (n = 34) and benign diseases in groupⅠ(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0℃ (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupⅠand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group Ⅱ. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupⅠ, 24 group Ⅱ, stent: 64 groupⅠ, 28 group Ⅱ) without any significant age related difference in the success rate. Abdominalpain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupⅠ(2-15 d) compared to 10 d in 47 patients of group Ⅱ (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupⅠcompared to 15 d (5-26 d) in 47 patients in group Ⅱ. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group Ⅱ and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group Ⅱ despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group Ⅱ patients (16.4 ± 5.6, 7-30 d) than in groupⅠpatients (8.2 ± 2.4, 7-20 d).CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound(EUS)is often used to detect the cause of acute pancreatitis(AP)after the acute attack has subsided.The limited data on its role during hospitalization for AP are reviewed here.The ability of EUS to visualize the pancreas and bile duct,the sonographic appearance of the pancreas,correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies.The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis.Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications.The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.

Biliary reflux detection in anomalous union of the pancreaticobiliary duct patients

AIM： To demonstrate the imaging findings of biliopan creatic and pancreatico-biliary reflux in patients with anomalous union of the pancreatico biliary duct （AUPBD） on gadoxetic acidenhanced functional magnetic resonance cholangiography （fMRC）.

Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy

Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and metaanalyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.

Endoscopic ultrasound guided biliary drainage

Endoscopic retrograde cholangio-pancreatography is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peripapillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography- guided biliary drainage using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.

Optimization of biliary drainage in inoperable distal malignant strictures

BACKGROUND Given most patients with distal malignant biliary obstruction present in the nonresectable stage,palliative endoscopic biliary drainage with fully covered metal stent(FCMS)or uncovered metal stent(UCMS)is the only available measure to improve patients’quality of life.Half covered metal stent(HCMS)has been recently introduced commercially.The adverse effects and stent function between FCMS and UCMS have been extensively discussed.AIM To study the duration of stent patency of HCMS and compare it with FCMS and UCMS to optimize biliary drainage in inoperable patients with distal malignant obstruction.Secondary aims in our study included evaluation of patients’survival and the rates of adverse events for each type of stent.METHODS We studied 210 patients and randomized them into three equal groups;HCMS,FCMS and UCMS were inserted endoscopically.RESULTS Stent occlusion occurred in(18.6%,17.1%and 15.7%in HCMS,FCMS and UCMS groups,respectively,P=0.9).Stent migration occurred only in patients with FCMS(8.6%of patients).Cholangitis and cholecystitis occurred in 11.4%and 5.7%of patients,respectively,in FCMS.Tumor growth occurred only in 10 cases among patients with UCMS after a median of 140 d,sludge occurred in nine,seven and one patients in HCMS,FCMS and UCMS,respectively(P=0.04).CONCLUSION Given the prolonged stent functioning time,the use of HCMS is preferred over the use of UCMS and FCMS for optimizing biliary drainage in patients with distal malignant biliary obstruction.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography:A meta-analysis and systematic review

AIM:To assess the safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO2 insufflation with air insufflation during ERCP. The trials were included in the review irrespec-tive of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes.Sensitivity and subgroup analyses were performed if necessary. R ESULTS:Seven double-blind RCTs involving a total of 818 patients were identified that compared CO2 insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-random- ization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO2 insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insuf-flation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI:0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO2 level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI:-14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI:-0.26-0.17, P = 0.67) between the two groups. C ONCLUSION:CO2 insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

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.

Endoscopic ultrasound guided biliary and pancreatic duct interventions

When endoscopic retrograde cholangio-pancreatog-raphy fails to decompress the pancreatic or biliary system, alternative interventions are required. In this situation, endosonography guided cholangio-pancrea-tography(ESCP), percutaneous radiological therapy or surgery can be considered. Small case series reporting the initial experience with ESCP have been superseded by comprehensive reports of large cohorts. Although these reports are predominantly retrospective, they demonstrate that endoscopic ultrasound(EUS) guided biliary and pancreatic interventions are associated with high levels of technical and clinical success. The proce-dural complication rates are lower than those seen with percutaneous therapy or surgery. This article describes and discusses data published in the last five years relat-ing to EUS-guided biliary and pancreatic intervention.

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.

Utility of multiple endoscopic techniques in differential diagnosis of gallbladder adenomyomatosis from gallbladder malignancy with bile duct invasion: A case report

BACKGROUND Gallbladder adenomyomatosis(GAM) is a benign lesion, characterized by thickening of the gallbladder wall and a focal mass, which overlap with the features of gallbladder malignancy. Consequently, differential diagnosis of GAM from gallbladder cancer is difficult and approximately 20% of suspected malignant biliary strictures are postoperatively confirmed as benign lesions.Herein, we report a case in which a preoperative diagnosis of GAM was made by a combination of endoscopic and imaging techniques.CASE SUMMARY A 40-year-old man was referred to our hospital chiefly for a fever and right upper abdominal pain with dark urine. Enhanced computed tomography showed thickening of the gallbladder wall and a mass in the gallbladder neck with involvement of the hepatic bile ducts, which was suspected to be malignant.Gallbladder malignancy with bile duct invasion was ruled out by subsequent endoscopic examinations, including endoscopic retrograde cholangiopancreatography, intraductal ultrasound, and Spy Glass. Endoscopic examinations showed a homogeneous hyperechoic lesion with smooth margins of benign bile duct stricture suggestive of inflammatory stenosis of the bile duct.The patient underwent laparoscopic cholecystectomy. GAM was postoperatively diagnosed and confirmed based on the histopathology results, which are consistent with the preoperative diagnosis. Notably, no malignant event occurred in the patient during a 12-mo follow-up period.CONCLUSION A combination of endoscopic techniques may help in the differential diagnosis of GAM from gallbladder cancer.

Fetal radiation exposure: Is monitoring really needed?

The effect of fetal radiation during endoscopic retro-grade cholangiopancreatography (ERCP) on pregnant women is a very interesting topic. Smith et al recently estimated the fetal radiation exposure in pregnant women undergoing ERCPs using thermoluminescent dosimeters (TLDs). The authors concluded that TLDs are unnecessary during ERCP with modified techniques. We believe that an extreme caution is needed in clinical practice before drawing such conclusions when they are not strongly supported by enough experimental evidence. Therefore, we recommend that fetal radiation exposure be monitored in clinical practice by using dosimeters, bearing in mind that all relevant techniques to control and minimize the exposure must be applied.

Oldest biliary endoprosthesis in situ

The advantages of endoscopic retrograde cholangio-pancreatography over open surgery have made it the predominant method of treating patients with choledo-cholithiasis. After sphincterotomy, however, 10%-15% of common bile duct stones cannot be removed with a basket or balloon. The methods for managing "irretrievable stones" include surgery, mechanical lithotripsy, intraductal or extracorporeal shock wave lithotripsy and biliary stenting. The case presented was a referred 82-year-old Caucasian woman with a 7-year-old plastic biliary endoprosthesis in situ . To the best of our knowledge the examined endoprosthesis is the oldest endo-prosthesis in situ reported in the literature. Endoscopic biliary endoprosthesis placement remains a simple and safe procedure for patients with stones that are difficult to manage by conventional endoscopic methods and for patients who are unfit for surgery or who are high surgical risks. To date no consensus has been reached regarding how long a biliary prosthesis should remain in situ . Long-term biliary stenting may have a role in selected elderly patients if stones extraction has failed because the procedure may prevent stones impaction and cholangitis.