Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

BACKGROUND At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography(ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.AIM To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.METHODS Demographic/clinical variables and records of ERCP patients at the beginning(2008), middle(2013) and end(2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard"(short position) or "non-standard"(e.g., long, semi-long).RESULTS Patients undergoing ERCP were older in 2018 compared to 2008(69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018(P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2%(2008) to 5.6%(2013) and 16.1%(2018)(P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7%(2008) to 0.9%(2013) to 6.6%(2018)(P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/d L predicted use of advanced cannulation techniques(P < 0.03 for each).CONCLUSION Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

Short turn radius colonoscope in an anatomical model: Retroflexed withdrawal and detection of hidden polyps

AIM: To evaluate the new Retro View^(TM) colonoscope and compare its ability to detect simulated polyps "hidden" behind colonic folds with that of a conventional colonoscope, utilizing anatomic colon models.METHODS: Three anatomic colon models were prepared,with twelve simulated polyps "hidden" behind haustral folds and five placed in easily viewed locations in each model. Five blinded endoscopists examined two colon models in random order with the conventional or Retro View^(TM) colonoscope, utilizing standard withdrawal technique. The third colon model was then examined with the Retro View^(TM) colonoscope withdrawn initially in retroflexion and then in standard withdrawal. Polyp detection rates during standard and retroflexed withdrawal of the conventional and Retro View^(TM) colonoscopes were determined. Polyp detection rates for combined standard and retroflexed withdrawal(combination withdrawal) with the Retro View^(TM) colonoscope were also determined.RESULTS: For hidden polyps, retroflexed withdrawal using the Retro View^(TM) colonoscope detected more polyps than the conventional colonoscope in standard withdrawal(85% vs 12%, P = 0.0001). For hidden polyps, combination withdrawal with the Retro View^(TM) colonoscope detected more polyps than the conventional colonoscope in standard withdrawal(93% vs 12%, P ≤ 0.0001). The Retro View^(TM) colonoscope in "combination withdrawal" was superior to other methods in detecting all(hidden + easily visible) polyps, with successful detection of 80 of 85 polyps(94%) compared to 28(32%) polyps detected by the conventional colonoscope in standard withdrawal(P < 0.0001) and 67(79%) polyps detected by the Retro View^(TM) colonoscope in retroflexed withdrawal alone(P < 0.01). Continuous withdrawal of the colonoscope through the colon model while retroflexed was achieved by all endoscopists. In a post-test survey, four out of five colonoscopists reported that manipulation of the colonoscope was easy or very easy.CONCLUSION: In simulated testing, the Retro View^(TM) colonoscope increased detection of hidden polyps. Combining standard withdrawal with retroflexed withdrawal may become the new paradigm for "complete screening colonoscopy".

Diagnostic yield of third eye retroscope on adenoma detection during colonoscopy:A systematic review and meta-analysis

AIM: To determine the diagnostic yield of the "third eye retroscope",on adenoma detection rate during screening colonoscopy.METHODS: The "third eye retroscope" when used with standard colonoscopy provides an additional retrograde view to visualize lesions on the proximal aspects of folds and flexures.We searched MEDLINE(Pub Med and Ovid),SCOPUS(including MEDLINE and EMBASE databases),Cochrane Database of Systemic Reviews,Google Scholar,and CINAHL Plus databases to identify studies that evaluated diagnostic yield of "third eye retroscope" during screening colonoscopy.Der Simonian Laird random effects model was used to generate the overall effect for each outcome.We evaluated statistical heterogeneity among the studies by using the Cochran Q statistic and quantified by I2 statistics.RESULTS: Four distinct studies with a total of 920 patients,mean age 59.83(95%CI: 56.77-62.83) years,were included in the review.The additional adenoma detection rate(AADR) defined as the number of additional adenomas identified due to "third eye retroscope" device in comparison to standard colonoscopy alone was 19.9%(95%CI: 7.3-43.9).AADR for right and left colon were 13.9%(95%CI: 9.4-20) and 10.7(95%CI: 1.9-42),respectively.AADR for polyps ≥ 6 mm and ≥ 10 mm were 24.6%(95%CI: 16.6-34.9) and 24.2%(95%CI: 12.9-40.8),respectively.The additional polyp detection rate defined as the number of additional polyps identified due to "third eye retroscope" device in comparison to standard colonoscopy alone was 19.8%(95%CI: 7.9-41.8).There were no complications reported with use of "third eye retroscope" device.CONCLUSION: The "third eye retroscope" device when used with standard colonoscopy is safe and detects 19.9% additional adenomas,compared to standard colonoscopy alone.

Incidental biliary dilation in the era of the opiate epidemic:High prevalence of biliary dilation in opiate users evaluated in the Emergency Department

BACKGROUND Biliary dilation is frequently related to obstruction;however,non-obstructive factors such as age and previous cholecystectomy have also been reported.In the past two decades there has been a dramatic increase in opiate use/dependence and utilization of cross-sectional abdominal imaging,with increased detection of biliary dilation,particularly in patients who use opiates.AIM To evaluate associations between opiate use,age,cholecystectomy status,ethnicity,gender,and body mass index utilizing our institution’s integrated informatics platform.METHODS One thousand six hundred and eighty-five patients(20%sample)presenting to our Emergency Department for all causes over a 5-year period(2011-2016)who had undergone cross-sectional abdominal imaging and had normal total bilirubin were included and analyzed.RESULTS Common bile duct(CBD)diameter was significantly higher in opiate users compared to non-opiate users(8.67 mm vs 7.24 mm,P<0.001)and in patients with a history of cholecystectomy compared to those with an intact gallbladder(8.98 vs 6.72,P<0.001).For patients with an intact gallbladder who did not use opiates(n=432),increasing age did not predict CBD diameter(r^2=0.159,P=0.873).Height weakly predicted CBD diameter(r^2=0.561,P=0.018),but weight,body mass index,ethnicity and gender did not.CONCLUSION Opiate use and a history of cholecystectomy are associated with CBD dilation in the absence of an obstructive process.Age alone is not associated with increased CBD diameter.These findings suggest that factors such as opiate use and history of cholecystectomy may underlie the previously-reported association of advancing age with increased CBD diameter.Further prospective study is warranted.

Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis

AIM: To assess the safety and efficacy of self-expandable metal stents(SEMSs) for malignant colorectal obstruction. METHODS: Data regarding technical success, clinical success, and procedure related complications were collected from included studies. Der Simonian-Laird random effects model was used to generate the overall outcome. Thirty international studies with a total of 2058 patients with malignant colorectal obstruction were included. RESULTS: The technical and clinical success rates for SEMS placement were 94%(95%CI: 92-96) and 91%(95%CI: 88-93), respectively. Overall complication rate for SEMS was 23%(95%CI: 18-29). Stent migration8%(95%CI: 6-10) and stent obstruction 8%(95%CI: 6-11) were the most common complications, followed by perforation 5%(95%CI: 4%-7%). Surgical or endoscopic re-interventions were needed in 14%(95%CI: 10-18) of patients. Endoscopic repeat stent placement was required in 8%(95%CI: 6-10), while surgical intervention was needed in 6%(95%CI: 4-8).CONCLUSION: SEMS are effective when used as palliation or bridge to surgery for malignant colorectal obstruction with high technical and clinical success. About 14% of patients require repeat endoscopic or surgical intervention for stent failure or to manage stent related complications.