The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope:A multicenter retrospective international study

Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Endoscopic retrograde cholangiopancreatography:Current practice and future research

Endoscopic retrograde cholangiopancreatography(ERCP)has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease.Most commonly,ERCPs are performed for choledocholithiasis with or without cholangitis,but improvements in technology and technique have allowed for management of pancreatic duct stones,benign and malignant strictures,and bile and pancreatic leaks.As an example of necessity driving innovation,the new disposable duodenoscopes have been introduced into practice.With the advantage of eliminating transmissible infections,they represent a paradigm shift in quality improvement within ERCP.With procedures becoming more complicated,the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined.The improvements in endoscopic ultrasound(EUS)have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP.In patients with surgically altered anatomy,selective cannulation can be performed with overtube-assisted enteroscopy,laparoscopic surgery assistance,or the EUS-directed transgastric ERCP.Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones,indeterminate strictures,and hepatobiliary and pancreatic neoplasia.This review summarizes the recent advances in infection prevention,quality improvement,pancreaticobiliary access,and management of hepatobiliary and pancreatic diseases.Where appropriate,future research directions are included in each section.

Retrieval-balloon-assisted enterography in post-pancreaticoduodenectomy endoscopic retrograde cholangiopancreatography

This case reports an application of conventional duodenoscope in a post pancreaticoduodenectomy patient with the help of retrieval balloon assisted enterography.The 56-year-old woman had pancreaticoduodenectomy with Child reconstruction 9 mo ago because of pancreatic adenocarcinoma and now there are recurrent enlarged lymph nodes in the anastomotic stoma of hepaticojejunostomy.Considering the patient's late-stage cancer,a plastic stent was then successfully placed there to drainage.The main challenge in this case was the extremely long afferent loop and blind cannulation through the anastomotic stoma of hepaticojejunostomy.Retrieval balloon assisted enterography is very helpful for duodenoscope going through the reconstructed intestinal tract and for the cannulation.After two weeks,the patient remained free of painful symptoms and free of fever.Liver function improved well.Four months after the placement of stent,the patient died of cachexia without jaundice,fever and abdominal pain according to her daughter's statement.

Retrieval-balloon-assisted enterography for ERCP after Billroth Ⅱ gastroenterostomy and Braun anastomosis

AIM: To describe an optimal route to the Braun anastomosis including the use of retrieval-balloon-assisted enterography.METHODS: Patients who received a Billroth Ⅱ gastroenterostomy(n = 109) and a Billroth Ⅱ gastroenterostomy with Braun anastomosis(n = 20) between January 2009 and May 2013 were analyzed in this study. Endoscopic ret-rograde cholangiopancreatography(ERCP) was performed under fluoroscopic control using a total length of 120 cm oblique-viewing duodenoscope with a 3.7-mm diameter working channel. For this procedure, we used a triplelumen retrieval balloon catheter in which a 0.035-inch guidewire could be inserted into the "open-channel" guidewire lumen while the balloon could be simultaneously injected and inflated through the other 2 lumens.RESULTS: For the patients with Billroth Ⅱ gastroenterostomy and Braun anastomosis, successful access to the papilla was gained in 17 patients(85%) and there was therapeutic success in 16 patients(80%). One patient had afferent loop perforation, but postoperative bleeding did not occur. For Billroth Ⅱ gastroenterostomy, there was failure in accessing the papilla in 15 patients(13.8%). ERCP was unsuccessful because of tumor infiltration(6 patients), a long afferent loop(9 patients), and cannulation failure(4 patients). The papilla was successfully accessed in 94 patients(86.2%), and there was therapeutic success in 90 patients(82.6%). Afferent loop perforation did not occur in any of these patients. One patient had hemorrhage 2 h after ERCP, which was successfully managed with conservative treatment.CONCLUSION: Retrieval-balloon-assisted enterography along an optimal route may improve the ERCP success rate after Billroth Ⅱ gastroenterostomy and Braun anastomosis.

SpyGlass application for duodenoscope working channel inspection: Impact on the microbiological surveillance

BACKGROUND Patient-ready duodenoscopes were designed with an assumed contamination rate of less than 0.4%;however,it has been reported that 5.4%of clinically used duodenoscopes remain contaminated with viable high-concern organisms despite following the manufacturer’s instructions.Visual inspection of working channels has been proposed as a quality control measure for endoscope reprocessing.There are few studies related to this issue.AIM To investigate the types,severity rate,and locations of abnormal visual inspection findings inside patient-ready duodenoscopes and their microbiological significance.METHODS Visual inspections of channels were performed in 19 patient-ready duodenoscopes using the SpyGlass visualization system in two endoscopy units of tertiary care teaching hospitals(Tri-Service General Hospital and National Taiwan University Hospital)in Taiwan.Inspections were recorded and reviewed to evaluate the presence of channel scratches,buckling,stains,debris,and fluids.These findings were used to analyze the relevance of microbiological surveillance.RESULTS Seventy-two abnormal visual inspection findings in the 19 duodenoscopes were found,including scratches(n=10,52.6%),buckling(n=15,78.9%),stains(n=14,73.7%),debris(n=14,73.7%),and fluids(n=6,31.6%).Duodenoscopes>12 mo old had a significantly higher number of abnormal visual inspection findings than those≤12 mo old(46 findings vs 26 findings,P<0.001).Multivariable regression analyses demonstrated that the bending section had a significantly higher risk of being scratched,buckled,and stained,and accumulating debris than the insertion tube.Debris and fluids showed a significant positive correlation with microbiological contamination(P<0.05).There was no significant positive Spearman’s correlation coefficient between negative bacterial cultures and debris,between that and fluids,and the concomitance of debris and fluids.This result demonstrated that the presence of fluid and debris was associated with positive cultures,but not negative cultures.Further multivariate analysis demonstrated that fluids,but not debris,is an independent factor for bacterial culture positivity.CONCLUSION In patient-ready duodenoscopes,scratches,buckling,stains,debris,and fluids inside the working channel are common,which increase the microbiological contamination susceptibility.The SpyGlass visualization system may be recommended to identify suboptimal reprocessing.

Entering the duodenal diverticulum:A method for cannulation of the intradiverticular papilla

Successful cannulation of the common bile duct may be difficult in patients in whom the papilla is located entirely within a diverticulum.In this study,we report successful biliary cannulation in three patients following intubation of the distal tip of the duodenoscope into the duodenal diverticulum and locating the major papilla.No complications occurred during the operation or during the postoperative period.This method didn't need second incubation an endoscope and might lower the burden of patients.So this skill is useful to deal with the papilla hidden inside the large diverticulum because of its safety and convenience.

Application of a wire-guided side-viewing duodenoscope in total esophagectomy with colonic interposition

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay treatment for bile duct disease. The procedure is difficult per se, especially when a side-viewing duodenoscope is used, and when the patient has altered anatomical features, such as colonic interposition. Currently, there is no consensus on the standard approach for therapeutic ERCP in patients with total esophagectomy and colonic interposition. We describe a novel treatment design that involves the use of a side-viewing duodenoscope to perform therapeutic ERCP in patients with total esophagectomy and colonic interposition. A gastroscope was initially introduced into the interposed colon and a radio-opaque standard guidewire was advanced to a distance beyond the papilla of Vater, before the gastroscope was withdrawn. A sideviewing duodenoscope was then introduced along the guidewire under fluoroscopic guidance. After cannulation into the papilla of Vater, endoscopic retrograde chol-angiography (ERC) revealed a filling defect (maximum diameter: 15 cm) at the distal portion of the common bile duct (CBD). This defect was determined to be a stone, which was successfully retrieved by a Dormia basket after complete sphincterotomy. With this treatment design, it is possible to perform therapeutic ERCP in patients with colonic interposition, thereby precluding the need for percutaneous drainage or surgery.

Treatment for 63 cases of the elderly with choledocholith by duodenoscope

Objective To explore the effect of duodenoscope in the treatment for the elderly cases.Method Retrospective analysis of the treatment by duodenoscope for 63 elderly patients (all aged over 80 years old) with high risk choledocholith from Jan 2006 to Dec 2010.Results All of the 63 cases obtained a success in the endoscopic operation.The operative time was within 15~60 min.Endoscopic stone extraction was performed on 21 cases,bile duct plastic stent in 35,of them 2 cases had the second operation because their stones were too big.In 2 cases of 9 who suffered from acute obstructive suppurative cholangitis (AOSC),plastic stents were placed.In the rest 7 cases,nasobiliary drainages (NBD) were inserted,on 4 of the 7 cases,stone extraction were performed 5-7 days later,in 3 of the 7 cases,stents were inserted for the second time,of the 3 cases,2 were found blood oozing on the surface of wound after EST (endoscopic sphicterectomy),the bleeding was stopped by local spray of noradrenaline,no hematorrhea or perforation occurred.Postoperative choledochitis was found in 1 case,to whom antiinflammatory therapy was applied.Pancreatitis was found in 3 cases,blood amylase increasing in 12,who were cured with fast,pancreatic secretion inhibition and antiinflammatory drugs.One patient died of acute left heart failure (ALHF),no death from the bile duct diseases or concerned were found.Conclusion Although many basal diseases of the elderly increase the risks in the endoscopic treatment,it proves to be practical for it has less complications,high security and definite curative results.