Percutaneous transhepatic cholangioscopy-assisted biliary polypectomy for local palliative treatment of intraductal papillary neoplasm of the bile duct

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)is a premalignant biliarytype epithelial neoplasm with intraductal papillary or villous growth.Currently reported local palliative therapeutic modalities,including endoscopic nasobiliary drainage,stenting and biliary curettage,endoscopic biliary polypectomy,percutaneous biliary drainage,laser ablation,argon plasma coagulation,photodynamic therapy,and radiofrequency ablation to relieve mechanical obstruction are limited with weaknesses and disadvantages.We have applied percutaneous transhepatic cholangioscopy(PTCS)-assisted biliary polypectomy(PTCS-BP)technique for the management of IPNB including mucin-hypersecreting cast-like and polypoid type tumors since 2010.AIM To assess the technical feasibility,efficacy,and safety of PTCS-BP for local palliative treatment of IPNB.METHODS Patients with mucin-hypersecreting cast-like or polypoid type IPNB and receiving PTCS-BP between September 2010 and December 2019 were included.PTCS-BP was performed by using a half-moon type snare with a soft stainless-steel wire,and the tumor was snared and resected with electrocautery.The primary outcome was its feasibility,indicated by technical success.The secondary outcomes were efficacy,including therapeutic success,curative resection,and clinical success,and safety.RESULTS Five patients(four with mucin-hypersecreting cast-like type and one with polypoid type IPNB)were included.Low-and high-grade intraepithelial neoplasia(HGIN)and recurrent IPNB with invasive carcinoma were observed in one,two,and two patients,respectively.Repeated cholangitis and/or obstructive jaundice were presented in all four patients with mucin-hypersecreting cast-like type IPNB.All five patients achieved technical success of PTCS-BP.Four patients(three with mucin-hypersecreting cast-like type and one with polypoid type IPNB)obtained therapeutic success;one with mucin-hypersecreting cast-like type tumors in the intrahepatic small bile duct and HGIN had residual tumors.All four patients with mucin-hypersecreting IPNB achieved clinical success.The patient with polypoid type IPNB achieved curative resection.There were no PTCS-BP-related serious adverse events.CONCLUSION PTCS-BP appears to be feasible,efficacious,and safe for local palliative treatment of both mucin-hypersecreting cast-like and polypoid type IPNB.

Efficacy and safety of percutaneous transhepatic biliary radiofrequency ablation in patients with malignant obstructive jaundice

BACKGROUND Percutaneous transhepatic cholangiodrainage(PTCD)and endoscopic retrograde cholangiopancreatography/endoscopic nasobiliary drainage are the most common clinical procedures for jaundice control in patients with unresectable malignant obstructive jaundice,yet the safety and effect of endobiliary radiofrequency ablation(EB-RFA)combined PTCD is rarely reported,in this article,we report our experience of EB-RFA combined PTCD in such patients.AIM To retrospectively study the efficacy and safety of EB-RFA combined PTCD in patients with unresectable malignant obstructive jaundice.METHODS Patients with unresectable malignant obstructive jaundice treated with EB-RFA under PTCD were selected,the bile ducts of the right posterior lobe was selected as the target bile ducts in all cases.The general conditions of all patients,preoperative tumour markers,total bilirubin(TBIL),direct bilirubin(DBIL),albumin(ALB),alkaline phosphatase(ALP),and glutamyl transferase(GGT)before and on the 7th day after the procedure,as well as perioperative complications,stent patency time and patient survival were recorded.RESULTS All patients successfully completed the operation,TBIL and DBIL decreased significantly in all patients at the 7th postoperative day(P=0.009 and 0.006,respectively);the values of ALB,ALP and GGT also decreased compared with the preoperative period,but the difference was not statistically significant.Perioperative biliary bleeding occurred in 2 patients,which was improved after transfusion of blood and other conservative treatments,pancreatitis appeared in 1 patient after the operation,no serious complication and death happened after operation.Except for 3 patients with loss of visits,the stent patency rate of the remaining 14 patients was 100%71%and 29%at the 1^(st),3^(rd),and 6^(th)postoperative months respectively,with a median survival of 4 months.CONCLUSION EB-RFA under PTCD in patients with unresectable malignant obstructive jaundice has a satisfactory therapeutic effect and high safety,which is worthy of further clinical practice.

Three-dimensional visualization technology for guiding one-step percutaneous transhepatic cholangioscopic lithotripsy for the treatment of complex hepatolithiasis

BACKGROUND Biliary stone disease is a highly prevalent condition and a leading cause of hospitalization worldwide.Hepatolithiasis with associated strictures has high residual and recurrence rates after traditional multisession percutaneous transhepatic cholangioscopic lithotripsy(PTCSL).AIM To study one-step PTCSL using the percutaneous transhepatic one-step biliary fistulation(PTOBF)technique guided by three-dimensional(3D)visualization.METHODS This was a retrospective,single-center study analyzing,140 patients who,between October 2016 and October 2023,underwent one-step PTCSL for hepatolithiasis.The patients were divided into two groups:The 3D-PTOBF group and the PTOBF group.Stone clearance on choledochoscopy,complications,and long-term clearance and recurrence rates were assessed.RESULTS Age,total bilirubin,direct bilirubin,Child-Pugh class,and stone location were similar between the 2 groups,but there was a significant difference in bile duct strictures,with biliary strictures more common in the 3D-PTOBF group(P=0.001).The median follow-up time was 55.0(55.0,512.0)days.The immediate stone clearance ratio(88.6%vs 27.1%,P=0.000)and stricture resolution ratio(97.1%vs 78.6%,P=0.001)in the 3D-PTOBF group were significantly greater than those in the PTOBF group.Postoperative complication(8.6%vs 41.4%,P=0.000)and stone recurrence rates(7.1%vs 38.6%,P=0.000)were significantly lower in the 3D-PTOBF group.CONCLUSION Three-dimensional visualization helps make one-step PTCSL a safe,effective,and promising treatment for patients with complicated primary hepatolithiasis.The perioperative and long-term outcomes are satisfactory for patients with complicated primary hepatolithiasis.This minimally invasive method has the potential to be used as a substitute for hepatobiliary surgery.

Efficacy and safety analysis of continued nursing of complications in discharged patients after percutaneous transhepatic biliary drainage

BACKGROUND Percutaneous hepatobiliary drainage(PTCD)is an effective method for the treatment of biliary obstruction and other diseases,but postoperative complications are still one of the important problems faced by patients.Continuous nursing is a comprehensive nursing model that plays an important role in postoperative recovery.The purpose of this study was to investigate the effect of continuous nursing on the incidence of complications in patients after PTCD surgery through meta-analysis and to evaluate its efficacy and safety.AIM To evaluate the effect of extended nursing on the incidence of complications in discharged patients after percutaneous transhepatic biliary drainage(PTBD).METHODS Randomized controlled studies on PTBD postdischarge extended care were identified in the CNKI,Wanfang,VIP,CBM,PubMed,Cochrane Library,Embase,Web of Science,and other databases.The quality of the included studies was evaluated using the Joanna Briggs Institute of Australia literature quality evaluation tool,and a meta-analysis of the included studies was performed with RevMan 5.4 software.RESULTS Finally,9 studies were included,with a total sample size of 854 patients(425 patients in the control group and 429 patients in the intervention group).Meta-analysis revealed that extended care effectively reduced biliary tract infection(RR:0.42,95%CI:0.30-0.57),puncture wound infection(RR:0.19,95%CI:0.06-0.65),catheter protrusion or displacement in discharged patients after PTBD(RR:0.31,95%CI:0.18-0.54),catheter blockage(RR:0.23,95%CI:0.13-0.42),skin infection around the drainage tube(RR:0.30,95%CI:0.12-0.77),and catheter-related readmissions(RR:0.34,95%CI:0.18-0.65)(P<0.05).CONCLUSION Compared with conventional discharge care,extended care can effectively reduce the occurrence of complications such as biliary tract infection,puncture wound infection,catheter prolapse or displacement,catheter blockage,skin infection around the drainage tube,and catheter-related readmission in discharged patients after PTBD.

Percutaneous transhepatic cholangiography:An effective option for endo-biliary radiofrequency ablation before stent insertion in unresectable biliary cancer?

Biliary cancer is a highly aggressive disease that is typically diagnosed at advanced stages when surgical removal is no longer an option.In these cases,palliative care and mechanical widening of the blocked biliary system are preferred.The insertion of a stent is often necessary to prevent the recurrence of blockages caused by cancer progression.Prior to stent placement,endo-biliary radiofrequency ablation(EB-RFA)appears to result in longer-lasting stent effectiveness without increasing the risk of severe complications.However,its impact on overall survival is not yet clear.Additionally,while endoscopic retrograde cholangiopancreatography is the most common method for performing EB-RFA,percutaneous transhepatic cholangiodrainage seems to be a safe and potentially more efficient alternative,particularly for long,angulated,or significantly narrowed bile ducts.

Evaluating effectiveness and safety of combined percutaneous transhepatic gallbladder drainage and laparoscopic cholecystectomy in acute cholecystitis patients:Meta-analysis

BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients without complications,LC is the recommended treatment plan,but there is still controversy regarding the treatment strategy for moderate AC patients,which relies more on the surgeon's experience and the medical platform of the visiting unit.Percutaneous transhepatic gallbladder puncture drainage(PTGBD)can effectively alleviate gallbladder inflammation,reduce gallbladder wall edema and adhesion around the gallbladder,and create a"time window"for elective surgery.AIM To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients,providing a theoretical basis for choosing reasonable surgical methods for AC patients.METHODS In this study,we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC.We performed searches in the following databases:PubMed,Web of Science,EMBASE,Cochrane Library,China National Knowledge Infrastructure,and Wanfang Database.The search encompassed literature published from the inception of these databases to the present.Subsequently,relevant data were extracted,and a meta-analysis was conducted using RevMan 5.3 software.RESULTS A comprehensive analysis was conducted,encompassing 24 studies involving a total of 2564 patients.These patients were categorized into two groups:1371 in the LC group and 1193 in the PTGBD+LC group.The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD+LC group and the LC group in multiple dimensions:(1)Operative time:Mean difference(MD)=17.51,95%CI:9.53-25.49,P<0.01;(2)Conversion to open surgery rate:Odds ratio(OR)=2.95,95%CI:1.90-4.58,P<0.01;(3)Intraoperative bleeding loss:MD=32.27,95%CI:23.03-41.50,P<0.01;(4)Postoperative hospital stay:MD=1.44,95%CI:0.14-2.73,P=0.03;(5)Overall postoperative compli-cation rate:OR=1.88,95%CI:1.45-2.43,P<0.01;(6)Bile duct injury:OR=2.17,95%CI:1.30-3.64,P=0.003;(7)Intra-abdominal hemorrhage:OR=2.45,95%CI:1.06-5.64,P=0.004;and(8)Wound infection:OR=0.These find-ings consistently favored the PTGBD+LC group over the LC group.There were no significant differences in the total duration of hospitalization[MD=-1.85,95%CI:-4.86-1.16,P=0.23]or bile leakage[OR=1.33,95%CI:0.81-2.18,P=0.26]between the two groups.CONCLUSION The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety,suggesting its broader application value in clinical practice.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP),with its clinical ad-vantages of less trauma and faster recovery,has become the primary treatment for choledocholithiasis.AIM To investigate the effects of different ERCP procedures on the sphincter of Oddi.METHODS The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively.The patients were divided into endoscopic sphinc-terotomy(EST,n=24)and endoscopic papillary balloon dilation(EPBD,n=67)groups.The duration of operation,pancreatic development,pancreatic sphinc-terotomy,intubation difficulties,stone recurrence,and incidence of reflux cho-langitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction in the EST and EPBD groups.RESULTS Differences in hypertension,diabetes,increased bilirubin,small diameter of the common bile duct,or ampullary diverticulum between the two groups were not significant.Statistically significant differences were observed between the two groups concerning sex and age(<60 years).Patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group.The number of cases of pancreatic development,pancreatic duct sphincterotomy,and difficult intubation were higher in the EST group than in the EPBD group.The number of Oddi’s sphincter manometries,ERCP surgical outcomes,and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group.The numbers of stone recurrences,reflux cholangitis,and cholecystitis were higher in the EST group than in the EPBD group.CONCLUSION In summary,common bile duct stones,pancreatitis history,and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD.Based on this evidence,this study can provide actionable insights for clinicians and researchers.

Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise?

AIM： To determine the rates of success and complications of precut biliary sphincterotomy （PBS） based on prior experience and to compare the complication rates between PBS and standard endoscopic sphincterotomy （ES）. METHODS： A retrospective evaluation of prospectively collected non-randomized data at an academic tertiary referral center, The study included all patients in an eight-year period who underwent PBS and ES by a single endoscopist who had no formal training in PBS. The main outcorne measures of the study were success and complications of PBS with a comparison to complications of ES.RESULTS： A total of 2939 endoscopic retrograde chola ngiopancreatographies （ERCPs） were performed during the study period, including 818 （28%） ES and 150 （5%） PBS procedures. Selective biliary cannulation via PBS was successful at the first attempt in 75% of the patients. Cannulation was achieved in an additional 13% of the patients at a subsequent attempt （total 87%）. Complication rate from PBS was 45% higher than ES, but did not differ significantly [7% （10/50） vs 5% （38/818）, P = 0.29]. None of the complications from PBS was severe. A significant trend towards increasing success existed with regard to the endoscopist＇s first attempt at precut （P = 0.0393, Cochran-Armitage exact test for trend, Z = -1.7588）. CONCLUSION： Despite the lack of specific training in this technique, PBS was performed with a high success rate and a complication rate similar to or less than reports from other experienced centers. These results suggest that endoscopic experience and perhaps innate endoscopic skill may play an important role in the outcome of this procedure.

Endoscopic papillary large balloon dilation alone or combined with small or complete sphincterotomy for the removal of large common bile duct stones

Background:Endoscopic papillary large balloon dilation(EPLBD)has been proposed as an alternative to manage large bile duct stones.However,EPLBD alone or combined with sphincterotomy remains controversial.Methods:Between Jan.2014 and Dec.2017,195 consecutive patients with proven large common bile duct stones(size≥10 mm)were retrospectively analyzed.We compared the baseline characteristics,procedure time,success rate of stone removal and morbidity outcomes in different groups.Results:There were no significant difference between baseline characteristics of the groups compared.A total of 89.2%,95.4%,and 93.8% of the patients in the EPLBD,EPLBD+small sphincterotomy(SES),and EPLBD+complete sphincterotomy(CES)groups had stones cleared(P=0.473),respectively.There was no difference in terms of procedure time(33.5±10.2,34.8±9.0,34.9±8.2,in the EPLBD,EPLBD+SES,and EPLBD+CES groups,respectively).However,when assigned to tvvo groups according to bile duct stones diameter(bile duct stones<13 mm,bile duct stones≥13 mm).in the bile duct stones<13 mm group,the procedure time was significantly less in the EPLBD group than the EPLBD+SES group and the EPLBD+CES group(P=0.028).In the bile duct stones≥13 mm group,the mechanical lithotripsy rate of EPLBD was significantly higher compared to EPLBD+SES or EPLBD+CES(P=0.032).The complication rates were similar among all groups.Conclusions:The diameter of bile duct stones should be taken into consideration when choosing EPLBD alone or combined with small sphincterotomy for the removal of common bile duct stones.

Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis

Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis:A meta-analysis

AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND Endoscopic sphincterotomy(EST) for the management of common bile duct stones(CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy(OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.AIM To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.METHODS Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching(1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic(ROC)curve was generated for qualifying independent risk factors.RESULTS In total, 302 patients undergoing successful EST(n = 168) or OCT(n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT(P <0.001). The number of complete stone clearance sessions increased significantly in the EST group(P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in18.8%(33/176) of the patients overall, but no difference was found between the EST(20.5%, 18/88) and OCT(17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct(CBD) diameter > 15 mm(OR =2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS(OR = 5.09; 95%CI: 2.58-10.07; P< 0.001), and distal CBD angle ≤ 145°(OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81(95%CI: 0.76-0.87).CONCLUSION EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Endoscopic papillary large balloon dilation after limited sphincterotomy for difficult biliary stones

AIM:To assess the efficacy and safety of endoscopic papillary large balloon dilation after biliary sphincterotomy for difficult bile duct stones retrieval.METHODS:Retrospective review of consecutive patients submitted to the technique during 18 mo.The main outcomes considered were:efficacy of the procedure(complete stone clearance;number of sessions;need of lithotripsy) and complications.RESULTS:A total of 30 patients with a mean age of 68 ± 10 years,23 female(77%) and 7 male(23%) were enrolled.In 10 patients,a single stone was found in the common bile duct(33%) and in 20 patients multiple stones(67%) were found.The median diameter of the stones was 17 mm(12-30 mm).Dilations were performed with progressive diameter Through-TheScope balloons(up to 12,15) or 18 mm.Complete retrieval of stones was achieved in a single session in 25 patients(84%) and in two sessions in 4 patients(13%).Failure occurred in 1 case(6%).Mechanical lithotripsywas performed in 6 cases(20%).No severe complications occurred.One patient(3%) had mild-grade post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis.CONCLUSION:Endoscopic balloon dilatation with a large balloon after endoscopic sphincterotomy is a safe and effective technique that could be considered an alternative choice in therapeutic ERCP.

Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

AIM:To compare the outcomes between doubleguidewire technique(DGT) and transpancreatic precut sphincterotomy(TPS) in patients with difficult biliary cannulation.METHODS:This was a prospective,randomized study conducted in single tertiary referral hospital in Korea.Between January 2005 and September 2010.A total of 71 patients,who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved,were randomized into DGT(n = 34) and TPS(n = 37) groups.DGT or TPS was done for selective biliary cannulation.We measured the technical success rates of biliary cannulation,median cannulation time,and procedure related complications.RESULTS:The distribution of patients after randomization was balanced,and both groups were comparable in baseline characteristics,except the higher percentage of endoscopic nasobiliary drainage in the DGT group(55.9% vs 13.5%,P < 0.001).Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min,P = 0.732,respectively.There was no significant difference between the two groups.The overall incidence of post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis was 38.2% vs 10.8%,P < 0.011 in the DGT group and the TPS group;post-procedure pancreatitis was significantly higher in the DGT group.But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups;DGT group vs TPS group:14.7% vs 16.2%,P < 1.0.CONCLUSION:When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved,DGT and TPS facilitated biliary cannulation and showed similar success rates.However,post-procedure pancreatitis was significantly higher in the DGT group.

Precut sphincterotomy:A reliable salvage for difficult biliary cannulation

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy(EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Endoscopic papillary balloon dilation after sphincterotomy for difficult choledocholithiasis:A case-controlled study

AIM:To evaluate the efficacy and safety of endoscopic sphincterotomy(EST) + endoscopic papillary large balloon dilation(EPLBD)vs isolated EST.METHODS:We conducted a retrospective single center study over two years,from February 2010 to January 2012.Patients with large(≥ 10 mm),single or multiple bile duct stones(BDS),submitted to endoscopic retrograde cholangio-pancreatography(ERCP) were included.Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy(EST+EPLBD),using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram.Patients in Group B(control group) underwent isolated sphincterotomy.Stones were removed using a retrieval balloon catheter and/or a dormia basket.When necessary,mechanical lithotripsy was performed.Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure.In case of residual lithiasis,a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk.Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP.Outcomes of EST+EPLBD(Group A) vs isolated EST(Group B) were compared regarding efficacy(complete stone clearance,number of therapeutic sessions,mechanical and/or extracorporeal lithotripsy,biliary stent placement) and safety(frequency,type and grade of complications).Statistical analysis was performed using χ 2 or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables.A P-value of less than 0.05 was considered statistically significant.RESULTS:One hundred and eleven patients were included,68(61.3%) in Group A and 43(38.7%) in Group B.The mean diameter of the stones was similar in the two groups(16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B,respectively).Forty-eight(70.6%) patients in Group A and 21(48.8%) in Group B had multiple BDS(P = 0.005).Overall,balloon dilation was performed up to 12 mm in 10(14.7%) patients,13.5 mm in 17(25.0%),15 mm in 33(48.6%),16.5 mm in 2(2.9%) and 18 mm in 6(8.8%) patients,taking into account the diameter of the largest stone and that of the bile duct.Complete stone clearance was achieved in sixty-five(95.6%) patients in Group A vs 30(69.8%) patients in Group B,and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B(P 【 0.001).Patients submitted to EST+EPLBD underwent fewer therapeutic sessions(1.1 ± 0.3 vs 1.8 ± 1.1,P 【 0.001),and fewer required mechanical(14.7% vs 37.2%,P = 0.007) or extracorporeal(0 vs 18.6%,P 【 0.001) lithotripsy,as well as biliary stenting(17.6% vs 60.5%,P 【 0.001).The rate of complications was not significantly different between the two groups.CONCLUSION:EST+EPLBD is a safe and effective technique for treatment of difficult BDS,leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.

Biliary stenting with or without sphincterotomy for malignant biliary obstruction:A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).