Clinical Evaluation of ERCP and Naobiliary Drainage for Biliary Fungal Infection——A Report of Five Cases of Severe Combined Bacterial and Fungal Infection of Biliary Tract

Summary： This study studied the use of ERCP and nasobiliary tube in the diagnosis of fungal infection of hiliary tract and the efficacy of combined use of local administration via nasohiliary tube and intravenous antifungal treatment for severe biliary tract fungal infection. 5 patients in our series, with age ranging from 47 to 68 y （mean 55.8）, were diagnosed as having mixed bacterial and fungal infection of hiliary tract as confirmed by smear or/and culture of bile obtained by ERCP and nasohiliary drainage. Besides routine anti-bacteria therapy, all patients received local application of flu- conazole through nasohiliary tube and intravenous administration of fluconazole or itraconazole in terms of the results of in vitro sensitivity test. The mean duration of intravenous fluconazole or itraconazole was 30 days （24-40 days）, and that of local application of fluconazole through nasobiliary drainage tube was 19 days （8 24 days）. During a follow up period of 3-42 months, all patient＇s fungal infection of biliary tract was cured. It is concluded that on the basis of typical clinical features of biliary tract infection, fungal detection of smear/culture of bile obtained by ERCP was the key for the diagnosis of fungal infection of biliary tract. Local application antifungal drug combined with intravenous anti-fungal drugs might be an effective and safe treatment for fungal infection of biliary tract.

Efficacy and safety of endoscopic transpapillary gallbladder drainage in acute cholecystitis:An updated meta-analysis

BACKGROUND Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery.Endoscopic transpapillary gallbladder drainage(ETGBD)has evolved into an alternative treatment.There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis,though results have been variable.AIM To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis.METHODS We performed a systematic review of major literature databases including PubMed,OVID,Science Direct,Google Scholar(from inception to March 2021)to identify studies reporting technical and clinical success,and post procedure adverse events in ETGBD.Weighted pooled rates were then calculated using fixed effects models for technical and clinical success,and post procedure adverse events,including recurrent cholecystitis.RESULTS We found 21 relevant articles that were then included in the study.In all 1307 patients were identified.The pooled technical success rate was 82.62%[95%confidence interval(CI):80.63-84.52].The pooled clinical success rate was found to be 94.87%(95%CI:93.54-96.05).The pooled overall complication rate was 8.83%(95%CI:7.42-10.34).Pooled rates of post procedure adverse events were bleeding 1.03%(95%CI:0.58-1.62),perforation 0.78%(95%CI:0.39-1.29),peritonitis/bile leak 0.45%(95%CI:0.17-0.87),and pancreatitis 1.98%(95%CI:1.33-2.76).The pooled rates of stent occlusion and migration were 0.39%(95%CI:0.13-0.78)and 1.3%(95%CI:0.75-1.99)respectively.The pooled rate of cholecystitis recurrence following ETGBD was 1.48%(95%CI:0.92-2.16).CONCLUSION Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

Sequential therapy with combined trans-papillary endoscopic nasopancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

BACKGROUND Endoscopic retrograde pancreatic drainage(ERPD)and stent implantation has become the major treatment method for pancreatic pseudocysts.However,it is associated with a high recurrence rate and infection.AIM To manage pancreatic pseudocysts by sequential therapy with endoscopic nasopancreatic drainage(ENPD)combined with ERPD and evaluate the treatment outcome.METHODS One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed.There were 152 cases of intubation via the duodenal papilla,of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD(two-step procedure).The success rate of the procedure,incidence of complications(infection,bleeding,etc.),recurrence,and length and cost of hospitalization were compared between the two groups.RESULTS The incidence of infection was significantly higher in the ERPD group(12 cases)than in the two-step procedure group(2 cases).Twelve patients developed infection in the ERPD group,and anti-infection therapy was effective in five cases but not in the remaining seven cases.Infection presented as fever and chills in the two-step procedure group.The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group(P<0.05).Similarly,the recurrence rate was significantly higher in the ERPD group(19 cases)than in the two-step procedure group(0 cases).CONCLUSION Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.

Application of endoscopic nasobiliary cutting in the treatment of hilar cholangiocarcinoma

Objective The aim of the study was to study the clinical efficacy and prognosis of endoscopicallycutting the nasobiliary duct and leaving its residual segment as a biliary stent in the treatment of hilarcholangiocarcinoma (HC).Methods The clinical data of 55 patients with HC treated by endoscopic biliary drainage at theGastrointestinal Endoscopy Center of our hospital (Renmin Hospital of Wuhan University, China) fromAugust 2017 to August 2019 were retrospectively analyzed. According to different drainage schemes,patients were divided into the endoscopic nasobiliary cutting group (n = 26) and the endoscopic retrogradebiliary drainage (ERBD) group (n = 29). The postoperative liver function indexes, incidence of postoperativecomplications, median patency period of stents, and median survival time of patients were comparedbetween the two groups.Results Liver function indexes (total bilirubin, direct bilirubin, alanine aminotransferase, aspartateaminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase) were significantly decreased in55 patients a week postoperaticely (P < 0.05), and decreases in liver function indexes in the endoscopicnasobiliary cutting group were more significant than those in the ERBD group (P < 0.05). The incidenceof biliary tract infection in the endoscopic nasobiliary cutting group was significantly lower than that in theERBD group (15.40% vs. 41.4%, P < 0.05). In the endoscopic nasobiliary cutting subgroups, there were 1and 3 cases of biliary tract infection in the gastric antrum cutting group (n = 21) and duodenal papilla cuttinggroup (n = 5), respectively, and 0 cases and 2 cases of displacement, respectively;there was a statisticallysignificant difference in terms of complications between the two subgroups (P < 0.05). The median patencyperiod (190 days) and median survival time (230 days) in the nasobiliary duct cutting group were higherthan those (169 days and 202 days) in the ERBD group, but there was no significant difference (P > 0.05).Conclusion The nasobiliary duct was cut by using endoscopic scissors in Stage II after the bile was fullydrained through the nasobiliary duct. The residual segment could still support the bile duct and drain bile.The reduction of jaundice and the recovery of liver enzymes were significant, and the incidence of biliarytract infection was low. Cutting off the nasobiliary duct at the duodenal papilla results in a higher incidenceof biliary tract infection, and the residual segment of the nasobiliary duct is more likely to be displaced.Endoscopic nasobiliary-cutting drainage is an effective, simple, and safe method to reduce jaundice in thepalliative treatment of HC.

Biliary spontaneous dislodgement spiral stent for patients who underwent mechanical lithotripsy

BACKGROUND The incidence of post-endoscopic retrograde cholangiopancreatography(ERCP)cholangitis(PEC)in patients who underwent mechanical lithotripsy(ML)for large stone removal is high(up to 13.3%).One of the main causes is remaining small fragments or sludge that can impair normal biliary drainage.Endoscopic placement of a nasobiliary tube or a conventional plastic biliary stent has been commonly used under such conditions,but the patient may suffer from significant discomfort after the placement of a nasobiliary tube,while additional endoscopy is required for stent removal.We developed a biliary spontaneous dislodgement spiral stent(BSDSS)to overcome those shortcomings.AIM To evaluate the feasibility,safety,and effectiveness of inserting a BSDSS for patients who underwent ML for large stone removal.METHODS We conducted a single-center,retrospective,cohort study at West China Hospital,Sichuan University.A total of 91 consecutive patients with large biliary stones(≥10 mm)in the common bile duct who underwent ML between November 2017 and July 2018 were included.The 49 eligible patients were divided into the BSDSS group and the nasobiliary tube group.Technical success,post-ERCP adverse events(including PEC,post-ERCP pancreatitis,stone recurrence,BSDSS retention,self-extraction and dislocation of the nasobiliary tube),drainage time,and postoperative stay were measured and compared.RESULTS Twenty-one patients in the BSDSS group and 28 patients in the nasobiliary tube group were included in the analyses.The baseline characteristics and clinical information were similar in the two groups.Insertions of BSDSS and nasobiliary tube were technically successful in all 49 patients.There was no significant difference in the incidence of overall post-ERCP adverse events between the two groups(4.8%in the BSDSS group vs 17.9%in the nasobiliary tube group,P=0.219).The median duration of drainage time(3 d in the BSDSS group vs 4 d in the nasobiliary tube group)and length of postoperative stay(4 d in the BSDSS group vs 5 d in the nasobiliary tube group)also did not differ(P=0.934,and P=0.223,respectively).CONCLUSION Endoscopic placement of a BSDSS appears to be feasible,safe and effective for patients who underwent ML for large stone removal.