TEACHING DEEP CANNULATION OF THE BILE DUCT DURING ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY

When performing endoscopic retrograde cholangiopancreatography (ERCP), the smooth introduction of the duodenoscope into the papilla of Vater, an appropriate view of the papilla of Vater, and deep cannulation of the bile duct are essential. The operator must know the difference between the side‐viewing endoscope and the forward‐viewing endoscope. The rotation of the body and the left arm of the operator, switching with the left wrist, and dialing of the endoscope are essential for appropriately viewing the papilla of Vater. When training operators to do ERCP, a model is useful for helping them understand basic handling. The approach to deep cannulation of the bile duct should be selected based on the type of papilla (slit type, onion type, tongue protrusion type, flat type, and tumor type). Cannulation is more difficult in patients with the tongue protrusion‐type of papilla than with a slit type, onion type, or tumor type. According to previous reports, therapeutic ERCP requires the ability to cannulate the common bile duct deeply 80% of the time; 180 to 200 supervised ERCP are necessary to achieve this success rate.     

SUPINE POSITION ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A PATIENT WITH SITUS AMBIGUOUS WITH POLYSPLENIA

A 58‐year‐old woman complained of painless jaundice. The serology showed total bilirubin 10.6 mg/dL with direct bilirubin of 7.0 mg/dL. Abdominal computed tomography (CT) scan disclosed an abnormal arrangement of the abdominal viscera and dilation of the biliary tree. A nearly 1.4 cm‐sized periampullary mass was seen. These findings are compatible with situs ambiguous with polysplenia and were suggestive of a periampullary tumor. Due to her unusual anatomical features, the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) in the supine position instead of in the conventional prone position. ERCP showed that the common bile duct (CBD) diameter was increased to 20 mm. Microscopic findings of the biopsy specimen of papillary mass were compatible with an adenocarcinoma of the ampulla of Vater. The clinical stage was stage IA (T1N0M0). Eight days later, a papillectomy was carried out by endoscopic snare resection. Six months later, follow‐up studies, including ERCP, abdominal CT and 18‐fluorodeoxyglucose positron emission tomography (¹⁸‐FDG PET)‐CT scan, showed no evidence of recurrence. Although the success rate of supine position ERCP may be influenced by the extent of the intestinal malrotation and the position of the duodenum, we conclude that supine position ERCP can be carried out effectively in a patient with situs anomaly.     

JUXTAPAPILLARY DIVERTICULA AND ENDOSCOPIC TREATMENT OF BILE DUCT STONES

Aim: To assess the influence of juxtapapillary diverticula on endoscopic treatment of bile duct stones. Methods: Two hundred and fifty‐eight consecutive patients with bile duct stones who had undergone endoscopic treatment at our department were included in this study. Comparison was done between a group that had a juxtapapillary diverticulum (Group D) and a group that did not (Group N). Results: Deep cannulation was achieved in 98% and 100% of Group D and Group N, respectively. The time required for cannulation was 18 min in both groups. Deep cannulation of the bile duct tended to be difficult in cases with the papilla located at the edge of or in the diverticulum in Group D. Complete removal of stones was achieved in 97.7% and 96.9% of the respective groups. The number of sessions and the total time required for removal of stones in Group D and Group N were 1.6 and 47 min, and 1.5 and 47 min, respectively (n.s.). The occurrence rate of complications was not statistically different (12.4%vs 10.1%); however, it was higher (50%) in those who had a papilla inside the diverticulum. Conclusions: Although the presence of juxtapapillary diverticula has only a subtle influence on endoscopic treatment of bile duct stones, caution is necessary when treating patients with a papilla in a diverticulum because of the high incidence of complications in such patients.     

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY FOR INTRABILIARY RUPTURE OF HYDATID CYST

The most common complication of hydatid cysts of the liver is cholestasis due to rupture of hepatic cysts into the biliary tree. Such a complicated cyst is usually managed by surgical cyst resection. Endoscopic retrograde cholangiogram with sphincterotomy is a well‐established method for preoperative and postoperative extraction of cyst material from the biliary tree. Successful nonsurgical treatments of complicated hydatid cyst are reported with a combination of pharmaceutical therapy and endoscopic techniques consisting of endoscopic sphincterotomy and instillation of hypertonic saline solutions. We report feasibility and outcome of the endoscopic method for treatment of ruptured hepatic hydatid cyst into the biliary tract that also benefited from drainage of the whole cyst and membranes into the major biliary duct.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.     

DOUBLE BALLOON ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN ROUX‐EN‐Y ANASTOMOSIS PATIENTS

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux‐en‐Y anastomosis. We herein present the results of ERCP for patients with a Roux‐en‐Y anastomosis using a double‐balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux‐en‐Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle‐knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N‐butyl‐2‐cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux‐en‐Y anastomosis.     

DUPLICATE GALLBLADDER DIAGNOSED WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND TREATED WITH LAPAROSCOPIC CHOLECYSTECTOMY

A 44‐year‐old man was admitted to hospital because of sudden severe postprandial right epigastric pain. Abdominal echography showed multiple calculi in the gallbladder and evidence of a probable septum at the neck. Based on the results, tentative diagnoses were made of gallbladder calculosis with associated gallbladder curvature or malformation, and gallbladder adenomyomatosis. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed a duplicate gallbladder consisting of two cystic ducts with two connected gallbladders. Laparoscopic cholecystectomy (Lap‐C) was performed. Inflammation of the Calot's triangle was mild. The two cystic ducts with one common bile duct were identified, and the cystic ducts separated by individual clipping. Duplicate gallbladder, a malformation of the gallbladder, has been reported to occur at an incidence of 0.02%. To date, a total of 60 cases have been reported in Japan, and recent cases have been treated with Lap‐C. In the present case, the surgery could be safely performed because the bifurcation of the cystic ducts could be identified by preoperative ERCP.     

ENDOSCOPIC SPHINCTEROTOMY PLUS ENDOPROSTHESES IN THE TREATMENT OF LARGE OR MULTIPLE COMMON BILE DUCT STONES

Background and Aim: Little information is available on the outcomes of endoscopic sphincterotomy plus biliary stent placement without stone extraction as primary therapy at initial endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large or multiple common bile duct (CBD) stones. The aim of the present study was to study the effect of biliary stents and sphincterotomy as primary therapy for patients with choledocholithiasis. Methods: Patients with large (≥20 mm) or multiple (≥3) CBD stones were retrospectively studied. The patients underwent endoscopic sphincterotomy and placement of plastic stents in the bile duct without stone extraction at the initial ERCP. Three or more months later, a second ERCP was carried out and stone removal was attempted. Differences in stone size and the largest CBD diameter before and after stenting were compared. Stone clearance and complications were also evaluated. Results: 52 patients were enrolled. After a median of 124 days of biliary plastic stent placement the mean maximal stone diameter decreased from 16.6 mm to 10.0 mm (P < 0.01). The mean CBD diameter also decreased from 15.3 mm to 11.5 mm (P < 0.01). The total stone clearance at second ERCP was 94.2%, only 5.7% of which needed mechanical lithotripsy. Complications: pancreatitis in one (1.9%) at initial ERCP, cholangitis in two (3.8%) after 52 days and 84 days of placement of stent. No complications were recorded at second ERCP. Conclusions: Biliary plastic stents plus endoscopic sphincterotomy without stone extraction as primary therapy at initial ERCP is a safe and effective method in the management of large or multiple CBD stones.     

ENDOSCOPIC OCCLUSION OF CYSTIC DUCT USING N‐BUTYL CYANOACRYLATE FOR POSTOPERATIVE BILE LEAKAGE

Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N‐butyl cyanoacrylate glue. A 51‐year‐old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N‐butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow‐up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct.     

NEW MEASURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY CATHETER FOR STENTING

Background: The first stent inserted by endoscopic retrograde cholangiopancreatography (ERCP) for a biliary stricture is often either too long or too short, because the length as measured on the ERCP film is a magnified image. To overcome this magnification factor, a new measuring catheter was designed to incorporate radio‐opaque markers at known intervals. This is termed a radio‐opaque ruler for measuring the stricture on the ERCP film. Method: The catheter is inserted until the tip sits at the position where the upper end of a stent should reach. The distance from the tip to the papilla is measured and divided by the distance between the two most distant markers. This ratio is then multiplied by the actual distance between the markers to give the exact length. One cm is added to allow for the lower end to protrude into the duodenum. When the two markers exactly mark the desired distance, the known distance between the markers becomes the exact length because the ratio is one. Results: Six patients with biliary strictures were stented using this measuring catheter. The correct stent was inserted at the first attempt every time. In two patients, the stent was trimmed down to the desired length exactly. The average time taken to complete the procedure was 35 min and no additional sedation was required after the first dose.     

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.     

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938–3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.     

COMPLICATIONS OF ENDOSCOPIC SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS: SAFETY AND BENEFITS OF PANCREATIC STENT PREPLACEMENT

Endoscopic sphincterotomy (EST) is one of the most common procedures for treatment of choledocholithiasis. However, EST sometimes causes complications such as pancreatitis and bleeding. Especially, precut is more risky for pancreatitis. In contrast, bleeding after EST should be treated immediately. Clipping technique is the ideal method for bleeding but is very difficult technically. The authors have carried out precut with needle knife and treated bleeding with argon plasma coagulation after placement of pancreatic duct stent (PS) to prevent pancreatitis. This retrospective study showed the safety and benefit of stent preplacement for these two representative problems. Complications in 174 patients with choledocholithiasis treated by EST were collected and investigated retrospectively. In total, 92% were standard EST, 8% were precut over PS. Pancreatitis occurred in 13.1% of the standard EST group and in 7.1% of the precut over PS group. Bleeding after EST occurred in three cases (1.7%). Two patients were treated easily and safely by argon plasma coagulation after placement of PS.     

Angioleiomyoma of the Common Bile Duct

ABSTRACT An 80-year-old woman with angioleiomyoma in the common bile duct is described. Apart from weakness and jaundice, the patient had no signs or symptoms until after endoscopic retrograde cholangiopancreatography, when cholangitis and septicaemia due to Pseudomonas aeruginosa developed. X-ray during endoscopy revealed a tumour obstructing the common bile duct and was assumed to be malignant. Because the patient was so old and her general condition had deteriorated, no treatment was given. Autopsy revealed a benign angioleiomyoma of the common bile duct and suppurative cholangitis, the latter obviously caused by the endoscopy.     

EFFICACY AND SAFETY OF PROPHYLACTIC PANCREATIC DUCT STENT (PIT‐STENT) PLACEMENT IN PATIENTS AT HIGH RISK OF POST‐ERCP PANCREATITIS

Background: The usefulness of prophylactic pancreatic stent placement for preventing post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis has been reported. We developed a new pancreatic duct stent, which was a 5 Fr, 4 cm‐long stent with a single duodenal pigtail (Pit‐stent). Patients and Methods: Pancreatic duct stenting using a Pit‐stent was attempted in 76 patients (40 men, 36 women; mean age, 65 years; age range, 42–91 years) at high risk of post‐ERCP pancreatitis. The frequency of post‐ERCP pancreatitis and spontaneous passage of the stent were investigated. Results: Pancreatic duct stent placement was successfully performed in 93% of the patients. One patient developed mild pancreatitis after ERCP (1.4%). Spontaneous passage of the stent was observed in 92%. There were no other complications or procedure‐related deaths in this group. Conclusions: Pancreatic duct stent insertion may reduce the incidence of post‐ERCP pancreatitis in patients at high risk of post‐ERCP pancreatitis. Spontaneous migration of a pancreatic stent that contributes to a lessening of the need for additional ERCP can be expected with the use of a Pit‐stent.     

Success rate and complications of endoscopic extraction of common bile duct stones over 2 cm in diameter

BACKGROUND:Clinically,common bile duct (CBD) stones >2 cm are difficult to remove by endoscopic retrograde cholangiopancreatography (ERCP).To evaluate this observation,the rates of successful clearance of CBD stones and complications were compared between ERCP extraction of CBD stones of >2 cm and <2 cm in diameter.METHODS:All patients who had undergone endoscopic extraction of CBD stones at the Endoscopy Center of Shanghai First People's Hospital from May 2004 to May 2008 were reviewed.Patients with CBD st...