Combined use of a two-channel endoscope and a flexible tip catheter for difficult biliary cannulation

A 69-year-old woman with jaundice was referred to our hospital. After a final diagnosis of pancreatic cancer with liver metastasis, we performed transpapillary biliary drainage with a covered self-expandable metal stent (SEMS). Three months later, we also placed an uncovered duodenal stent for duodenal stricture in a side-to-end fashion. Another month later, for biliary SEMS obstruction, we attempted a transpapillary approach. A duodenoscope was advanced and a guidewire was passed through the mesh of the duodenal stent into the bile duct with a flexible tip catheter, but the catheter was not. Thus, we exchanged the duodenoscope for a forward-viewing two-channel endoscope and used the left working channel with a flexible tip catheter. By adjusting the axis, we finally succeeded biliary cannulation and accomplished balloon cleaning for recanalization of the SEMS. This is the first case with successful biliary cannulation by combined use of a two-channel endoscope and a flexible tip catheter.

Duodenoscope-Associated Infections: A Literature Review and Update / 대한췌담도학회지

A duodenoscope is complex instrument with an elevator and an elevator wire channel which are difficult to access and not readily amenable to cleaning and disinfection. Lapses in endoscope reprocessing have been regarded as a major cause of duodenoscope-associated transmission of infection. However, recent outbreaks of carbapenem-resistant Enterobacteriaceae or other multidrug-resistant organisms have emerged in spite of proper adherence to the manufacturer's reprocessing instructions. It is the time to reestablish reprocessing protocol appropriate for duodenoscope and revise a new design of duodenoscope that makes reprocessing easier in order to prevent cross-transmission of infection by duodenoscope. This manuscript reviews current state of duodenoscope-associated infections, recent measures from the United States government agencies and its limitations, and future strategies to prevent duodenoscope-associated infections.

Common Bile Duct Stone Removal with Side-viewing Duodenoscope after Forward-Viewing Endoscope-Guided Pancreatic Stent Insertion in a Patient with Periampullary Diverticulum / 대한췌담도학회지

No abstract available.

Synchronous Esophageal and Gastric Cancer Detected by Iatrogenic Esophageal Mucosal Injury Incurred During Endoscopic Retrograde Cholangiopancreatography / 대한췌담도학회지

Esophageal mucosal tear occurred during scope insertion in a 71-year-old male patient who previously underwent endoscopic retrograde cholangiopancreatography (ERCP) several times without any complications. The mucosal tear was successfully sealed with endoclips using a forward-viewing scope. However, this mishap leads to the incidental discovery of both esophageal cancer and early gastric cancer. Duodenoscope has inherent limitation in observing the gastrointestinal tract, especially the esophagus, and may miss clinically significant lesions. Therefore, in addition to applying sufficient lubricant to the scope tip and considering the possibility of anatomical variation to prevent mucosal injury or perforation, performing upper endoscopy during ERCP should be considered in a certain patient population, albeit the utility of and the population benefiting from it remains to be proven by a large-scale study.

Post-Endoscopic Retrograde Cholangiopancreatography Infection / 대한췌담도학회지

Infection is a known complication of endoscopic retrograde cholangiopancreatography (ERCP), occurring in up to 1.5% of cases. However, it is important to realize that true incidence may be underestimated because infection may go unnoticed. Post-ERCP infections are considered to be endogenous infections arising from the intestinal bacteria of the patient and introduction of exogenous bacteria through inadequately reprocessed duodenoscopes. During the past years, carbapenem resistance has become a major concern for public health. The infection outbreaks after ERCP are linked to breaches in adherence to disinfection manual and complex design of duodenoscopes difficult to reprocess. The most important risk factor for ERCP-related cholangitis is inadequate biliary drainage. To minimize the risk of post-ERCP infection it would be helpful that the volume of contrast injected into the biliary tree has to be minimized to obtain adequate cholangiogram. In patients with bile duct obstruction and failed drainage of infected bile via ERCP, every effort should be made to achieve prompt decompression of an obstructed biliary system. Antibiotic prophylaxis is recommended only in patients with biliary obstruction in which there is a possibility that complete drainage may not be achieved at the ERCP.

Post-Endoscopic Retrograde Cholangiopancreatography Infection / 대한췌담도학회지

Infection is a known complication of endoscopic retrograde cholangiopancreatography (ERCP), occurring in up to 1.5% of cases. However, it is important to realize that true incidence may be underestimated because infection may go unnoticed. Post-ERCP infections are considered to be endogenous infections arising from the intestinal bacteria of the patient and introduction of exogenous bacteria through inadequately reprocessed duodenoscopes. During the past years, carbapenem resistance has become a major concern for public health. The infection outbreaks after ERCP are linked to breaches in adherence to disinfection manual and complex design of duodenoscopes difficult to reprocess. The most important risk factor for ERCP-related cholangitis is inadequate biliary drainage. To minimize the risk of post-ERCP infection it would be helpful that the volume of contrast injected into the biliary tree has to be minimized to obtain adequate cholangiogram. In patients with bile duct obstruction and failed drainage of infected bile via ERCP, every effort should be made to achieve prompt decompression of an obstructed biliary system. Antibiotic prophylaxis is recommended only in patients with biliary obstruction in which there is a possibility that complete drainage may not be achieved at the ERCP.

Endoscopic Ablation Therapy for Biliopancreatic Malignancies

Biliopancreatic malignancies such as cholangiocarcinoma (CCA) has notoriously been diagnosed late. As such most therapy have been palliative in nature. Cholangioscopy allows for an earlier diagnosis to be made. Brachytherapy with the insertion of catheter with iridium-132 seeds, percutaneously or through endoscopic retrograde cholangiopancreatography (ERCP) was the earliest ablative techniques used. It has been shown to have a beneficial effect only in prolonging survival. Photodynamic therapy (PDT) has also been used for several years. stenting with PDT versus stenting alone for unresectable CCA showed a marked survival benefit with the addition of PDT. However the most exciting endoscopic ablative modality appears to be intraductal radiofrequency ablation using the Habib catheter and device. Several case series have shown the effectiveness of this technique in ablating tumors. This technique is evolving and coupled with early diagnosis of CCA through cholangioscopy will allow for a curative therapy. The crux to the effective treatment of early cancerous lesions in the bile or pancreatic duct is the early diagnosis of such lesions. Effective endoscopic ablative therapy is now available with the advent of radiofrequency ablation probes that can be passed through the duodenoscope via ERCP.

Current Issues in Duodenoscope-Associated Infections: Now Is the Time to Take Action

A duodenoscope has a very complex structure that contains many small parts which make reprocessing more challenging. The difficulty in cleaning duodenoscopes contributes to a higher risk of infection than that of conventional gastrointestinal endoscopes. However, a duodenoscope shares similar disinfection process with other gastrointestinal endoscopes. Recent outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) infections associated with duodenoscopes used for endoscopic retrograde cholangiopancreatography procedures have raised many concerns worldwide. Duodenoscope-associated infections involving CRE or other multidrug-resistant bacteria pose a great threat to patients undergoing procedures using duodenoscopes and should be dealt with a great concern. Updated guidelines regarding cleaning and disinfection of duodenoscope needs to be developed urgently to prevent transmission of infection and ensure patient safety. Meanwhile, healthcare staff should pay special attention to thorough cleaning and disinfection of duodenoscopes.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy. METHODS: Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications. RESULTS: Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred. CONCLUSIONS: Without preceding sphincterotomy, one-step EPBD (> or =10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (> or =10 mm) with CBD dilatation in Billroth II gastrectomy.

Three Cases of Successful Treatment of Iatrogenic Duodenal Perforation / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography has become a standard procedure for the diagnosis and treatment of pancreatobiliary disease. Like any invasive procedure, it carries a small, but significant rate of serious complications such as duodenal perforation. Primary surgical closure is the treatment of choice for the cases of duodenal perforation. However, there have been some case reports in which endoscopic metal clip closure of an iatrogenic duodenal perforation was successful. We experienced three cases of successful treatment of the iatrogenic duodenal perforation using endoscopic clipping and fibrin glue injections during a duodenoscope insertion.

Endoscopic Retrograde Cholangiopancreatography in Thirty-four Children / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is being used with increasing frequency as a diagnostic and therapeutic tool in children with suspected disorders of the pancreaticobiliary tract. We reviewed ERCPs performed in children and investigated clinical indications and usefulness of ERCP. METHODS: A total of 80 ERCPs were performed in 34 patients (age: 17 months~15 yrs) at Asan Medical Center from 1994 to 2001. Adult side-viewing duodenoscope, Olympus JF or TJF, was used for all procedures. General anesthesia was used in 73% of the patients, whereas intravenous sedation was employed in the remainder. RESULTS: Cannulation was successful in 77 attempts (96%). ERCP was commonly indicated for the evaluation of pancreatic disease (18 cases) such as acute pancreatitis (4), recurrent pancreatitis (4), chronic pancreatitis (9), and non-resolving acute pancreatitis (1). Biliary tract diseases (15 cases) were common bile duct stones (4), choledochal cyst (8), and traumatic or nontraumatic common bile duct stricture (3). Therapeutic ERCP (n=20) included sphincterotomy (55.9%), insertion of stents (12%), and removal of common bile duct stones or pancreatic duct stones with balloon or basket (32%). The complications were developed in 12 out of 80 attempts (15%) and resolved with medical management. CONCLUSIONS: ERCP seems to be a useful and relatively safe procedure in the evaluation of pancreaticobiliary disorders in children and also can be used for nonoperative treatment of these diseordrs.

Endoscopic Biliary Drainage Using Soehendra Stent Retriever in Difficult Malignant Biliary Stricture / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic biliary drainage (EBD) has been used effectively as the palliative treatment for malignant biliary obstruction. In high grade strictures, endoscopic stenting can be achieved by dilating devices such as dilating or balloon catheters. Subgroup of malignant biliary obstructions are too stenotic to allow passage of plastic or metal stents. In cases of failure of conventional stenting, we evaluated the efficacy and safety of the 7-Fr Soehendra stent retriever (SSR) used as a dilator. METHODS: From January 1999 to September 2001, 14 patients with malignant pancreaticobiliary stirictures (2 pancreatic, 12 biliary) that could not be traversed with plastic or metal stents, underwent stricture dilation with SSR. An endoscopic sphincterotomy was performed and a guide wire was inserted beyond the stricture. Then the SSR was introduced over the guide wire via duodenoscope. Then the stricture was traversed by torquing the SSR clockwise while pushing it. The SSR was removed and then the plastic or metal stents were inserted above the stricture. RESULTS: Of the 14 patients, 13 patients (93%) underwent successful stenting using SSR. Symptom relief was observed in all patients after endoscopic biliary stenting. One patient (7%) went on to percutaneous biliary drainage because we failed to insert the metal stent into the stenotic left hepatic duct after traversing the stricture with SSR. There were no significant complications such as bile duct or duodenal perforation and bleeding. CONCLUSIONS: The Soehendra stent retriever is useful and safe for dilation with subsequent stent placement of malignant pancreaticobiliary stirictures resistant to conventional stenting. However, this device may be difficult to pass a tortuous or small-diameter hilar stricture.

A Stent-Guided Sphincterotomy in Patients with a Difficult Periampullary Diverticulum or with a Billroth-II Gastrectomy / 대한소화기내시경학회지

BACKGROUND/AIMS: Patients with a congenitally or surgically altered anatomy such as a large diverticulum in which an ampullary orifice exists or a Billroth-II gastrectomy, have an increased complication rate after endoscopic sphincterotomy (EST) compared to normal anatomies. An experience involving a stent-guided sphincterotomy using an endoprosthesis is herein reported. METHODS: 10 patients with a Billroth-II gastrectomy and 9 patients with a large diverticulum received a stent-guided EST. In the diverticula cases, all the ampullary orifices were located either inside the diverticulum or in an unusual position. All patients had common bile duct stones and symptoms of cholangitis. After a 0.035 inch guide wire was inserted through the side-viewing duodenoscope, a 10 Fr. endoprosthesis (MTW, Germany) was inserted and a needle-knife sphincterotome was introduced. In patients with a Billroth-II anatomy, the incision was made from the papillary orifice of the 12 o'clock position toward 6 o'clock. In patients with periampullary diverticula, the incision was made with sweeps of the needle-knife in a 6 to 12 o'clock direction. The cautery current was applied to the mucosa along the stent and the stent was retrieved by a polypectomy snare through the biopsy channel without removal of an endoscope. RESULTS: Among the 19 patients, the guide wire and stent insertion were possible in all except one patient due to the inability of selective cannulation. An EST was performed in all patients after stent insertion. There were no serious complications during and after the stent-guided EST except for two minor bleedings which were treated with a coagulation current using the needle-knife. Consequently, complete endoscopic stone removal was achieved in all patients including three patients in whom a mechanical lithotriptor was needed. CONCLUSIONS: In stent-guided EST, the stent not only guides the adequate direction of the incision but also allows a controlled incision under a favorable visual field. Therefore, blind cutting and exploration during EST can be avoided and successful EST is possible even in difficult situations such as that created by an altered anatomy.

Diagnostic and Therapeutic Efficacy of Endoscopic Retrograde Cholangiopancreatography in Children

PURPOSE: Endoscopic retrograde cholangiopancreatography (ERCP) may provide more definite diagnosis, preoperative guidance, and endoscopic therapy in many children with known or suspected disorders of the pancreas and biliary tract. But the reports about the ERCP in children are rare, so this study is conducted to evaluate the indication, efficacy and safety of the ERCP in children. METHODS: Twenty nine ERCPs in 19 children were included in this study from July, 1994 to Dec, 1996. The children were nine boys and ten girls and their mean age was 6.9 years old (24 months-14 years). The examination was performed in 16 children under general anesthesia while the other 3 adolescent under conscious sedation with Olympus JF or JF1T duodenoscope. We evaluated the indication, efficacy and complication of the ERCPs. RESULTS: All cannulations were successful except one and endoscopic sphincterotomy (EST) was done in 12 children. Among 19 children, we could confirm the clinical diagnosis in 6, add the additional information in 5, revise the diagnosis in 4 (operation guidance in 3), but give no diagnosis in 4 even after ERCP. The diagnosis after ERCPs are choledochol cyst (4), choledochocele (1), bile duct stricture (1), GB and CBD stone (1), pancreatitis with biliary sludge (5), chronic pancreatitis (2) and pancreatic fistula (1). We could achieve therapeutic goal in 8 children after therapeutic ERCP in 11 children. As complications of ERCP, pancreatitis developed in 2 children, moderate delayed hemorrhages requiring transfusion in 2, retroduodenal perforation in 1 and cholangitis in 1 child. No fatality was observed and all complications improved after supportive cares. Most of the complications developed after EST. CONCLUSIONS: All ERCPs were successful, although most of them were done under general anesthesia. In this study we could conclude that ERCP may provide more definite diagnosis, preoperative guidance, and endoscopic therapy in many children with known or suspected disorders of the pancreas and biliary tract. But special care should be paid especially after EST.

Diagnostic and Therapeutic Efficacy of Endoscopic Retrograde Cholangiopancreatography in Children

PURPOSE: Endoscopic retrograde cholangiopancreatography (ERCP) may provide more definite diagnosis, preoperative guidance, and endoscopic therapy in many children with known or suspected disorders of the pancreas and biliary tract. But the reports about the ERCP in children are rare, so this study is conducted to evaluate the indication, efficacy and safety of the ERCP in children. METHODS: Twenty nine ERCPs in 19 children were included in this study from July, 1994 to Dec, 1996. The children were nine boys and ten girls and their mean age was 6.9 years old (24 months-14 years). The examination was performed in 16 children under general anesthesia while the other 3 adolescent under conscious sedation with Olympus JF or JF1T duodenoscope. We evaluated the indication, efficacy and complication of the ERCPs. RESULTS: All cannulations were successful except one and endoscopic sphincterotomy (EST) was done in 12 children. Among 19 children, we could confirm the clinical diagnosis in 6, add the additional information in 5, revise the diagnosis in 4 (operation guidance in 3), but give no diagnosis in 4 even after ERCP. The diagnosis after ERCPs are choledochol cyst (4), choledochocele (1), bile duct stricture (1), GB and CBD stone (1), pancreatitis with biliary sludge (5), chronic pancreatitis (2) and pancreatic fistula (1). We could achieve therapeutic goal in 8 children after therapeutic ERCP in 11 children. As complications of ERCP, pancreatitis developed in 2 children, moderate delayed hemorrhages requiring transfusion in 2, retroduodenal perforation in 1 and cholangitis in 1 child. No fatality was observed and all complications improved after supportive cares. Most of the complications developed after EST. CONCLUSIONS: All ERCPs were successful, although most of them were done under general anesthesia. In this study we could conclude that ERCP may provide more definite diagnosis, preoperative guidance, and endoscopic therapy in many children with known or suspected disorders of the pancreas and biliary tract. But special care should be paid especially after EST.