The rate of endoscopic observation of the major duodenal papilla can be increased by simple guideline

Background:Ampullary lesions are being detected with increased frequency with the growing use of esophagogastroduodenoscopy. However, it is uncertain how frequently endoscopists properly visualize the major papilla in routine clinical practice. This study was undertaken to determine the actual rate of observing the major papilla by endoscopists and if there is a room for improvement in visualizing the duodenal major papilla when performing esophagogastroduodenoscopy.Methods:This was a single-center, prospective, randomized study involving 3,088 consecutive patients referred for diagnostic esophagogastroduodenoscopy at tertiary-care referral center between September and November 2010. Six fellows-in-training in the study group attempted to visualize the major papillaup to three times, while six fellows-in-training in the control group performed endoscopy in a standard fashion.Results:The overall observation rate was significantly higher in study group (975 of 1070 [91.1%]) than in control group (624 of 1022 [61%], p<0.001). 揅omplete observation� was achieved in 68.2% of the cases in study group compared to 45.0% of the cases in control group (p<0.001). The total procedure time was slightly, but significantly longer in the study group (5.82�38 min versus5.52�11 min, p=0.003).Conclusions:The rate of observing the major papilla for endoscopists is not as high as expected in routine clinical practice; however, the rate of observing the major papilla might improve significantly through application of additional effort with but a modest increase in procedural time.

Needle-knife fistulotomy for difficult cannulation during ERCP / 中华消化内镜杂志

Objective To evaluate the effectiveness and safety of needle-knife fistulotomy (NKF)for difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Methods Data of patients, who received NKF on the back of major papilla when bile duct could not be accessed by conventional cannulation and/or other pre-cut methods during ERCP, were retrospectively reviewed. The success rate of deep cannulation and its complications were observed and analyzed. Results NKF was performed in 108patients due to difficult cannulation, which succeeded in 97 (91.2%) in access to the bile duct and failed in 11 patients with malignant biliary strictures. The failure rate in patients with distal malignant obstruction was higher (25. 8%, 8/31) than those with proximal lesions (5.3%, 3/57) (P = 0. 014, χ2 = 5. 983).Post-ERCP pancreatitis occurred in 5 cases (4. 6%), with the incidence significantly higher in NKF-failure group (18. 2%, 2/11) than that in NKF-suocess group (3.1% ,3/97) (P = 0. 006, χ2 = 7.418). Intestinal perforation occurred in 1 patient and cholangitis developed in 4 others, which all recovered after conservative managements. Conclusion NKF for difficult cannulations in ERCP is safe and effective, especially in hands of experienced operators, but cannulation success rate is relatively low in distal malignant biliary obstruction.

Endoscopic Papillectomy for Tumors of the Duodenal Major Papilla / 대한소화기내시경학회지

BACKGROUND/AIMS: A surgical resection has traditionally been used to treat tumors of the duodenal major papilla. However, radical surgery may cause significant morbidity and mortality. Endoscopic papillectomy has been reported in patients with benign papillary tumors. We evaluated the safety and outcomes of endoscopic papillectomy in patients with a papillary tumor. METHODS: Between January 1994 and December 2003, fifteen patients with ampullary tumors underwent an endoscopic papillectomy using a snare resection. Endoscopic papillectomy was performed in 13 patients diagnosed with an adenoma and in 2 patients diagnosed with an adenocarcinoma, who were contraindicated for surgery. RESULTS: Endoscopic papillectomy was performed in fifteen patients (11 men, 4 women: median age 61.7 years). All the tumors were removed either "en bloc" (14 tumors) or in a "piecemeal" fashion (one tumor). Ten patients were available for follow-up (median, 20.9 months: range, 1~62 months). The procedure-related complications were bleeding (n=1), pancreatitis (n=3), and a duodenal perforation (n=1). The follow-up endoscopy revealed a recurrent adenocarcinoma in 2 patients after 13 months (20%). CONCLUSIONS: Endoscopic papillectomy is a useful alternative for treating a papillary adenoma. The relatively high incidence of pancreatitis this study suggests that stenting into the pancreatic duct will be needed to prevent postprocedure pancreatitis.