O uso da pinça de biópsia como técnica auxiliar na visualização da papila duodenal maior utilizando-se o esofagogastroduodenoscópio de visão frontal / The use of the forceps biopsy as an auxiliary technique for the visualization of the major duodenal papilla using the foward-viewing upper endoscopy

ABSTRACT BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

RESUMO CONTEXTO: Esofagogastroduodenoscopia convencional é o melhor método para avaliação do trato gastrointestinal superior, mas apresenta limitações para identificação da papila duodenal maior, mesmo após emprego da manobra de retificação. Exame completo da papila duodenal maior está indicado para pacientes de alto risco para adenocarcinoma da papila duodenal maior. OBJETIVO: Avaliar a utilização da pinça de biópsia durante esofagogastroduodenoscopia convencional como ferramenta adicional à manobra de retificação na avaliação da papila duodenal maior. MÉTODOS: Foram estudados 671 pacientes entre 2013-2015 com busca ativa da papila duodenal maior em três etapas: endoscópio não retificado, endoscópio retificado e uso da pinça de biópsia após retificação. Em todas se registrou: se a papila duodenal maior foi totalmente visualizada (posição A), se parcialmente visualizada (posição B) ou se não visualizada (posição C). Caso a papila duodenal maior não tenha sido completamente visualizada, o paciente foi direcionado para a etapa seguinte. RESULTADOS: Um total de 341 era do sexo feminino (50,8%) com idade média de 49 anos. Dos 671 pacientes, em 324 (48,3%) a papila duodenal maior foi identificada na posição A, 112 (16,7%) em posição B e, 235 (35%) em posição C. Dos 347 pacientes submetidos à manobra de retificação, posição A foi encontrada em 186 (53,6%), posição B em 51 (14,7%) e posição C em 110 (31,7%). Dos 161 pacientes restantes que utilizaram a pinça de biópsia, posição A foi vista em 94 (58,4%), posição B em 14 (8,7%) e posição C em 53 (32,9%). A taxa acumulativa de visualização completa da papila duodenal maior foi de 90%. CONCLUSÃO: O uso da pinça de biópsia aumentou a taxa de visualização completa da papila duodenal maior em 14%, alcançando 604/671 (90%) dos pacientes (P<0,01) avaliados e pode ser facilmente incorporada aos exames endoscópicos de rotina do trato gastrointestinal superior.

Audit of ERCP at Ibn Sina Hospital from 2009-2010

Surgeons are expected to deal with expect some failure of ERCP in extraction of missed CBD stones. Re-do surgery is difficult; however surgeons have to stand for it. To audit the outcome of ERCP in extraction of CBD stone for patients referred to Ibn Sina Teaching Hospital. This is prospective, hospital based study; carried in the period from January 2009 to June 2010 in Ibn Sina Teaching Hospital .A total of 119 patients referred for ERCP extraction of CBD stones were studied. Male to female ratio was 1:5. The mean age [ +/- SD] is 55.4 [ +/- 17.57]. Post cholecystectomy missed stones were 7[6%], post CDB exploration retained stones were 4[3.4%] and re-do ERCP was done in 9[7.6%] patients. Failure of stone extraction occurred in 10[25%] cases due to failure of cannulation while another 10[25%] cases had multiple impacted stones and nine [22.2%] had too big stone to be extracted. In addition, five [12.5%] cases had CBD stricture, and the procedure was not completed because of bleeding in two cases and impaction of the dormia basket in two [5%] cases. The success of redo ERCP is seven out of nine cases. Complication occurred in seven [5.88%] patients. These were bleeding in two [1.68%], cholangitis in one [0.84%] CBD and retro-peritoneal duodenal perforations in two [1.68%] and retained dormia basket in two [1.68%] cases. The mortality rate was one [0.8%] patient. ERCP, at Ibn Sina Hospital, has success rate in stone extraction in 79[66.4%] and complication rate in seven [5.88%] patients. About one third of cases attending ERCP for stone extraction were referred back for open exploration of CBD

Papillary stenosis in King Chulalongkorn Memorial Hospital: endoscopic findings, treatments and result.

Papillary stenosis usually presents with biliary type abdominal pain, significantly elevated liver enzymes, and cholangiogram revealing dilated common bile duct without stone. In the Western world, endoscopic biliary sphincterotomy is accepted as a standard treatment for papillary stenosis. In Asia, there are only a few reports regarding papillary stenosis. This is a report of our experience on endoscopic biliary sphincterotomy for papillary stenosis in Thai patients. From our ERCP database, twenty-five patients presented with biliary type abdominal pain, elevated liver enzymes and dilated common bile duct by ultrasonography. All of them underwent ERCP for a diagnosis of possible biliary obstruction. Of these 25 cases, seven patients with papillary stenosis were identified. All underwent endoscopic biliary sphincterotomy with or without biliary dilation and stent placement. These patients were followed for clinical improvement and normalization of liver enzymes. Endoscopic biliary sphincterotomy was successful in all patients. One patient required additional biliary dilation and stent placement. All seven patients reported significant improvement of biliary type abdominal pain. Liver enzymes also normalized 3 months after endoscopic treatment. There were no severe complications except one patient who developed post ERCP pancreatitis while another developed minimal bleeding at the sphincterotomy site. Endoscopic biliary sphincterotomy is effective and safe in patients with papillary stenosis. Results of our series are comparable to previous reports from Western countries.