Choledocholithiasis in a patient carrying an intragastric balloon. Removal or direct ERCP?

Endoscopic retrograde cholangio-pancreatography (ERCP) is a diagnostic, therapeutic technique for the management of pancreato-biliary conditions. Technical contraindications include the presence of intraluminal foreign bodies precluding endoscope passage. Intragastric balloon (IGB) is a bariatric procedure that provides sensations of early fullness and satiety from intragastric occupation, thus leading to weight loss. While, according to guidelines, choledocholithiasis and cholangitis do not represent an indication for IGB removal in contrast to moderate-severe pancreatitis, where need for an ERCP and the procedure's technical difficulty most commonly require it. We report the case of a female patient with an IGB where ERCP was indicated. CASE REPORT: A 47-year-old woman visited the emergency room for epigastric abdominal pain radiating to her back. She had jaundice without pyrexic symptoms. At the ER an ultrasonogram revealed cholelithiasis and a dilated common bile duct (11 mm in diameter), no cause being then identified. Lab tests rule out pancreatic involvement and associated infection. The patient had an IGB (Photo 1a) implanted 5 months before the present episode. She was admitted to the gastroenterology ward with choledocholithiasis as suspected diagnosis. The study was completed by endoscopic ultrasound (EUS), which confirmed a dilated hepatocholedochal duct at 15.3 mm in diameter (Photo 1b), secondary to multiple choledochal stones. A direct ERCP procedure was initiated where the IGB precluded rectification and proper placement, which forced the use of a double-guidewire technique for cannulation (Photo 1c)5. Sphincterotomy and sphincteroplasty to 10 mm ensued, and 8 stones were removed using a balloon and then a basket catheter (Photo 1d). The patient was discharged at 24 hours after the procedure with no complications. DISCUSSION: No prior studies are available that describe the possibility of therapeutic ERCP for choledocholithiasis in IGB-carrying patients; in most cases IGB removal is taken for granted because of the procedure's technical difficulty. Our case report may well show a safe alternative to IGB removal by using less conventional cannulation techniques without higher complication rates. However, further cases are needed in order to draw significant conclusions regarding their widespread use.

Jejunal Dieulafoy's lesion as a cause of difficult-to-manage obscure gastrointestinal bleeding. Combined endoscopic treatment.

Dieulafoy's lesion (DL) is an uncommon vascular malformation-an aberrant, dilated submucosal arteriole (1-3 mm thick, 10 x nv). It runs near the mucosal surface and protrudes, and may potentially induce gastrointestinal bleeding (GIB). It usually originates in the stomach (upper lesser curvature), with endoscopy being the diagnostic, therapeutic modality of choice. Jejunal DL (JDL) is a rare cause of obscure GIB (OGIB) that is challenging for endoscopists and threatens patient lives. Other diagnostic techniques such as Tc99m-labeled red blood cell scintigraphy, well established in the classic armamentarium for OGIB diagnosis, cannot overcome endoscopic procedures. We report the case of a patient with OGIB secondary to an exceptionally located Dieulafoy's lesion who underwent combined endoscopic treatment.

Acute pancreatitis secondary to migration and impaction of intragastric balloon.

Obesity represents a significant global health problem, and reducing its alarmingly high incidence is an urgent challenge. The intragastric balloon is a safe and effective device for weight loss; therefore, it is widely used. Although the frequency of serious complications resulting from its use is low, it is not exempt from them. We would like to present a case of a severe but infrequent complication secondary to this device, with the aim of highlighting the most appropriate procedure in such cases and emphasizing the importance of awareness regarding it.

Hematoma post-endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures in the treatment of biliary-pancreatic diseases. Hematoma after ERCP is an infrequent and highly serious complication. We present three cases with hepatic hematoma after a CPRE.

MALT lymphoma of the colon: an endoscopic challenge.

Colonic lymphoma involving the mucosa-associated lymphoid tissue (MALT) is an uncommon pathology, with an unknown pathogenesis and varied endoscopic appearance. We present the case of a 78-year-old female with challenging endoscopic findings that resulted in the diagnosis of a colonic MALT lymphoma.

Spanish Intragastric Balloon Consensus Statement (SIBC): practical guidelines based on experience of over 20 000 cases.

BACKGROUND: intragastric balloons (IGBs) are a minimally invasive, increasingly popular option for obesity treatment. However, there is only one worldwide guideline standardizing the technical aspects of the procedure (BIBC, SOARD 2018). OBJECTIVES: to construct a practical guideline for IGB usage by reproducing and expanding the BIBC survey among the Spanish Bariatric Endoscopy Group (GETTEMO). METHODS: a 140-question survey was submitted to all GETTEMO members. Twenty-one Spanish experienced endoscopists in IGBs answered back. Eight topics on patient selection, indications/contraindications, technique, multidisciplinary follow-up, results, safety, and financial/legal aspects were discussed. Consensus was defined as consensus ≥ 70 %. RESULTS: overall data included 20 680 IGBs including 12 different models. Mean age was 42.0 years-old, 79.9 % were women, and the mean preoperative body mass index (BMI) was 34.05 kg/m². Indication in BMI > 25 kg/m², 10 absolute contraindications, and nutritional and medication measures at follow-up were settled. A mean %TBWL (total body weight loss) of 17.66 % ± 2.5 % was observed. Early removal rate due to intolerance was 3.62 %. Adverse event rate was 0.70 % and 6.37 % for major and minor complications with consensual management. A single case of mortality occurred. IGBs were placed in private health, prior contract, and with full and single payment at the beginning. Seven lawsuits (0.034 %) were received, all ran through civil proceeding, and with favorable final resolution. CONCLUSIONS: this consensus based on more than 20 000 cases represents practical recommendations to perform IGB procedures. This experience shows that the device leads to satisfactory weight loss with a low rate of adverse events. Most results are reproducible compared to those obtained by the BIBC.

Linfangiectasia intestinal primaria: una enfermedad rara como causa de enteropatía pierde-proteínas / Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy

La linfangiectasia intestinal primaria es un trastorno raro asociado a una enteropatía pierde-proteínas. Las principales manifestaciones son las derivadas de la hipoalbuminemia. Para lograr el diagnóstico se necesita la imagen endoscópica típica de la linfangiectasia intestinal y el aumento de las cifras de alfa-1-antitripsina en las heces de 24 horas. El tratamiento es básicamente dietético. (AU)

Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy.

Primary intestinal lymphangiectasia is a rare disorder associated with protein-losing enteropathy. The main manifestations are those resulting from hypoalbuminemia. Diagnosis requires the typical endoscopic image of intestinal lymphangiectasia and increased 24-hour fecal alpha-1-antitrypsin clearance. Treatment is basically dietary.

Single-balloon enteroscopy-assisted ERCP in patients with Roux-en-Y anatomy and choledocholithiasis: do technical improvements mean better outcomes?

BACKGROUND: endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy is challenging. Single-balloon enteroscopy-assisted ERCP (SBE-ERCP) is an innovative alternative to reach the bile duct. OBJECTIVE: to report our experience in SBE-ERCP in patients who presented with Roux-en-Y anatomy and choledocholithiasis. PATIENTS AND METHODS: patients who presented choledocholithiasis and underwent SBE-ERCP between January 2018 and April 2020 were retrospectively identified via medical records and the digestive endoscopy database. Enteroscopy success was defined as reaching the biliary limb and papilla identification. ERCP diagnostic success was defined as a successful duct cannulation and cholangiography, and ERCP procedural success was defined as the ability to successfully carry out choledocholithiasis extraction. Complications of ERCP were defined according to standard criteria. RESULTS: a total of eleven patients (two females) with a mean age of 81 years (range 60-91 years) with Roux-en-Y anastomosis underwent ERCP using a SBE on 13 occasions. The indication for all procedures was choledocholithiasis, which had been previously confirmed by magnetic resonance cholangiopancreatography (MRCP). Enteroscopy success occurred in 13/13 (100 %) of procedures. Overall ERCP diagnostic success was achieved in 11/13 (84.6 %) of procedures. The ERCP procedural success was obtained in 11/11 (100 %) of patients (84.6 % of procedures). A mild pancreatitis occurred in a patient with native papilla. CONCLUSIONS: SBE-ERCP is feasible, efficacious and safe in patients with postsurgical Roux-en-Y anatomy and choledocholithiasis. Technical improvements may mean better outcomes

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Single-balloon enteroscopy-assisted ERCP in patients with Roux-en-Y anatomy and choledocholithiasis: do technical improvements mean better outcomes?

BACKGROUND: endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy is challenging. Single-balloon enteroscopy-assisted ERCP (SBE-ERCP) is an innovative alternative to reach the bile duct. OBJECTIVE: to report our experience in SBE-ERCP in patients who presented with Roux-en-Y anatomy and choledocholithiasis. PATIENTS AND METHODS: patients who presented choledocholithiasis and underwent SBE-ERCP between January 2018 and April 2020 were retrospectively identified via medical records and the digestive endoscopy database. Enteroscopy success was defined as reaching the biliary limb and papilla identification. ERCP diagnostic success was defined as a successful duct cannulation and cholangiography, and ERCP procedural success was defined as the ability to successfully carry out choledocholithiasis extraction. Complications of ERCP were defined according to standard criteria. RESULTS: a total of eleven patients (two females) with a mean age of 81 years (range 60-91 years) with Roux-en-Y anastomosis underwent ERCP using a SBE on 13 occasions. The indication for all procedures was choledocholithiasis, which had been previously confirmed by magnetic resonance cholangiopancreatography (MRCP). Enteroscopy success occurred in 13/13 (100 %) of procedures. Overall ERCP diagnostic success was achieved in 11/13 (84.6 %) of procedures. The ERCP procedural success was obtained in 11/11 (100 %) of patients (84.6 % of procedures). A mild pancreatitis occurred in a patient with native papilla. CONCLUSIONS: SBE-ERCP is feasible, efficacious and safe in patients with postsurgical Roux-en-Y anatomy and choledocholithiasis. Technical improvements may mean better outcomes.

MRCP before ERCP: the added value in the management of common bile duct stones.

Nowadays, some endoscopists believe that knowing a patient has common bile duct stones (CBDS) is not enough. An added value is required that allows the endoscopist performing the endoscopic retrograde cholangiopancreatography (ERCP) to obtain accurate and useful information in order to offer the best management of the condition. The added value of magnetic resonance cholangiopancreatography (MRCP) is attractive and can contribute to the success of the procedure.

Las técnicas de rescate en la canulación biliar difícil / Rescue techniques in difficult biliary cannulation

La colangiopancreatografía retrógrada endoscópica (CPRE) es la técnica de elección para el tratamiento de diferentes enfermedades biliopancreáticas. La canulación selectiva del conducto deseado (biliar o pancreático) es el punto clave inicial del objetivo terapéutico. Actualmente, la forma más utilizada para conseguir el acceso a la vía biliar, y que podemos denominar "técnica estándar", es la que emplea un esfinterótomo asociado con una guía hidrófila. Cuando dicha canulación estándar falla, existen diferentes alternativas que nos permitirán conseguir la canulación en un alto porcentaje de pacientes. En situaciones de canulación difícil, las técnicas de rescate a utilizar pueden estar condicionadas, entre otras, por el perfil de riesgo de complicaciones del paciente, por la experiencia o las preferencias del endoscopista y por haber conseguido o no previamente la canulación del conducto pancreático. Si se consiguió la canulación del conducto pancreático puede intentarse la técnica de doble guía, la esfinterotomía transpancreática y el precorte de aguja sobre prótesis pancreática. Si no se consiguió la canulación del conducto pancreático, probablemente la mejor opción sea una fistulotomía. Es conveniente conocer, en el contexto de una canulación difícil, cuándo hay que decidir la finalización de la prueba, principalmente si no existe una urgencia de drenaje de la vía biliar para el paciente. En estos casos debemos considerar repetir el procedimiento unos días más tarde. Si la urgencia del paciente es evidente, puede intentarse el acceso de la vía biliar asistido por técnicas alternativas.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice in treating different biliopancreatic diseases. Selective cannulation of the desired duct (biliary or pancreatic) is the initial key point of the therapeutic goal. Currently, the most used method to obtain access to the bile duct is what we can call "standard technique", which uses the sphincterotome associated with a hydrophilic guide. When such standard cannulation fails, there are different alternatives that will allow us to achieve cannulation in a high percentage of patients. In situations of difficult cannulation the rescue techniques may be conditioned by the risk profile of the patient's complications, by the experience and/or preferences of the endoscopist, or by whether or not he has previously been able to cannulate the pancreatic duct. If cannulation of the pancreatic duct is achieved, the double guide technique, and needle precut on pancreatic prosthesis can be attempted. If cannulation of the pancreatic duct is not achieved, fistulotomy is probably the best option. In the case of a difficult cannulation, it is important to know when to decide the end of the test, especially if there is no urgency to drain the bile duct. In these cases we should consider repeating the procedure a few days later. If the patient's urgency is evident, access to the bile duct assisted by alternative techniques can be attempted.

Combined precut in difficult biliary cannulation.

AIM: precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. PATIENTS AND METHODS: we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. RESULTS: we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needleknife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. CONCLUSIONS: combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.

Combined precut in difficult biliary cannulation / Precorte combinado en la canulación biliar difícil

Aim: precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. Patients and methods: we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. “Combined precut” consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. Results: we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needleknife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. Conclusions: combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation (AU)