The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis.

BACKGROUND: Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. METHODS: The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. RESULTS: 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. CONCLUSION: POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.

EUS-Guided Biliary Drainage Versus ERCP in Malignant Biliary Obstruction Before Hepatobiliary Surgery: An International Multicenter Comparative Study.

INTRODUCTION: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is the procedure of choice for patients who cannot undergo endoscopic retrograde cholangiopancreatography (ERCP). The outcomes of patients undergoing surgery after EUS-BD for malignancy are unknown. METHODS: We conducted an international, multicenter retrospective comparative study of patients who underwent hepatobiliary surgery after having undergone EUS-BD or ERCP from 6 tertiary care centers. Patient demographics, procedural data, and follow-up care were collected in a registry. RESULTS: One hundred forty-five patients were included: EUS-BD n=58 (mean age 66, 45% male), ERCP n=87 (mean age 68, 53% male). The majority of patients had pancreatic cancer, cholangiocarcinoma, or gallbladder malignancy. In the EUS-BD group, 29 patients had hepaticogastrostomy, 24 had choledochoduodenostomy, and 5 had rendezvous technique done. The most common surgery was Whipple in both groups (n=41 EUS-BD, n=56 ERCP) followed by partial hepatectomy (n=7 EUS-BD, n=14 ERCP) and cholecystectomy (n=2 EUS-BD, n=2 ERCP). Endoscopy clinical success was comparable in both groups (98% EUS-BD, 94% ERCP). Adverse event rates were similar in both groups: EUS-BD (n=10, 17%) and ERCP (n=23, 26%). Surgery technical success and clinical success were significantly higher in the EUS-BD group compared with the ERCP group (97% vs. 83%, 97% vs. 75%). Total Hospital stay from surgery to discharge was significantly higher in the ERCP group (19 d vs. 10 d, P =0.0082). DISCUSSION: Undergoing EUS-BD versus ERCP before hepatobiliary surgery is associated with fewer repeat endoscopic interventions, shorter duration between endoscopy and surgical intervention, higher rates of surgical clinical success, and shorter length of hospital stay after surgery.

Cholangioscopy-guided lithotripsy in the treatment of difficult bile ducts stones - Bulgarian and Egyptian experience.

Introduction: Up to 10% of bile duct stones are deemed 'difficult' because they cannot be extracted using standard endoscopic techniques. In these situations, cholangioscopy allows for stone fragmentation under direct visual control.

Post-liver transplant biliary complications: Current knowledge and therapeutic advances.

Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives.

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

Intraductal Papillary Mucinous Neoplasm of the Pancreas: Need for a Tailored Approach to a Rare Entity.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively new entity that has gained increased attention because of its unique features - presence of different subtypes with different malignant potential, biological behavior, and prognosis, higher rates of recurrences and concomitant or metachronous pancreatic duct cancer. It is rare with an incidence of 4 to 5 cases per 100 000. The relative lack of experience significantly hampers decision making for surgery (pancreatic head resection, distal pancreatectomy or enucleation) or follow-up.Herein we present two cases managed by diametrically different tactic according to the risk stratification - distal pancreatectomy with splenectomy and observation, respectively. An up-to-date literature review on the key points in diagnostics, indications for surgery, the extent of surgery, follow-up, and prognosis is provided.The tailored approach based on risk stratification is the cornerstone of management. Absolute indications for surgery are the lesions with high-risk stigmata, whereas the worrisome features should be evaluated by endoscopic ultrasound and fine-needle aspiration. Main duct and mixed type are usually referred to surgery, whereas the management of a branch type is more conservative due to the lower rate of invasive cancer. Strict postoperative follow-up is mandatory even in negative resection margins due to a high risk for recurrences and metachronous lesions.Despite the guidelines, the intraductal papillary mucinous neoplasm remains a major challenge for clinicians and surgeons in the balance the risk/benefit of observation versus resection. Risk stratification plays a key role in decision-making. Future trials need to determine the optimal period of surveillance and the most reliable predictive factors for concomitant pancreatic duct cancer.

Drug-induced Bile Duct Injury - A Short Review.

The liver represents the major site of drug metabolism, i.e. the key organ in the processes of detoxification and elimination of drugs from the organism. It is therefore often affected by toxic metabolites and suffers sometimes fatal consequences. The spectrum of pathologies differs by the cell type primarily damaged and the group of the cholangiopathies includes those conditions affecting the bile duct epithelium or the cholangiocytes. They can range from transient cholestasis to vanishing bile duct syndrome and sclerosing cholangitis, both leading eventually to the development of biliary fibrosis and cirrhosis. In this review article, we focus on the etiology, predisposing factors, clinical manifestations, and histopathological characteristics of bile duct injury as a consequence of drug treatment and discuss separately the different bile duct pathologies.

Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders.

Due to the need for improvement in the diagnosis and minimally invasive therapy of the bile duct disorders new technologies for cholangioscopy have been recently developed. Per-oral cholangioscopy has become an important diagnostic and therapeutic tool leading to avoidance of aggressive and unnecessary surgery in many clinical scenarios. This paper focuses on the newly developed SpyGlass DS technology, its advantages, and the technique of single-operator cholangioscopy (SOC), biliary indications and possible adverse events. We also review the available literature; discuss the limitations and future expectations. Digital SOC (D-SOC) is a useful technique, which provides endoscopic imaging of the biliary tree, optical diagnosis, biopsy under direct vision and therapeutic interventions. The implementations are diagnostic and therapeutic. Diagnostic indications are indeterminate biliary strictures, unclear filling defects, staging of cholangiocarcinoma, staging of ampullary tumors (extension into the common bile duct), unclear bile duct dilation, exploring cystic lesions of the biliary tree, unexplained hemobilia, posttransplant biliary complications. Therapeutic indications are lithotripsy of difficult stones, retrieval of migrated stents, foreign body removal, guide wire placement, transpapillary gallbladder drainage and endoscopic tumor ablative therapy. Most studied and established indications are the diagnosis of indeterminate biliary stricture and intraductal lithotripsy of difficult stones. The adverse events are not different and more common compared to those of Endoscopic retrograde cholangiopancreatography (ERCP) alone. D-SOC is a safe and effective procedure, adjunct to the standard ERCP and the newly available digital technology overcomes many of the limitations of the previous generations of cholangioscopes.

Intraluminal duodenal ("windsock") diverticulum: a rare cause of biliary obstruction and acute pancreatitis in the adult.

An intraluminal duodenal diverticulum (IDD) is a rare congenital anomaly, which is a result of incomplete recanalization of the foregut lumen during embryonic development. Most patients are asymptomatic. Symptoms usually occur after the third decade of life and mainly include epigastric pain, nausea, vomiting, or bloating. Less commonly, IDD may complicate with bleeding, duodenal obstruction, or acute pancreatitis. We present a case of IDD, manifested for a first time in adult with acute biliary obstruction and mild pancreatitis after laparoscopic cholecystectomy for acute calculous cholecystitis, successfully managed with endoscopic retrograde cholangiopancreatography (ERCP).