Conventional endoscopic retrograde cholangiopancreaticography vs the Olympus V-scope system.

AIM: To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP). METHODS: Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naïve patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient's clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test. RESULTS: Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m(2), 159-5039 cGy/m(2) vs 1296 cGy/m(2), 202.2-6421 cGy/m(2), P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires. CONCLUSION: ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

Description of a new, endoscopic technique to remove the over-the-scope-clip in an ex vivo porcine model (with video).

BACKGROUND: Various studies have demonstrated the usefulness of the over-the-scope-clip (OTSC) to treat perforations, anastomotic leaks, and fistulae. Endoscopic removal of the OTSC was previously described in a series of 3 patients by using the Nd:YAG laser. OBJECTIVE: To evaluate a new endoscopic technique to remove the OTSC. DESIGN: Prospective, single-arm, pilot study in an ex vivo porcine model. INTERVENTIONS: Perforations were created by using a surgical scalpel and a blunt trocar. Then they were endoscopically closed with the OTSC. Next, the OTSC was removed under endoscopic control by inserting a 0.035-inch straight hydrophilic tip guidewire into the oval hole on the side of the OTSC jaw. Afterward, the OTSC clip was removed by pulling on the wire. RESULTS: Fifteen perforations were closed: with the OTSC. In all of the cases, the endoscopic closure of the defects was feasible and effective. Successful visualization of the oval hole of the OTSC was possible in 12 cases (80%), and guidewire cannulation was possible in all of these 12 cases (100%). Advancement of the guidewire through the OTSC and then the lumen of the stomach was accomplished in 8 cases (53.3%). In all of the cases with successful cannulation of the orifice, removal of the OTSC was managed safely. The result was an overall success rate of 53.3% (8 of 15 cases). LIMITATIONS: Ex vivo porcine model. CONCLUSIONS: Guidewire removal is a new and feasible technique to remove the OTSC. Future studies should refine the technique to enhance visualization and cannulation of the oval hole of the OTSC.

Refinement of ERCP by using the Olympus V-scope system with a 0.025 in. compatible and complete fixable Visiglide(®) guidewire.

AIM: Prospective evaluation of the new 0.025 in. Visiglide(®) guidewire to facilitate endoscopic retrograde cholangiopancreaticography using the Olympus V-scope. MATERIALS AND METHODS: Interventional endoscopic retrograde cholangiopancreaticography was performed in 9 patients with the Olympus V-scope and the 0.025 in. Visiglide(®) guidewire (VS group), whilst 9 other patients underwent endoscopic retrograde cholangiopancreaticography with a conventional Olympus duodenoscope using 0.035 in. conventional guidewires (controls). Exchange time of accessories, X-ray time, dose and endoscopic retrograde cholangiopancreaticography examination time were investigated. RESULTS: The VS group showed a significantly lower exchange time of endoscopic retrograde cholangiopancreaticography accessories (9; 4-10s, p<0.0001) than controls (29; 19-44s). The Visiglide(®) guidewire was complete fixable by the elevator in 35/36 instrument exchanges (97%) compared to 16/31 exchanges (52%) using conventional guidewires. LIMITATIONS: Single-centre study, small patient numbers, two investigators. CONCLUSIONS: Endoscopic retrograde cholangiopancreaticography using the Olympus V-scope with the new 0.025 in. Visiglide(®) guidewire enables a 3-fold faster exchange of accessories due to a nearly complete fixation of the guidewire.

Successful interventional treatment of postoperative bile duct leakage after Billroth II resection by unusual procedure using double balloon enteroscopy.

BACKGROUND: Endoscopic treatment of advanced biliary disorders and their complications following surgical procedures is often difficult especially after Billroth II gastric resection. In such cases, endoscopic access to the papilla and neopapilla is often low, and access to the choledocho- or hepaticojejunostomy is often difficult. Thus, percutaneous cholangiodrainage or re-operation is therefore indicated when endoscopic access to the papilla failed. But both of those methods are much more invasive and more likely to be followed by complications than use of a purely endoscopic approach. CASE REPORT: The present case report describes endoscopic access to the papilla with both push enteroscopy and double-balloon enteroscopy (DBE, push-and-pull enteroscopy) in a female patient after Billroth II resection with bile leakage following cholecystectomy. Successful closure of the bile duct fistula could be achieved via an unusual abdominal-biliary-jejunal cannulation way after several attempts of modern enteroscopy and in this way re-operation was avoided. CONCLUSIONS: Modern enteroscopy by experienced investigators using push-and-pull enteroscopes can provide access to the papilla even in complex postoperative anatomic rearrangements. Push-and-pull enteroscopes offer a further option for successful cannulation of the papilla and therapeutic interventions via additional stabilization with balloons and the modern enteroscopic approach by push-and-pull enteroscopy appears to provide more patient comfort, requires less analgo-sedation and examination time and in cases with intra-abdominal drainage this external access may be used as an additional aid for exploration and intervention in complex individual cases with extremely difficult treatable bile duct injuries.