[Association between the type of major duodenal papilla and difficult biliary cannulation in a private tertiary center]. / Asociación entre el tipo de papila duodenal mayor y canulación biliar difícil en centro terciario privado.

INTRODUCTION: Difficult cannulation in cases of endoscopic retrograde cholangiopancreatography (ERCP) could be associated with several factors, including: type of major papilla, however, there are limited data regarding this possible association. OBJECTIVES: To determine the association between the type of papilla and difficult biliary cannulation. MATERIALS AND METHODS: A retrospective cross-sectional analytical study was conducted in patients over 18 years old who underwent ERCP on papilla naive, from July 2019 to April 2021, in a private institution. Unsuccessful cannulations were excluded. The papilla was classified based on Haraldsson classification. The crude association and adjusted for possible confounders between the type of papilla and difficult cannulation was evaluated. Relative risks (RR) and 95% confidence intervals were calculated. RESULTS: 188 patients were included. The mean age was 55 years, 66% female. The most frequent indication was choledocholithiasis with 88.5%. The most frequent type of major duodenal papilla was type 1 (32%), followed by type 3 (27%), type 2 (25%) and type 4 (16%). Type 2, 3, 4 papillae showed a significant relationship with difficult cannulation compared to type 1 (p<0.001, p<0.001 and p=0.008 respectively). The indication other than choledocholithiasis also showed a significant relationship with difficult cannulation (p<0.001). In the adjusted analysis, the RR for difficult cannulation compared to type 1 papilla was: 2.51 (95% CI 1.23-5.94) for type 2 papilla, 3.72 (95% CI 1.79-7.71) for papilla type 3 and 3.41 (95% CI 1.54-7.71) for type 4. Theindication other than choledocholithiasis was also associated with a higher risk of difficult cannulation with a RR of 2.36 (95% CI 1.57-3.56). The fistulotomy type precut was used more frequently in the type 3 papilla (46%), while the use of cannula was more frequent in the type 4 papilla (29.6%). CONCLUSIONS: Papilla types 2, 3 and 4 are associated with a higher risk of difficult cannulation. This should be considered when performing ERCP in order to reduce the risk of complications.

Cap-assisted endoscopy increases ampulla of Vater visualization in high-risk patients.

BACKGROUND: Periampullary adenocarcinoma is a major clinical problem in high-risk patients including FAP population. A recent modification for visualizing the ampulla of Vater (AV) involves attaching a cap to the tip of the forward-viewing endoscope. Our aim was to compare the rates of complete visualization of AV using this cap-assisted endoscopy (CAE) approach to standard forward-viewing endoscopy (FVE). We also determined: (i) the rates of complications and additional sedation; (ii) the mean time required for duodenal examination; and (iii) the reproducibility among endoscopists performing this procedure. METHODS: We performed esophagogastroduodenoscopy for AV visualization in 102 > 18 years old using FVE followed by CAE. Video recordings were blinded and randomly selected for independent expert endoscopic evaluation. RESULTS: The complete visualization rate for AV was higher in CAE (97.0%) compared to FVE (51.0%) (p <  0.001). The additional doses of fentanyl, midazolam, and propofol required for CAE were 0.05, 1.9 and 36.3 mg. in 0.9, 24.5, and 77.5% patients, respectively. The mean time of duodenal examination for AV visualization was lower on CAE compared to FVE (1.41 vs. 1.95 min, p <  0.001). Scopolamine was used in 34 FVE and 24 CAE, with no association to AV complete visualization rates (p = 0.30 and p = 0.14). Three more ampullary adenomas were detected using CAE compared to FVE. Cap displacement occurred in one patient, and there was no observed adverse effect of the additional sedatives used. Kappa values for agreement between endoscopists ranged from 0.60 to 0.85. CONCLUSIONS: CAE is feasible, reproducible and safe, with a higher success rate for complete visualization compared to FVE. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02867826 , 16 August 2016.

Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años / Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years

Antecedentes: La canulación biliar difícil es un factor de riesgo para la pancreatitis post-CPRE. En estos casos el precorte es la técnica más usada. Objetivo: Demostrar que el precorte tipo fistulotomía es seguro y eficaz. Materiales y métodos: Se revisaron los datos de mayo de 2016 a mayo de 2018. Se definió canulación difícil como: litiasis impactada, canulación inadvertida del conducto pancreático en tres ocasiones e incapacidad para lograr la canulación en 3 minutos. Las medidas de resultados fueron la canulación biliar exitosa y la pancreatitis post-CPRE. Resultados: Se realizó precorte tipo fistulotomía en 96 casos (67 mujeres, 29 hombres). La tasa de éxito de la canulación biliar fue del 95,8% (92/96). Ochenta pacientes tenían factores de riesgo para pancreatitis post CPRE: 29 tuvieron un solo factor de riesgo, 26 tuvieron dos, 19 tuvieron tres y 6 tuvieron cuatro. Factores de riesgo ampulares de canulación difícil: calculo impactado 9 casos, abultamiento de la papila en 10 casos, ubicación inferior del orificio papilar en 38 casos, localización parcial del poro papilar en 23 y estenosis del orificio papilar en 16 casos. Diez pacientes tuvieron divertículo periampular, 7 pacientes tuvieron conducto biliar normal. Ninguno de los pacientes experimentó pancreatitis. Tres pacientes tuvieron sangrado precoz, una paciente presento sangrado tardío. Un paciente (2%) tuvo fiebre y fue hospitalizado. Conclusiones: En casos de canulación biliar difícil el precorte tipo fistulotomía es seguro y eficaz.

Background: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. Objective: To demonstrate that precut fistulotomy is safe and effective. Materials and methods: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. Results: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. Conclusions: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

Carcinosarcoma of the ampulla of Vater.

Carcinosarcomas, are very rare tumors in gastrointestinal tract, and at the ampulla of Vater location, are extremely uncommon. They are also called spindle cell carcinomas or sarcomatoid carcinomas. These tumors have an aggressive clinical course with frequent metastasis. We report the case of a male patient of 64 y.o with anemia and jaundice, and a diagnosis of carcinosarcoma of the ampulla of Vater.

Carcinoma adenoneuroendocrino mixto de la ampolla de Vater: reporte de caso / Mixed adenoneuroendocrine carcinoma of the ampulla of Vater: case report

INTRODUCCIÓN: Los carcinomas adenoneuroendocrinos mixtos (MANEC) son tipos de tumores bifásicos, reconocidos morfológicamente ante la presencia de una formación neoplásica constituida de manera simultánea por epitelio glandular y células neuroendocrinas. Dentro del tracto gastrointestinal, estas neoplasias predominan en el estómago o el colon. Solo 19 casos localizados en la ampolla de Vater han sido reportados por la literatura. OBJETIVO: Reportar un caso de MANEC; revisar la epidemiología, pronóstico y tratamiento de estos tumores. MATERIALES Y MÉTODO: Presentación de caso clínico de una paciente con diagnóstico de adenocarcinoma neuroendocrino mixto de la región ampular. DISCUSIÓN: La presentación clínica, el manejo y el pronóstico son similares al del adenocarcinoma ampular. Se diagnostican con el examen histopatológico de la muestra resecada. Ambos componentes deben ser histológicamente malignos, y cada uno de ellos debe representar al menos el 30% de la lesión. CONCLUSIÓN: Los MANEC ampulares son tumores poco comunes a nivel mundial, siendo éste el primer caso reportado en nuestro instituto.

INTRODUCTION: Mixed adenoneuroendocrine carcinomas (MANEC) are types of biphasic tumors, morphologically recognized in the presence of a neoplastic formation constituted simultaneously by glandular epithelium and neuroendocrine cells. Only 19 cases located in the ampulla of Vater have been reported in the literature. Within the gastrointestinal tract, these neoplasms predominate in the stomach or colon. AIM: Report a case of MANEC; review of the epidemiology, prognosis and treatment of these tumors. MATERIALS AND METHOD: Case presentation of a patient diagnosed with mixed adeno-neuroendocrine carcinoma of the ampullary region. DISCUSSION: The clinical presentation, management and prognosis are similar to ampullary adenocarcinoma. These tumors are diagnosed with a histopathological examination of the resected specimen. Both components must be histologically malignant, and each of them must represent at least 30% of the lesion. CONCLUSION: MANEC of the ampulla are rare tumors worldwide, being this case the first reported in our institute.

[Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years]. / Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años.

BACKGROUND: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. OBJECTIVE: To demonstrate that precut fistulotomy is safe and effective. MATERIALS AND METHODS: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. RESULTS: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. CONCLUSIONS: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

THE USE OF THE FORCEPS BIOPSY AS AN AUXILIARY TECHNIQUE FOR THE VISUALIZATION OF THE MAJOR DUODENAL PAPILLA USING THE FOWARD-VIEWING UPPER ENDOSCOPY.

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.

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.

Unusual involvement in mycosis fungoides: Duodenal papilla.

BACKGROUND: Mycosis fungoides (MF) is a type of T-cell lymphoma with cutaneous involvement. It is a rare disease, of low incidence and usually affects middle-aged men. In most cases only the skin is involved although in advanced stages may present with extra cutaneous involvement including the gastrointestinal tract. CASE REPORT: We report the first case of MF with compromise of duodenal papilla, emphasizing the diagnostic approach and a brief review of the subject. DISCUSSION: This case report proves the value of the endoscopic studies in patients with lymphoproliferative disorders, because of the impact in the diagnosis and prognosis. Also, this case report is relevant because there is no scientific evidence, as far as we know, of similar cases reported.

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the functions of biliary sphincter subjected to dilation hydrostatic balloon by the point of view of the radiographic and manometric alterations. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). The computerized manometry and the cholangiography were done before and immediately after the initial procedure, one and four weeks after the dilation or the sham. It was calculated from the radiographic images: the mean, standard deviation, absolute and percentual variation of the diameter measures of the papilla. It was measured: the basal pressure in the papilla region, the contraction amplitudes and the choledoc pressure in all observation times (t0, t7 and t28). RESULTS: There was not differences in the diameter measures of the papilla in t0 (GA=5,14 +/- 1,1) (GB=4,64 +/-0,9), as well as in the absolute (0,14 mm) or relative (-2,7%) variations. In the animals of GA the papilla basal pressure measure was found to be smaller in t28 (11,1) than in t0 (18,6) and t7 (16,2). The contraction amplitudes measures were significantly smaller in the postoperatory times (post-t0, t7 and t28) when comparing to the initial time (pre-t0), in the animals of groups A and B. The average pressure values in the choledoc were also smaller in t28 (7,5) than in t0 (17,8) and t7 (12,6) in the animals of GA. CONCLUSION: the function of the major duodenal papilla is partially committed with the dilation, therefore it provoked the basal pressure decrease and compromising of the capacity of sphincter in its cyclical contractions up to the 28 days of observation.

Pancreaticoduodenectomy as treatment of adenocarcinoma of the papilla of Vater diagnosed during pregnancy. A case report.

BACKGROUND: Papillary adenocarcinomas are rare tumors of the gastrointestinal tract. There are few reports of this neoplasm diagnosed during pregnancy. CASE: A case of adenocarcinoma of the papilla of Vater was diagnosed by sonographically guided biopsy during pregnancy. The patient underwent radical resection of the tumor at 25 weeks' gestation; pregnancy termination was not indicated. At 39 weeks' gestation, a cesarean-section was performed. The postoperative period entailed total parenteral nutrition until intestinal motility stabilized. This ensured the mother and fetus' well-being until delivery. CONCLUSION: Papillary adenocarcinoma is associated with good prognosis since it is totally removed by radical resection, and pancreaticoduodenectomy can be performed successfully during pregnancy, but the patient must receive special prenatal care.

[Diagnosis of carcinoma of Vater's ampulla by duodenoscopy]. / Diagnóstico del carcinoma de la papila de Vater por duodenoscopía.

Cancer of the ampula of Vater occurs in 10% of cases of jaundice caused by malignant neoplasms. Endoscopy with biopsy and citological study helps to establish the diagnosis in most instances, utilizing a duodeno fibroscope JFB-2. Fourteen patients, ten men and four women, were studied in a five year period in the Service of Endoscopy in the General Hospital of National Medical Center of the Mexican Institute of Social Security. All the patients presented with obstructive jaundice and only in four was papilary carcinoma suspected from the clinical and radiological studies. Direct biopsy was performed in all patients and brush biopsy for citology in 9. In all 14 patients a malignant lesion was observed macroscopically in the ampula of Vater projecting in to the duodenum. In thirteen of fourteen the lesion was diagnosed microscopically as adenocarcinoma and in eight of nine citologically. The utilization of this methodology facilitates the early diagnosis of the lesion in this way improves considerably the prognosis.