Management of difficult bile duct stones and indeterminate bile duct structures: Reduced ERCP radiation exposure with adjunct use of digital single-operator cholangioscopy.

INTRODUCTION: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an well-established endoscopic procedure for the management of biliary diseases. The use of fluoroscopy during ERCP has often raised concerns regarding potential risks from radiation exposure, particularly in complex cases. We investigated whether a new digital single-operator cholangioscopy (D-SOC) system, used adjunctively to ERCP, actually reduces patient radiation exposure. MATERIALS AND METHODS: We retrospectively analyzed a prospective database (April 2016 to October 2018) including consecutive patients who underwent successful management of difficult-to-treat biliary stones or indeterminate biliary strictures by using either conventional ERCP (ERCP cohort) or ERCP in conjunction with D-SOC (ERCP/D-SOC cohort). The overall patient radiation exposure outcomes were compared in terms of Kerma Area Product (KAP), Fluoroscopy time (T) and the total number of films (F). RESULTS: Overall, 47 patients (mean 71.8 years, 59.6% males) were included (ERCP cohort = 29, ERCP/D-SOC cohort = 18), referred either for difficult bile duct stones (n = 36) or indeterminate biliary strictures (n = 11). The median KAP, T and F in the ERCP/D-SOC cohort were 12.3 Gycm2, 3.7 min and 4 films respectively, compared with 52.1 Gycm2, 8.4 min, and 5 films respectively in the ERCP cohort. Statistically significant differences (P = 0.0001) were found for KAP and T. CONCLUSIONS: Adjunct use of a digital cholangioscopy platform appears to significantly reduce radiation exposure in patients undergoing ERCP for the management of difficult bile stones or indeterminate biliary strictures.

When perforation is not the culprit : case report and systematic review of mechanical small-bowel obstruction complicating colonoscopy.

Colonoscopy is generally safe, although expansion of colorectal cancer prevention programs is likely to increase the number of post-colonoscopy complications. We report the case of a 42-year old woman with a prior history of 2 cesarean section deliveries who developed abdominal pain after an otherwise uneventful screening colonoscopy. Urgent exploration revealed closed-loop obstruction involving the terminal ileum, caused by an adhesive band close to the site of her previous Pfannenstiel incision. A systematic review of the literature revealed 11 reports (1985-2008) describing a total of 13 cases of mechanical small bowel obstruction (MSBO) after colonoscopy, 9 of which were confirmed by laparotomy. Colonoscopy-induced MSBO is practically impossible to anticipate, and only a prior history of abdominal/pelvic surgery may be deemed as a predisposing factor. However, it is related to significant morbidity, as it often leads to an ischemic bowel with need for surgical resection. Thus, endoscopists should be aware and maintain a low operative threshold to this rare, but hazardous, complication of colonoscopy.

Intraductal papillary neoplasm of the bile duct : case report and review of the literature.

A variant of bile duct carcinoma, intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease mainly found in Eastern Asia which encompasses a spectrum of intraductal papillary growth occurring anywhere along the intrahepatic and/or extrahepatic biliary tree that carries a high potential for malignancy. We report the case of a patient with episodes of recurrent cholangitis that was diagnosed with IPNB, our clinical and diagnostic approach, the radiographic and endoscopic findings, the interventions used, while discussing the therapeutic options.

Preliminary diagnostic reference levels for endoscopic retrograde cholangio-pancreatography in Greece.

The main objective of this study was to determine the preliminary Diagnostic Reference Levels (DRLs) in terms of Kerma Area Product (KAP) and fluoroscopy time (Tf) during Endoscopic Retrograde Cholangio-Pancreatography (ERCP) procedures. Additionally, an investigation was conducted to explore the statistical relation between KAP and Tf. Data from a set of 200 randomly selected patients treated in 4 large hospitals in Greece (50 patients per hospital) were analyzed in order to obtain preliminary DRLs for KAP and Tf during therapeutic ERCP procedures. Non-parametric statistic tests were performed in order to determine a statistically significant relation between KAP and Tf. The resulting third quartiles for KAP and Tf for hospitals (A, B, C and D) were found as followed: KAPA=10.7Gycm(2), TfA=4.9min; KAPB=7.5Gycm(2), TfB=5.0min; KAPC=19.0Gycm(2), TfC=7.3min; KAPD=52.4Gycm(2), TfD=15.8min. The third quartiles, calculated for the total 200 cases sample, are: KAP=18.8Gycm(2) and Tf=8.2min. For 3 out of 4 hospitals and for the total sample, p-values of statistical indices (correlation of KAP and Tf) are less than 0.001, while for the Hospital A p-values are ranging from 0.07 to 0.08. Using curve fitting, we finally determine that the relation of Tf and KAP is deriving from a power equation (KAP=Tf(1.282)) with R(2)=0.85. The suggested Preliminary DRLs (deriving from the third quartiles of the total sample) for Greece are: KAP=19Gycm(2) and Tf=8min, while the relation between KAP and Tf is efficiently described by a power equation.

THE IMPACT OF X-RAY UNIT TYPE USED FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURES ON PATIENT DOSES.

To investigate whether the X-ray unit type used for interventional endoscopic retrograde cholangiopancreatography (ERCP) procedures may affect patient radiation doses. A total of 471 ERCP procedures performed in 4 hospitals with 4 types of X-ray units were studied. Kerma-area product (KAP), fluoroscopy time (T) and total number of radiographs acquired (F) were recorded. KAP, T and F values exhibited a great variation, ranging from 0.1 to 130.2 Gy cm2 (mean 16 Gy cm2), 0.13 to 33.7 min (mean 5.4 min) and 0 to 26 radiographs (mean 3.5), respectively. The respective mean values for the four types of X-ray units that were investigated were as follows: KAP: 17.4, 12.5, 5.6 and 36.3 Gy cm2, T: 4.7, 5.2, 3.8 and 11.5 min and F: 1.7, 7.4, 1.9 and 4.6 radiographs. The type of the X-ray unit seems to significantly affect patient radiation dose, with the C-arm delivering the lowest and the angiography unit the highest patient doses.

Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) guideline.

This article expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about radiation protection for endoscopic procedures, in particular endoscopic retrograde cholangiopancreatography (ERCP). Particular cases, including pregnant women and pediatric patients, are also discussed. This Guideline was developed by a group of endoscopists and medical physicists to ensure that all aspects of radiation protection are adequately dealt with. A two-page executive summary of evidence statements and recommendations is provided. The target readership for this Guideline mostly includes endoscopists, anesthesiologists, and endoscopy assistants who may be exposed to X-rays during endoscopic procedures.

Patient and endoscopist radiation doses during ERCP procedures.

The aim of the study was to calculate radiation doses for patients and staff during interventional Endoscopic retrograde cholangiopancreatography (ERCP) procedures. Patient age (A), kerma-area product (KAP), fluoroscopy time (T) and total number of films (F) were collected for 157 interventional ERCP procedures. One endoscopist (>10 y of experience) monitored using a thermoluminescent dosemeter worn over the lead apron performed the ERCPs. Median (range) KAP was 3.1 Gy cm(-2) (0.1-106.7 Gy cm(-2)). Median (range) A, T and F were 72 y, 2.6 (0.2-26.0) min and 2 (1-4) images, respectively. No correlation was observed between KAP and A, T or F. Monthly endoscopist dose was negligible due to the use of lead apron, collar and two lead-articulated ceiling mounted shields. The endoscopist dose is minimal when using appropriate protective measures. Patient doses showed large variation that has to be further investigated.

Sedation in digestive endoscopy: the Athens international position statements.

BACKGROUND: Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field. AIM: To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy. METHODS: Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll. RESULTS: The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures. CONCLUSIONS: While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Level of intended sedation.

Sedation and analgesia is the standard of care during diagnostic and therapeutic endoscopic gastrointestinal procedures in most areas of the world. Unsedated endoscopy is feasible in selected patients, but requires commitment on the part of both the patient and the provider. The American Society of Anesthesiologists has defined four stages of sedation, ranging from minimal to moderate, deep and general anesthesia. The level of sedation as well as the choice of sedative is based on the type of procedure, patient characteristics and the existence of the required structural conditions. Individuals administering sedation/analgesia should be trained to rescue a patient who has reached a level of sedation deeper than that intended.

Expression of Bax protein in gastric carcinomas. A clinicopathological and immunohistochemical study.

BACKGROUND AND STUDY AIMS: Reduced Bax protein expression has been shown to be a negative prognostic factor in patients with breast, ovarian, colorectal, esophageal and pancreatic cancer. Our aim was to immunohistochemically study Bax protein expression in gastric carcinomas and correlate its expression with clinicopathological parameters and prognosis. PATIENTS AND METHODS: Immunohistochemistry was performed, using a monoclonal antibody against bax, in paraffin-embedded tumor specimens from 47 cases of gastric cancer. RESULTS: Positive staining for the Bax protein was found in 20/47 (42.4%) adenocarcinomas examined. Negative Bax protein expression in tumour cells was correlated with lymph node metastasis (P < 0.05), and degree of differentiation (p < 0.05). Univariate analysis showed that the variables with a significant negative impact on survival were: high TNM tumour stage, depth of penetration in the gastric wall, lymph node involvement, and Bax protein expression. Multivariate analysis showed that the only variable with an impact on survival was Bax protein expression (p < 0.05, Relative Risk: 3.34). Kaplan-Meier curves showed that the 5-year survival was 36.8% in cases with positive compared with 16% in cases with negative Bax protein expression (p = 0.0427). CONCLUSION: Negative Bax expression in gastric cancer is associated with de-differentiation, lymph node metastases, and poor clinical prognosis. Bax protein expression might play an important role in the development and phenotypic differentiation of gastric carcinomas and tumor progression.

Radiation doses to patients from endoscopic retrograde cholangiopancreatography examinations and image quality considerations.

The purpose of this investigation was to measure the dose-area product (DAP) and the other relevant dosimetric quantities in diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Furthermore, the dependence of patient dose and image quality on the tube potential was investigated. A DAP meter was used for dose monitoring in seven diagnostic and 21 therapeutic ERCPs. For each ERCP the DAP meter readings, fluoroscopy time, number of radiographs and exposure data were recorded. From these data the fluoroscopy and radiography contributions to DAP, the entrance skin dose and the effective dose for each examination were estimated. For the investigation of the effect of tube potential on patient dose and image quality, a water phantom containing syringes filled with diluted contrast media was used. The average DAP was 13.7 Gy cm2 in diagnostic and 41.8 Gy cm2 in therapeutic ERCP whereas the average fluoroscopy times were 3.1 and 6.0 min respectively. DAP was strongly correlated to the fluoroscopy time. Measurements in the phantom showed that a good compromise between image quality and patient dose is obtained for tube potentials around 80 kV. Therapeutic ERCPs deliver on average higher doses to patients than diagnostic ERCPs. However, for a difficult diagnostic ERCP more patient exposure may be required than for a simple therapeutic ERCP.