Comparison of carbon dioxide and air insufflation use by non-expert endoscopists during endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is subject to several complications that include a lengthy procedure time, technical difficulty, and active bowel movement induced by air insufflation. In ERCP carried out by non-expert endoscopists who are prone to excessive luminal insufflation, insufflation with carbon dioxide (CO2 ) may provide better and safer outcomes. We aimed to assess the efficacy and safety of CO2 insufflation during ERCP by non-expert endoscopists. METHODS: This study included 208 consecutive patients who received ERCP, excluding those in poor general health or with obstructive lung disease. The first operator for each patient was a non-expert endoscopist having done 50 or fewer ERCP procedures. Primary outcomes were the changes in cardiopulmonary state during ERCP. Secondary outcomes were ERCP complications. We designed a single-center, randomized, prospective, double-blind, controlled trial with CO2 and air insufflation during ERCP. RESULTS: CO2 insufflation did not affect overall procedure progression or results. A positive correlation was observed between procedure time and change in maximal systolic blood pressure from baseline among patients in the air insufflation group, but not in the CO2 insufflation group (correlation coefficient 0.408 vs 0.114, change in the maximal systolic blood pressure from baseline +4.2 vs+1.2 mmHg/10 min). This was consistent with our findings in patients treated by the first operator alone. The occurrence rate of post-ERCP pancreatitis tended to be lower in the CO2 group than the air group (4/102 [3.9%]vs 0/106 [0%], P = 0.056). CONCLUSIONS: CO2 insufflation during ERCP by non-expert endoscopists is recommended from the standpoints of efficacy and safety.

Long-term follow-up of autoimmune pancreatitis: characteristics of chronic disease and recurrence.

Autoimmune pancreatitis is a unique disease, characterized by lymphoplasmacytic inflammation in the acute stages. However, the active clinical features are unlikely to persist for long periods. Through long-term follow-up, we investigated the disease course in 51 patients with autoimmune pancreatitis. We found recurrence in 21 (41%) patients and pancreatic stone formation in 9 (18%) patients. Pancreatic stone formation was significantly more frequent in the recurrence group (7/21, 33%), compared with the nonrecurrence group (2/30, 7%). Moreover, we found high serum immunoglobulin G4 concentrations in 13 of 175 (7.4%) patients with ordinary chronic pancreatitis. This suggested that pancreatic stone formation is closely associated with recurrence and that autoimmune pancreatitis might transform into ordinary chronic pancreatitis after several recurrences. We found that the immune complex level, with a cutoff value of 10 microg/dL, served as a good predictor of recurrence, with high sensitivity (61.9%), specificity (70.0%), and efficacy (66.7%). We also confirmed that HLA and cytotoxic T-lymphocyte antigen-4 polymorphisms were useful predictors for AIP recurrence.

Pancreaticobiliary fistula evident after ESWL treatment of pancreatolithiasis.

Here we report a patient with a pancreaticobiliary fistula that was possibly associated with pancreatolithiasis. He was admitted due to mild pancreatitis. Pancreatolithiasis was revealed in the parenchyma of the head region and in the main pancreatic duct of the pancreas body with distal dilatation. Extracorporeal shock wave lithotripsy (ESWL) effectively eliminated the pancreatic stones; however, an apparent internal fistula from the middle portion of the common bile duct (CBD) to the main pancreatic duct was revealed where the parenchymal stones had been located. The patient was considered to be in the same condition as pancreato-biliary malunion without CBD dilatation, and was treated with laparoscopic cholecystectomy.

Efficacy of preoperative endoscopic nasobiliary drainage for hilar cholangiocarcinoma.

BACKGROUND/PURPOSE: Although percutaneous transhepatic biliary drainage has previously been recommended as a primary preoperative step, endoscopic nasobiliary drainage (ENBD) is prevalent as an alternative procedure. Few reports assess the efficacy and safety of ENBD in a substantial patient cohort. METHODS: Of 116 patients with hilar cholangiocarcinoma who underwent surgery, 62 (43 men and 19 women, median age 69 years) underwent preoperative ENBD. After classification of lesions according to Bismuth-Corlette (B-C) criteria, we evaluated efficacy and safety with respect to B-C type. RESULTS: Patients were classified as B-C types I (n = 5), II (n = 21), IIIa (n = 23), IIIb (n = 5), and IV (n = 8). Preoperative single ENBD was effective in 46/62 patients (74%) including 5/5 (100%) B-C type I, 20/21 (94%) type II, 16/23 (70%) type IIIa, 4/5 (80%) type IIIb, and 1/8 (13%) type IV. Sixteen cases (26%) required additional drainages with ENBD or endoscopic biliary stenting (EBS) in 8/16 (50%), and with PTBD in 8/16 (50%). Mild acute pancreatitis (n = 1, 2%), segmental cholangitis (n = 2, 3%), and acute cholangitis with catheter obstruction (n = 7, 11%) occurred with ENBD. CONCLUSIONS: Preoperative single ENBD in the future remnant lobe is effective treatment for B-C type I-III hilar cholangiocarcinoma. Preoperative ENBD was rarely complicated with segmental cholangitis.