ERCP for common bile duct stones in the elderly: refine the procedure to improve outcomes.

Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.

Endoscopic drainage of malignant distal biliary obstruction. Will ERCP no longer be necessary?

We read with interest the Editorial by Vila et al. on the paradigm shift for endoscopic biliary drainage of malignant distal biliary obstruction (MDBO) which places Endoscopic Ultrasound (EUS) drainage as the first option instead of traditional ERCP drainage. The modern biliary endoscopist must have the duodenoscope in one hand and the therapeutic echoendoscope in the other. ERCP training alone is no longer appropriate because the goal is to drain the obstruction during a single session. That is why in more and more centers the patient signs a single consent for endoscopic biliary drainage, whether by ERCP, EUS or combined. Should EUS drainage be used first for MDBO without attempting ERCP? A possible protocol for endoscopic drainage of MDBO could be to start with the duodenoscope for ERCP. If the papilla of Vater is accessible, try cannulation considering the ESGE criteria for a difficult cannulation: more than 5 contacts with the papilla; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification. If biliary cannulation is not achieved, immediately switch to EUS drainage during the same session. Occasionally, the double guidewire technique or even transpancreatic biliary sphincterotomy could be used, but not needle-knife precut.

How to take advantage of a failed precut to achieve biliary cannulation in ERCP.

After nearly 50 years of therapeutic endoscopic retrograde cholangio-pancreatography (ERCP), deep cannulation of the desired duct, whether biliary or pancreatic, remains primarily an art. Most ERCP procedures are performed for biliary drainage.

[Colorectal cancer screening pilot program in Castilla-La mancha. Partial results after first round: 2015-2018.] / Programa piloto de cribado poblacional de cáncer colorrectal en Castilla-La Mancha. Resultados parciales tras primera ronda: 2015-2018.

OBJECTIVE: Colorectal cancer is considered a public health problem due to its high incidence and mortality in developed countries. Primary preventions is not easy owing to the lack of knowledge of the main risk factors and the difficulty of modifying known risk factors, but it is one of the few tumors that meet the criteria for screening. In Spain, the Colorectal Cancer Population Screening Program was implemented in Catalonia in 2000, followed by the Valencian Community in 2005, beginning in Castilla La Mancha in April 2015. The objetive was to carry out a descriptive study of the results obtained in the first round of the Colorectal Cancer Screening Program at the Virgen de la Luz Hospital in Cuenca. METHODS: A retrospective, descriptive and observational study was carried out from the colonoscopies carried out from May 1, 2015 to November 2018, analyzing the number of lesions detected, the histology, the sex and the age range with the greatest affectation, as well as if there was a relationship between the different variables using Pearson's Chi square test. The qualitative variables were presented by means of their distribution in absolute and relative frequencies, and the quantitative ones by mean and standard deviation. RESULTS: The participation rate was 48.06%. 7.25% of fecal occult blood test were positive and 89% with a positive test had a colonoscopy. The positive of inmunological fecal occult test and the detection rate of adenomas were higher in men. 70.7% of colorectal cancers were diagnosed in early stages. There was no relationship between age and the presence of advanced lesions. CONCLUSIONS: The rates of people with adenomas and people with invasive cancers in Cuenca province are lower than those registered in Castilla-La Mancha.

OBJETIVO: El cáncer colorrectal (CCR) es considerado un problema de salud pública por su alta incidencia y mortalidad en los países desarrollados. La prevención primaria no es fácil, debido al desconocimiento de los principales factores de riesgo y a la dificultad de modificar factores de riesgo conocidos, pero se trata de uno de los pocos tumores que cumple los criterios para ser susceptible de cribado. En España, el Programa de Cribado Poblacional de CCR se implantó en Cataluña en el año 2000, seguida de la Comunidad Valenciana en 2005, comenzando en Castilla-La Mancha en abril de 2015. El objetivo del trabajo fue realizar un estudio descriptivo de los resultados obtenidos en la primera ronda del Programa de Cribado Poblacional de CCR en el Hospital Virgen de la Luz de Cuenca. METODOS: Se realizó un estudio retrospectivo, descriptivo y observacional a partir de las colonoscopias realizadas desde el 1 de mayo de 2015 hasta noviembre de 2018, analizándose el número de lesiones detectadas, la histología, el sexo y la franja de edad con mayor afectación, así como si existió relación entre las distintas variables mediante prueba de Chi cuadrado de Pearson. Las variables cualitativas se presentaron mediante su distribución en frecuencias absolutas y relativas, y las cuantitativas por media y desviación estándar. RESULTADOS: La tasa de participación fue del 48,06%. El 7,25% de los test de sangre oculta en heces (TSOHi) realizados fueron positivos y el 89% de las personas con test positivo se realizaron una colonoscopia. La positividad del test de sangre oculta en heces inmunológico y la tasa de detección de adenomas fueron mayores en hombres. El 70,7% de los cánceres colorrectales se diagnosticaron en estadios precoces. No existió relación entre la edad y la presencia de lesiones avanzadas. CONCLUSIONES: Las tasas de personas con adenomas y con cánceres invasivos en la provincia de Cuenca resultan inferiores a las registradas en toda Castilla-La Mancha.

Straight plastic stents in tumors at the hepatic hilum and related duodenal perforations.

We read with interest the paper on the endoscopic treatment of a duodenal perforation related to a plastic biliary stent that was reported by Roa et al. We would like to add some comments about biliary stents inserted during endoscopic retrograde cholangiopancreatography (ERCP) to palliate malignant jaundice in hilar strictures. It is our belief that the most convenient strategy in non-operable patients should be the insertion of at least one uncovered self-expanding metal stent.

Inserción de prótesis pancreáticas tras la canulación involuntaria con guía del Wirsung en la CPRE / Pancreatic stent insertion after an unintentional guidewire cannulation of the pancreatic duct during ERCP

Introducción: en los intentos de canulación del colédoco durante la colangiopancreatografía retrógrada endoscópica (CPRE) la guía puede entrar en el conducto pancreático. No está definido qué maniobra es más eficaz para canular la vía biliar y prevenir la pancreatitis tras pasar la guía al Wirsung. Objetivo: estudiar la tasa de canulación coledociana y de pancreatitis post-CPRE cuando en la primera ocasión en que la guía pasó al conducto pancreático de forma involuntaria se insertó una prótesis pancreática. Material y métodos: análisis retrospectivo de pacientes a los que se realizó una CPRE para drenaje biliar e incluidos de forma prospectiva en una base de datos. Tras la inserción involuntaria de una guía en el conducto pancreático se insertó una prótesis plástica recta de 5 Fr y 4 cm de longitud, sin topes internos para facilitar su expulsión. El colédoco se intentó canular por encima de la prótesis. En los pacientes mayores de 60 años se realizó una esfinterotomía pancreática antes de insertar la prótesis. Resultados: en un grupo de 154 CPRE se insertaron 46 prótesis pancreáticas (29,8%) y en estos casos el colédoco se canuló en el 95,6% (44/46) de las ocasiones. Se realizaron 21/46 (45,6%) esfinterotomías pancreáticas. Hubo 1/46 (2,17%) pancreatitis leves. La mayoría de las prótesis se expulsaron de forma espontánea. Conclusiones: en este estudio, la inserción de una prótesis pancreática plástica cuando la guía ha pasado al conducto pancreático de forma involuntaria en los intentos de canulación del colédoco ayudó a canular la vía biliar en la mayoría de las ocasiones, sin que la inserción de las prótesis produjera efectos adversos

Introduction: the guidewire (GW) may enter the pancreatic duct during common bile duct (CBD) cannulation attempts in endoscopic retrograde cholangiopancreatography (ERCP). After GW passage into the pancreas, the most effective maneuver for CBD cannulation and pancreatitis prevention has not been determined. Aim: to study CBD cannulation and post-ERCP pancreatitis rates when a pancreatic stent is inserted after an unintentional GW cannulation of the pancreatic duct. Material and methods: a retrospective analysis of patients undergoing ERCP for biliary drainage that were included prospectively into a database. After unintentional GW cannulation of the pancreatic duct, a straight 5-Fr and 4-cm long plastic stent was inserted. The stents had no internal flaps to facilitate expulsion. CBD cannulation attempts were made above the stent. A pancreatic sphincterotomy was performed in patients older than 60 years before stent insertion. Results: a total of 46 pancreatic stents were inserted during 154 ERCP (29.8%) procedures. In the stent group, CBD cannulation was accomplished in 44/46 (95.6%) subjects. A total of 21/46 (45.6%) pancreatic sphincterotomies were performed. Only 1/46 (2.17%) mild pancreatitis cases were observed and most stents were spontaneously expelled. Conclusions: in this study, the CBD was eventually reached with the insertion of a plastic pancreatic stent after an unintentional GW passage into the pancreatic duct while attempting a CBD cannulation. No adverse events were observed following pancreatic stent insertion

Pancreatic stent insertion after an unintentional guidewire cannulation of the pancreatic duct during ERCP.

INTRODUCTION: the guidewire (GW) may enter the pancreatic duct during common bile duct (CBD) cannulation attempts in endoscopic retrograde cholangiopancreatography (ERCP). After GW passage into the pancreas, the most effective maneuver for CBD cannulation and pancreatitis prevention has not been determined. AIM: to study CBD cannulation and post-ERCP pancreatitis rates when a pancreatic stent is inserted after an unintentional GW cannulation of the pancreatic duct. MATERIAL AND METHODS: a retrospective analysis of patients undergoing ERCP for biliary drainage that were included prospectively into a database. After unintentional GW cannulation of the pancreatic duct, a straight 5-Fr and 4-cm long plastic stent was inserted. The stents had no internal flaps to facilitate expulsion. CBD cannulation attempts were made above the stent. A pancreatic sphincterotomy was performed in patients older than 60 years before stent insertion. RESULTS: a total of 46 pancreatic stents were inserted during 154 ERCP (29.8%) procedures. In the stent group, CBD cannulation was accomplished in 44/46 (95.6%) subjects. A total of 21/46 (45.6%) pancreatic sphincterotomies were performed. Only 1/46 (2.17%) mild pancreatitis cases were observed and most stents were spontaneously expelled. CONCLUSIONS: in this study, the CBD was eventually reached with the insertion of a plastic pancreatic stent after an unintentional GW passage into the pancreatic duct while attempting a CBD cannulation. No adverse events were observed following pancreatic stent insertion.

Lesión acral como primera manifestación de un adenocarcinoma de colon metastásico / Acral injury as first manifestation of a metastatic adenocarcinoma of the colon

No disponible

Fully covered self-expanding metal stents in the management of difficult common bile duct stones.

BACKGROUND AND OBJECTIVES: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. PATIENTS AND METHODS: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. RESULTS: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. CONCLUSIONS: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized.

Prótesis metálicas autoexpandibles totalmente recubiertas en el tratamiento de coledocolitiasis difíciles / Fully covered self-expanding metal stents in the management of difficult common bile duct stones

Introducción y objetivos: las prótesis biliares plásticas suelen emplearse tras una sesión de CPRE sin extracción completa de coledocolitiasis. En ocasiones, el calibre de drenaje con estas prótesis puede ser insuficiente. Presentamos nuestra experiencia en la utilización de prótesis metálicas autoexpandibles totalmente recubiertas (PMATR) en coledocolitiasis no extraídas. Pacientes y métodos: se insertó una PMATR (Wallflex biliar) en algunos pacientes con coledocolitiasis difíciles no extraídas tras una sesión de CPRE cuando se consideró que la esfinterotomía biliar y una prótesis plástica no aportaban un calibre de drenaje adecuado. Resultados: estudio retrospectivo en el que se utilizó una PMATR en 29 pacientes, edad media 81 años. Las coledocolitiasis no pudieron extraerse por la esfinterotomía biliar debido a su gran tamaño (n = 18) o por la presencia de estenosis distal inflamatoria (n = 11). Se consideró que era preciso el mayor drenaje biliar con el menor tiempo posible de CPRE debido a la situación de inestabilidad clínica de los pacientes y/o a la mala tolerancia a la sedación consciente administrada por el endoscopista. Se obtuvo un drenaje biliar adecuado en todos los casos. Las PMATR se retiraron tras una mediana de 199,5 días en 16 pacientes, obteniéndose una extracción completa de las coledocolitiasis en 15 (93,7%). No se extrajeron las PMATR en los 13 restantes debido a su situación clínica, manteniéndose una conducta expectante. Conclusiones: en casos seleccionados, la utilización de PMATR extraíbles es una buena opción para obtener un drenaje biliar adecuado y rápido en coledocolitiasis difíciles. El mayor coste de estas prótesis precisa que se individualice su utilización(AU)

Background and objectives: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. Patients and methods: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. Results: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. Conclusions: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized(AU)