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1.
Eur J Clin Microbiol Infect Dis ; 38(12): 2205-2213, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31482418

RESUMO

Flexible digestive endoscopes are used for the management of various conditions with hundreds of thousands of therapeutic procedures performed worldwide each year. Duodenoscopes are indispensable tools for the delivery of minimally invasive vital care of numerous pancreaticobiliary disorders. Despite the fact that nosocomial infections after endoscopic retrograde cholangiopancreatography (ERCP) have always been among the most frequently cited postprocedural complications, recent emergence of duodenoscope-transmitted multiple drug-resistant bacterial infections has led to intense research and debate yet with no clearly delineated solution. Duodenoscope-transmitted nosocomial infections have become one of the most visible topics in the recent literature. Hundreds of high-impact articles have therefore been published in the last decade. This review article discusses how such infections were seen in the past and what is the current situation in both research and practice and thus tries to solve some of the unanswered questions for the future. With the persistence of nosocomial infections despite strict adherence to both manufacturer-issued reprocessing protocols and international guidelines and regulations, an urgent and proper microbiologically driven common action is needed for controlling such nosocomial worldwide threat.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Infecção Hospitalar/etiologia , Infecção Hospitalar/prevenção & controle , Duodenoscópios/efeitos adversos , Reutilização de Equipamento/normas , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Desinfecção , Duodenoscópios/microbiologia , Contaminação de Equipamentos , Humanos , Controle de Infecções , Fatores de Risco
3.
World J Gastroenterol ; 25(29): 3857-3869, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31413524

RESUMO

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.


Assuntos
Colestase/terapia , Drenagem/métodos , Endossonografia/métodos , Stents Metálicos Autoexpansíveis , Ultrassonografia de Intervenção/métodos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase/etiologia , Neoplasias do Ducto Colédoco/complicações , Neoplasias do Ducto Colédoco/patologia , Drenagem/efeitos adversos , Drenagem/instrumentação , Eletrocoagulação/efeitos adversos , Eletrocoagulação/instrumentação , Eletrocoagulação/métodos , Humanos , Invasividade Neoplásica/patologia , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/patologia , Resultado do Tratamento
4.
World J Gastroenterol ; 25(24): 3091-3107, 2019 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-31293344

RESUMO

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients. AIM: To systematically review the literature regarding ERCP in Billroth II gastrectomy patients. METHODS: A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed. RESULTS: A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%). CONCLUSION: The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Endoscópios , Gastrectomia/efeitos adversos , Gastroenterostomia/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Gastrectomia/métodos , Gastroenterostomia/métodos , Humanos , Resultado do Tratamento
5.
Gastrointest Endosc ; 90(4): 602-612.e4, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31276674

RESUMO

BACKGROUND AND AIMS: Preoperative biliary drainage with self-expanding metal stents (SEMSs) brings liver function within an acceptable range in preparation for neoadjuvant therapy (NATx) and provides relief of obstructive symptoms in patients with pancreatic cancer. We compared fully-covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs) for sustained biliary drainage before and during NATx. METHODS: Patients with pancreatic cancer and planned NATx who need treatment of jaundice and/or cholestasis before pancreaticoduodenectomy were randomized to FCSEMSs versus UCSEMSs. The primary endpoint was sustained biliary drainage, defined as the absence of reinterventions for biliary obstructive symptoms, and was assessed from SEMS placement until curative intent surgery or at 1 year. RESULTS: The intention-to-treat population included 119 patients (59 FCSEMSs, 60 UCSEMSs). Sustained biliary drainage was equally successful with FCSEMSs and UCSEMSs (72.2% vs 72.9%, noninferiority P = .01). Reasons for FCSEMS and UCSEMS failure differed significantly between the groups and included tumor ingrowth in 0% versus 16.7% (P < .01), and stent migration in 6.8% versus 0% (P = .03), respectively. Serious adverse event rates related to stent placement were not significantly different in both groups (23.7% [14/59] vs 20.0% [12/60], P = .66), as were acute cholecystitis rates when the gallbladder was in situ (9.3% [4/43] vs 4.8% [2/42], P = .68) for FCSEMSs and UCSEMSs, respectively. In our study, independent of stent type, predictors of reinterventions were 4-cm stent length and presence of the gallbladder. CONCLUSION: FCSEMSs and UCSEMSs provide similar preoperative management of biliary obstruction in patients with pancreatic cancer receiving NATx, but mechanisms of stent dysfunction depend on stent type, stent length, and presence of the gallbladder. (Clinical trial registration number: NCT02238847.).


Assuntos
Adenocarcinoma/terapia , Antineoplásicos/uso terapêutico , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colestase/cirurgia , Drenagem/métodos , Neoplasias Pancreáticas/terapia , Stents Metálicos Autoexpansíveis , Adenocarcinoma/complicações , Idoso , Procedimentos Cirúrgicos do Sistema Biliar/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasias Pancreáticas/complicações , Pancreaticoduodenectomia , Esfinterotomia Endoscópica/métodos
6.
World J Gastroenterol ; 25(26): 3313-3333, 2019 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-31341358

RESUMO

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Sistema Biliar/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colecistectomia/instrumentação , Duodenoscópios , Endossonografia , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Derivação Gástrica/instrumentação , Derivação Gástrica/métodos , Humanos , Laparoscopia/instrumentação , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos Reconstrutivos/instrumentação , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção
9.
World J Gastroenterol ; 25(19): 2373-2382, 2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31148908

RESUMO

BACKGROUND: Endoscopic biliary stenting is a well-established palliative treatment for patients with unresectable distal malignant biliary obstruction (MBO). However, the main problem with stent placement is the relatively short duration of stent patency. Although self-expanding metal stents (SEMSs) have a longer patency period than plastic stents (PSs), the higher costs limit the wide use of SEMSs. A PS with an antireflux valve is an attractive idea to prolong stent patency, but no ideal design for an antireflux PS (ARPS) has been proposed. We developed a new ARPS with a "duckbilled" valve attached to the duodenal end of the stent. AIM: To compare the patency of ARPSs with that of traditional PSs (TPSs) in patients with unresectable distal MBO. METHODS: We conducted a single-center, prospective, randomized, controlled, double-blind study. This study was conducted at the West China Hospital of Sichuan University. Consecutive patients with extrahepatic MBO were enrolled prospectively. Eligible patients were randomly assigned to receive either an ARPS or a TPS. Patients were followed by clinic visits or telephone interviews every 1-2 mo until stent exchange, death, or the final study follow-up in October 2018. The primary outcome was the duration of stent patency. Secondary outcomes included the rate of technical success, the rate of clinical success, adverse events, and patient survival. RESULTS: Between February 2016 and December 2017, 38 patients were randomly assigned to two groups, with 19 patients in each group, to receive ARPSs or TPSs. Stent insertion was technically successful in all patients. There were no significant differences between the two groups in the rates of clinical success or the rates of early or late adverse events (P = 0.660, 1.000, and 1.000, respectively). The median duration of stent patency in the ARPS group was 285 d [interquartile range (IQR), 170], which was significantly longer than that in the TPS group (median, 130 d; IQR, 90, P = 0.005). No significant difference in patient survival was noted between the two groups (P = 0.900). CONCLUSION: The new ARPS is safe and effective for the palliation of unresectable distal MBO, and has a significantly longer stent patency than a TPS.


Assuntos
Refluxo Biliar/prevenção & controle , Colestase Extra-Hepática/terapia , Neoplasias/complicações , Desenho de Prótese , Stents/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Refluxo Biliar/etiologia , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase Extra-Hepática/etiologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/terapia , Cuidados Paliativos/economia , Cuidados Paliativos/métodos , Plásticos/economia , Estudos Prospectivos , Falha de Prótese , Stents/economia , Resultado do Tratamento
10.
J Gastroenterol Hepatol ; 34(8): 1450-1453, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31157459

RESUMO

BACKGROUND AND AIM: Although endoscopic papillary large balloon dilation (EPLBD) has been widely used to facilitate the removal of difficult common bile duct stones, however, the outcomes have not yet been investigated in terms of the diameter of the balloon used. We aimed to compare the clinical outcomes between EPLBD using smaller (12-15 mm, S-EPLBD) and larger balloons (> 15 mm, L-EPLBD). METHODS: Six hundred seventy-two patients who underwent EPLBD with or without endoscopic sphincterotomy for common bile duct stone removal were enrolled from May 2004 to August 2014 at four tertiary referral centers in Korea. The outcomes, including the initial success rate, the success rate without endoscopic mechanical lithotripsy, the overall success rate, and adverse events between S-EPLBD and L-EPLBD groups, were retrospectively compared. RESULTS: The initial success rate, the success rate without mechanical lithotripsy, the overall success rate, and the overall adverse events were not significantly different between the two groups. The rate of severe-to-fatal adverse events was higher in the L-EPBLD group than in the S-EPLBD group (1.6% vs 0.0%, 0.020). One case of severe bleeding and two cases of fatal perforation occurred only in the L-EPLBD group. In the multivariate analysis, the use of a > 15-mm balloon was the only significant risk factor for severe-to-fatal adverse events (>0.005, 23.8 [adjusted odds ratio], 2.6-214.4 [95% confidence interval]). CONCLUSIONS: L-EPLBD is significantly related to severe-to-fatal adverse events compared with S-EPLBD for common bile duct stone removal.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Coledocolitíase/terapia , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/mortalidade , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/mortalidade , Dilatação , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esfinterotomia Endoscópica , Resultado do Tratamento
12.
Gastrointest Endosc ; 90(5): 793-804, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31102643

RESUMO

BACKGROUND AND AIMS: Worldwide, an increasing number of duodenoscope-associated outbreaks are reported. The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP at risk of exogenous transmission of microorganisms. The contributing factors of the duodenoscope design to contamination are not well understood. This article reports on the investigation after the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes. METHODS: We conducted a contact patient screening and microbiologic laboratory database search. Reprocessing procedures were audited, and both duodenoscopes were fully dismantled to evaluate all potential contamination factors. Outcomes were reviewed by an experienced independent expert. RESULTS: In total, 102 patients who had undergone an ERCP procedure from January to August 2015 were invited for screening. Cultures were available of 81 patients, yielding 27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active infection. The 2 duodenoscopes had attack rates (the number of infected or colonized cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical MRKP isolates were cultured from channel flushes of both duodenoscopes. The review revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities, including the forceps elevator, elevator lever, and instrumentation port sealing. CONCLUSIONS: Outbreaks are associated with a combination of factors, including duodenoscope design issues, repair issues, improper cleaning, and systemic monitoring of contamination. To eliminate future duodenoscope-associated infections, a multipronged approach is required, including clear communication by all parties involved, a reliable servicing market, stringent surveillance measures, and eventually new duodenoscope designs and reprocessing procedures with a larger margin of safety.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Surtos de Doenças , Duodenoscópios/efeitos adversos , Infecções por Klebsiella/epidemiologia , Infecções por Klebsiella/microbiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Portador Sadio/epidemiologia , Portador Sadio/microbiologia , Criança , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Descontaminação/normas , Farmacorresistência Bacteriana Múltipla , Duodenoscópios/microbiologia , Contaminação de Equipamentos , Desenho de Equipamento , Feminino , Humanos , Klebsiella pneumoniae , Manutenção/normas , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Análise de Causa Fundamental
15.
Surg Laparosc Endosc Percutan Tech ; 29(3): 216-219, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30720694

RESUMO

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been commonly used for biliopancreatic diseases of patients with normal gastrointestinal (GI) anatomy with a success rate of >90%. However, this procedure may also be necessary in patients with altered GI anatomy such as Billroth II or Roux-en-Y reconstructions. Performing ERCP in these patients may pose extreme technical challenges, and increase the risk of complications. The aim of this study was to analyze the feasibility of ERCP using forward-viewing endoscopy in patients with altered GI anatomy. MATERIALS AND METHODS: Twenty-three patients with previous gastric resections and GI anastomosis, who underwent ERCP between 2012 and 2017, were included in this retrospective study. The major indication for ERCP was choledocholithiasis in 19 patients, and the others were acute cholangitis, sphincter Oddi dysfunction, and biliary pancreatitis. The sedation was induced using a combination of midazolam and propofol, and all procedures were performed using a forward-viewing endoscope. RESULTS: Among the 23 patients, 14 were male individuals and 9 were female individuals, with an average age of 62 (range: 58 to 73) years. The median procedure time was 24 (range: 19 to 43) minutes. The success rate of bile duct cannulation was 91.3% (21/23 patients) and that of stone extirpation was 89.4% (17/19 patients with choledocholithiasis). Plastic stents were placed in the 2 patients in whom stone extirpation was not successfully performed. ERCP was repeated in these patients 8 weeks after the initial approach, and stone extraction procedures were successfully completed. The only procedure-related complication was edematous pancreatitis, which was observed in 1 patient (4.7%). The mean length of hospitalization was 2 (range: 1 to 5) days. CONCLUSIONS: Forward-viewing endoscopes can be effectively used in patients with altered GI anatomy by facilitating the access to the papilla and bile duct cannulation without increasing the incidence of complications.


Assuntos
Anastomose em-Y de Roux , Colangiopancreatografia Retrógrada Endoscópica/métodos , Gastroenterostomia , Idoso , Cateterismo/métodos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Coledocolitíase/cirurgia , Endoscópios , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Stents
16.
Dig Dis Sci ; 64(8): 2300-2307, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30788687

RESUMO

BACKGROUND AND AIM: To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals. METHODS: We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate. RESULTS: Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5 days vs. 140.5 days, p < .0001). CONCLUSIONS: Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colangite/etiologia , Colestase/terapia , Drenagem/efeitos adversos , Drenagem/instrumentação , Stents , Adulto , Bilirrubina/sangue , Biomarcadores/sangue , Colangite/diagnóstico , Colangite/mortalidade , Colestase/diagnóstico por imagem , Colestase/etiologia , Colestase/mortalidade , Neoplasias do Sistema Digestório/complicações , Feminino , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
18.
Dig Dis Sci ; 64(8): 2291-2299, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30746630

RESUMO

BACKGROUND: Biliary cannulation failure is a major problem during endoscopic retrograde cholangiopancreatography. It remains unclear how duodenal papilla morphology affects biliary cannulation. Therefore, we proposed a new classification system for the duodenal papilla based on oral protrusion pattern (ratio of the length of the oral protrusion to the transverse diameter of the papilla) and papilla pattern. AIMS: To retrospectively compare biliary cannulation results with regard to classification and operator experience. METHODS: We analyzed 589 naïve major duodenal papillae. Our classification system comprised oral protrusion pattern, classified as small (Protrusion-S), regular (Protrusion-R), or large (Protrusion-L), and the papilla pattern, classified as annular (Papilla-A), unstructured (Papilla-U), longitudinal (Papilla-LO), isolated (Papilla-I), or gyrus (Papilla-G). Intra-evaluator concordance and the results of biliary cannulation were analyzed. RESULTS: The following oral protrusion pattern classifications were observed: Protrusion-S, 11.7%; Protrusion-R, 77.9%; and Protrusion-L, 10.4%. The following papilla patterns were observed: Papilla-A, 67.1%; Papilla-U, 7.0%; Papilla-LO, 7.5%; Papilla-I, 1.2%; Papilla-G, 15.6%; and unclassified, 1.7%. Intra-evaluator concordance value (Fleiss kappa) was 0.788 for oral protrusion pattern and 0.750 for papilla pattern. A logistic regression analysis of cannulations performed by an experienced endoscopist identified Protrusion-L as a significant risk factor for difficult cannulation (odds ratio 2.956; 95% confidence interval 1.115-7.84; p = 0.029). Multivariate analysis confirmed Protrusion-L as an independent risk factor for difficult biliary cannulation (odds ratio 3.772; 95% confidence interval 1.359-10.464; p = 0.011). CONCLUSIONS: We propose a new general classification system for the duodenal papilla. Protrusion-L is a significant risk factor for difficult biliary duct cannulation.


Assuntos
Ampola Hepatopancreática/diagnóstico por imagem , Cânula , Cateterismo/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Terminologia como Assunto , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/patologia , Cateterismo/efeitos adversos , Criança , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
19.
Dig Dis Sci ; 64(7): 1770-1781, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30734236

RESUMO

The advancement of pancreatic endotherapy has increased the availability of minimally invasive endoscopic pancreatic ductal drainage techniques. In this regard, familiarity with endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is critical for treatment of obstructed pancreatic ductal systems, especially in nonsurgical candidates and in patients desiring a minimally invasive approach. Two distinct forms of EUS-PDD exist, viz. rendezvous-assisted endoscopic retrograde pancreatography (rendezvous-assisted ERP) and anterograde EUS-PDD. Anterograde EUS-PDD refers to transmural anterograde passage of a pancreatic drainage catheter or stent directly into the main pancreatic duct, through either the gastric or enteral wall. Rendezvous-assisted ERP should be attempted after failed conventional ERP, and anterograde EUS-PDD should be considered if rendezvous-assisted ERP fails or is not technically feasible. Common clinical scenarios that fulfil these conditions are chronic pancreatitis with high-grade main pancreatic duct obstruction, surgically altered anatomy with ductal/anastomotic obstruction, pancreas divisum, and disconnected pancreatic duct syndrome. The focus of this review article is anterograde EUS-PDD and its indications, technique, and outcomes. It also provides a summary of our own experience with this procedure, and a video demonstration of the technique.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Drenagem/métodos , Endossonografia , Ductos Pancreáticos/diagnóstico por imagem , Pancreatite Crônica/terapia , Ultrassonografia de Intervenção , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Tomada de Decisão Clínica , Drenagem/efeitos adversos , Drenagem/instrumentação , Endossonografia/efeitos adversos , Humanos , Pancreatite Crônica/diagnóstico por imagem , Seleção de Pacientes , Fatores de Risco , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos
20.
Curr Gastroenterol Rep ; 21(2): 7, 2019 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-30741352

RESUMO

PURPOSE OF REVIEW: ERCP is undergoing its 50th anniversary with a steady conversion from a diagnostic procedure to a therapeutic procedure. This paper shows a reflection of my 42 years of experience in the accession of biliary and pancreatic ducts and how the techniques have evolved to achieve a high rate of primary duct cannulation. RECENT FINDINGS: There has been an increase in the primary approach to cannulation involving different cannulation catheters and guidewires, and we will review some of those available, realizing that the selection may vary depending on operator preference and team approach. Different views and experiences with these techniques will be presented. ERCP has evolved from a diagnostic to primarily a therapeutic procedure. This has resulted in the development of a variety of devices and techniques to access the ducts of interest. I have presented several of the techniques and my team approach that has evolved over a number of years. A more prospective evaluation of devices and wires is needed to see if one is superior to the other.


Assuntos
Ampola Hepatopancreática/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Ducto Colédoco/cirurgia , Ductos Pancreáticos/cirurgia , Cateterismo , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Humanos
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