Long-term outcomes of endoscopic papillary large-balloon dilation (12-15 mm) with or without limited sphincterotomy for removal of bile duct stones.

BACKGROUND: Limited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12-15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones. METHODS: Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed. RESULTS: Basic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357-6.640; P = 0.007) was an independent risk factor for stone recurrence. CONCLUSIONS: The application of a large balloon (12-15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.

Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis.

OBJECTIVES: The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). METHODS: Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic. RESULTS: A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ±â€¯1.7 vs. 1.1 ±â€¯0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically. CONCLUSIONS: Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology.

BACKGROUND: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. METHODS: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. RESULTS: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period. CONCLUSIONS: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth II gastrectomy patients.

BACKGROUND: Endoscopic papillary balloon dilation (EPBD) for common bile duct (CBD) stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients. METHODS: The records of patients with previous Billroth II gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography (ERCP) between July 1, 2008 and September 1, 2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events, and stone recurrence were analyzed. RESULTS: A total of 83 patients with previous Billroth II gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth II gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients (85.7%). ERCP-related adverse events was in 3 ERCP procedures (5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients (12.2%) had stone recurrence after a median period of 22.5 months (range 6-71 months) from the end of stone removal treatment. Female [odds ratio (OR) = 11.352; 95% confidence interval (95% CI): 1.040-123.912; P = 0.046] and previous mechanical lithotripsy (OR = 13.423; 95% CI: 1.070-168.434; P = 0.044) were significantly associated with stone recurrence. CONCLUSIONS: At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth II gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.

Diagnostic Utility of Endoscopic Retrograde Cholangiography/Intraductal Ultrasound (ERC/IDUS) in Distinguishing Malignant from Benign Bile Duct Obstruction.

BACKGROUND AND AIM: Accurately differentiating malignant diseases from benign ones in patients having bile duct obstruction is of significant importance and remains a major clinical problem. This study investigated the diagnostic yield of endoscopic retrograde cholangiography/intraductal ultrasound (ERC/IDUS) in distinguishing malignant from benign bile duct obstruction and assessed some image findings from ERC/IDUS which might be useful in differentiation. METHODS: From January 2008 to January 2015, patients who underwent ERC/IDUS for bile duct obstruction were enrolled. Patient's ERC/IDUS diagnosis was compared with the final diagnosis determined by pathologic findings and/or clinical outcome of follow-up. RESULTS: One hundred and ninety-three patients with bile duct obstruction were included. IDUS correctly identified 94 of 97 malignant diseases and 76 of 96 benign diseases with sensitivity, specificity, and accuracy rate of 96.91, 79.17, and 88.08 %, respectively. Additionally, the accuracy rate of IDUS for diagnosis of proximal bile duct obstruction was higher than that of distal bile duct obstruction (98.08 vs. 82.73 %, p = 0.006). Besides, there was a significant difference in the length at the obstruction site between benign and malignant diseases (13.76 ± 7.37 vs. 19.97 ± 11.37 mm, p < 0.001) as well as thickness of bile duct wall at the site of obstruction (3.06 ± 0.92 vs. 7.03 ± 3.70 mm, p = 0.008). Biliary wall thickness >7 mm without extrinsic compression had a positive predictive value (PPV) of 100 % for including malignancy, while length ≧20 mm demonstrated a PPV of 93.44 %. CONCLUSIONS: ERC/IDUS is effective in distinguishing malignant from benign bile duct obstruction, thus helping in further clinical management.

Is ERCP both effective and safe for common bile duct stones removal in octogenarians? A comparative study.

BACKGROUND: Some studies have investigated the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for octogenarians, but more and larger comparative studies are still needed. METHODS: From January 2008 to June 2011, patients who underwent ERCP for common bile duct stone removal were included and divided into three groups, based upon their age. Basic information, medical records, and ERCP operation notes were retrospectively reviewed. RESULTS: 868 patients were included, with 474 patients in Group 1 (<65 years old), 281 patients in Group 2 (≥65 years old and <80 years old), and 113 patients in Group 3 (≥80 years old). No difference was observed regarding the rate of complete stone removal and hospital stay among the three groups. Pancreatitis occurred more frequently in Group 1 than Group 3, and the incidence of pancreatitis in Group 2 had no statistical difference when compared with Group 1 or Group 3. The occurrence of biliary infection, hemorrhage, perforation, and other complications was not statistically different among the three groups. The mortality directly related to the ERCP procedure was zero (0). CONCLUSIONS: ERCP is an effective and safe therapeutic method for stone removal in octogenarians, and age per se should not be a contraindication to endoscopic intervention.

Usefulness of an algorithm for endoscopic retrieval of proximally migrated 5Fr and 7Fr pancreatic stents.

BACKGROUND: Proximal migration of pancreatic stent (PMPS) is an infrequent event but its management can be technically challenging and there are no standard retrieval methods. This study aimed to determine the results of an endoscopic stent retrieval algorithm in terms of feasibility and efficacy of the endoscopic procedure. METHODS: During the period from January 2008 to December 2009, 15 patients (8 women and 7 men with a mean age of 51.9 years) with PMPS were included in this study. Stent retrieval was approached initially with balloon extraction followed by rat-tooth forceps and basket. A rescue approach such as using a stent retriever was attempted when other approaches failed. RESULTS: All the PMPSs (six 5Fr, nine 7Fr) were retrieved successfully within one ERCP session. Balloon extraction was successful in 9 (60%) patients. In the 6 failed cases of balloon extraction, wire-guided rat-tooth forceps grasp was successful in 4, and stone extraction basket grasp was successful in 1 in whom forceps grasp failed. One stent was finally rescued with a stent retriever when balloon extraction, forceps and basket grasp all failed. In patients with successful balloon extraction, 44.4% (4/9) developed post-ERCP hyperamylasemia but none of them developed post-procedure pancreatitis. CONCLUSIONS: With this algorithm, 5Fr and 7Fr PMPS were successfully retrieved in all of the patients. Most PMPSs can be safely retrieved with the commonly-used approaches in this study. Those less used approaches can be used as a rescue method.

Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials.

BACKGROUND: There is no clear answer regarding use of precut technique versus conventional method in achieving successful biliary cannulation. OBJECTIVE: To compare the effectiveness of precut technique with that of conventional biliary cannulation by meta-analysis of available randomized controlled trials (RCTs). METHODS: Databases including MEDLINE, EMBASE, Cochrane Library, and Science Citation Index updated to July 2009 were searched. Main outcome measures were success rates of biliary cannulation, incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications, and post-ERCP pancreatitis rate. Meta-analysis of these clinical trials was performed. RESULTS: Six RCTs were included. The primary biliary cannulation rate reported with precut and conventional techniques was 89.3 and 78.1%, respectively. Pooled analysis of all selected studies comparing precut cannulation technique with conventional techniques yielded an odds ratio (OR) of 2.05 [95% confidence interval (CI): 0.64-6.63]. Pooled analysis comparing post-ERCP pancreatitis rates for the precut-cannulation groups with those for the conventional-method groups yielded an rate ratio (RR) of 0.46 (95% CI: 0.23-0.92). CONCLUSION: This meta-analysis shows that the precut technique does not increase the primary cannulation rate. However, the technique reduces the risk of post-ERCP pancreatitis compared with conventional technique. Further large, well-performed, randomized controlled studies are needed to confirm these findings.

Comparison of the Long-Term Outcomes of Endoscopic Papillary Large Balloon Dilation Alone versus Endoscopic Sphincterotomy for Removal of Bile Duct Stones.

BACKGROUND AND AIMS: Endoscopic papillary large balloon dilation (EPLBD) alone is an alternative to endoscopic sphincterotomy (EST) for treatment of common bile duct (CBD) stones. However, limited data exists regarding comparison of the long-term outcomes for these techniques. In this study, we compared the long-term outcomes after EST with those after EPLBD alone for removal of CBD stones. METHODS: The records of patients with EST or EPLBD alone referred for CBD stones retrieval between June 2008 and July 2015 were retrospectively reviewed. Complete stone clearance, ERCP-related adverse events, and late biliary complications during long-term follow-up were analyzed. RESULTS: Basic patient characteristics were similar between the groups that underwent EST (n = 60) and EPLBD alone (n = 161). EPLBD compared with EST resulted in similar outcomes in terms of complete stone clearance (99.4% versus 100%, P = 0.54) and ERCP-related adverse events (6.8% versus 6.7%, P = 1.00). The mean duration of the follow-up was 74.5 months and 71.6 months who underwent EST and EPLBD alone, respectively (P = 0.42). Late biliary complications were occurred frequently in the EST group than in the EPLBD alone group (11 [18.6%] versus 16 [10.2%]), although the difference did not reach statistical significance (P = 0.11). Multivariate analysis showed that mechanical lithotripsy ([OR], 2.815; 95% CI, 1.148-6.902; P = 0.024) was significantly associated with late biliary complications. CONCLUSION: As an alternative to EST, EPLBD has similar efficacy and safety for managing CBD stones. During long-term follow-up, patients who underwent EPLBD alone may have fewer late biliary complications compared with those after EST. In addition, mechanical lithotripsy may be an independent risk factor for late biliary complications.

Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography.

BACKGROUND AND AIM: Periampullary diverticulum (PAD) is frequently encountered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate the association of PAD with pancreaticobiliary diseases as well as the impact of PAD on the technical success of ERCP and different methods of bile duct stone extraction. PATIENTS AND METHODS: A total of 1489 cases of patients with PAD were identified from 6390 patients who underwent ERCP. These patients were compared with 1500 controls without PAD in terms of biliary stone formation, technical success, and complications of ERCP. RESULTS: Patients with PAD had increased prevalence of bile duct stones, gallstones, and cholangitis (P<0.01). Successful cannulation rates were similar in the PAD and the control group (98.59 vs. 99.07%, P=0.225). The incidence of complications did not differ between the PAD and the control group. Successful stone removal rate of endoscopic sphincterotomy (EST) was lower in the PAD group than in the control group (83.53 vs. 94.31%, P=0.005). In patients with PAD, the rate of successful stone removal was lower in the EST group than in the endoscopic papillary balloon dilation (EPBD) and EPBD combined with limited EST (ESBD) group. The rates of complications were similar among different treatments (EST, EPBD, or ESBD) in patients with PAD. CONCLUSION: PAD is associated with bile duct stones, gallstones, and cholangitis. In addition, PAD should not be considered a barrier to a successful cannulation. Moreover, EST is less effective than EPBD and ESBD in patients with PAD, whereas EST, EPBD, and ESBD are equally safe in patients with PAD.

Endoscopic therapy for patients with pancreaticobiliary maljunction: a follow-up study.

BACKGROUND: Data on the experience of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreaticobiliary maljunction (PBM) is limited. METHODS: A retrospective review of patients with PBM who underwent therapeutic ERCP at our endoscopy center between January 2008 and January 2016 was performed. Demographic, clinical, radiological and endoscopic data was documented. Patients who underwent sphincterotomy were divided into dilated group and undilated group based on their common channel diameter. RESULTS: Sixty-three PBM patients underwent 74 ERCP procedures. The technical success rate was 97.3%. ERCP therapy significantly decreased the levels of elevated liver enzymes and bilirubin. After an average of 27 months follow-up, 7 patients (11.1%) were lost. The overall effective rate of ERCP therapy was 60.7% (34/56). Decline in severity and frequency of abdominal pain was significant. Procedure-related complications were observed in 5 (6.8%) cases. Between the dilated group and undilated group, no significant difference was observed in effective rate, adverse events and follow-up results. CONCLUSIONS: ERCP can serve as a transitional step to stabilize PBM patients before definitive surgery. PBM patients with undilated common channel could benefit from sphincterotomy as well as those with dilated common channel.

Endoscopic Intervention through Endoscopic Retrograde Cholangiopancreatography in the Management of Symptomatic Pancreas Divisum: A Long-Term Follow-Up Study.

BACKGROUND/AIMS: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of symptomatic pancreas divisum (PD) and to discuss whether ERCP procedures and outcomes in younger patients differ from those of adults. METHODS: Symptomatic patients with PD were included in the study and divided into underaged (age ≤17 years) and adult (age ≥18 years) group. The clinical information of each patient was reviewed, and then the patients were contacted by telephone or their medical records were reviewed to determine their long-term followup outcomes. RESULTS: A total of 141 procedures were performed in 82 patients (17 underaged and 65 adult patients). The ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%), and other discomfort (12.20%). The endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68% of the patients, bouginage in 26.95%, pancreatic ductal stone extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. After a median follow-up of 41 months, the overall response rate was 62.32%. Between the underaged group and the adult group, significant differences were not observed in the ERCP procedures, complications and longterm follow-up results. CONCLUSIONS: ERCP is a safe and effective treatment for symptomatic PD. Based on the details, complications, and follow-up results, the ERCP procedure did not present differences between the underaged and adult groups.

Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis.

BACKGROUND: Photodynamic therapy with the placement of a biliary stent may improve the prognosis in patients with unresectable cholangiocarcinoma. The aim of this research is to determine the hazard ratio of photodynamic therapy with stent compared to biliary stenting alone or other therapies for the treatment of cholangiocarcinoma. METHODS: Several databases were searched from inception to December 31 2013 for trials comparing photodynamic therapy+stent vs. stent-only or other treatments for cholangiocarcinoma. The outcomes of interest included patient survival, the changes of serum bilirubin levels, the quality of life (Karnofsky performance status), and adverse events. The hazard ratios (HR) were extracted from the survival curves using Tierney's Method. LnHR and its variance were pooled using an inverse variance-weighted average. Inconsistency was quantified using I(2) statistics. RESULTS: In all, 8 trials comparing PDT+stent with other therapeutic methods were selected. We made a meta-analysis based on the 7 trials, which compared the result of PDT+stent and the stent-only group. HR summarizes the survival for the two groups. Overall survival was significantly better in patients who received photodynamic therapy than those who did not [HR=0.49, 95% confidence interval (CI), 0.33∼0.73, P=0.0005]. Among the 8 trials (642 subjects), 5 assessed the changes of serum bilirubin levels, and/or Karnofsky performance status, as other indications for improvement. In all, the incidence for phototoxic reaction is 11.11%. The incidence for other events in photodynamic therapy and the stent-only group was 13.64% and 12.79%, respectively. CONCLUSION: The palliative treatment of cholangiocarcinoma, with photodynamic therapy, is associated with an increased survival benefit, an improved biliary drainage, and a better quality of life. However, the quality of this evidence is low.

Endoscopic retrieval technique of proximally migrated pancreatic stents: a retrospective study in a tertiary centre.

Background. There were scarce trials concerning the treatments and outcomes of proximal pancreatic stent migration. Herein, we did a retrospective study to discuss this problem from an endoscopist's point of view. Patients and Methods. From January 2009 to June 2014, patients with proximally migrated pancreatic duct stents were identified. Their clinical information was viewed. Retrieval techniques, success rates, and adverse events were analyzed. Results. A total of 36 procedures were performed in 34 patients; the median age of the patients was 53 years, with 17 males and 17 females. Eight patients' pancreatic duct stents could still be seen in the major or minor papilla and were pulled out with a snare forceps or a grasping forceps; in the remaining 28 procedures, the management was somewhat thorny; the retrieval called for several devices. Final success was achieved in 31 patients. No adverse event was observed in the process of ERCP procedures, 5 patients developed post-ERCP pancreatitis (PEP), 1 patient got infection, and 1 patient had haemorrhage. Conclusions. Endoscopic retrieval of migrated pancreatic stent is safe and less invasive; nonetheless, attention should be paid so as to reduce the incidence and degree of related adverse events, especially PEP.

Short-term and long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.

OBJECTIVE: The aim of this study was to compare the short-term and long-term outcomes of endoscopic sphincterotomy (EST) with endoscopic papillary balloon dilation (EPBD), and to find out risk factors for long-term complications. PATIENTS AND METHODS: From January 2008 to June 2011, patients who underwent endoscopic retrograde cholangiopancreatography for common bile duct stone removal were included, and they were divided into EST and EPBD groups. Clinical information was retrospectively viewed, and the patients were contacted through telephone or by searching for the medical records to get long-term outcomes. RESULTS: A total of 863 patients were included, with 636 patients in the EST group and 227 patients in the EPBD group. There was no difference in the rate of complete stone removal and early complications, except for pancreatitis. In all, 493 patients in the EST group and 170 patients in the EST group were followed up for 36.7-77.6 months. More patients in the EST group developed cholangitis, stone recurrence, and cholecystitis in the long term. Multivariate analysis showed that EPBD was a protective factor for cholangitis, stone recurrence, and cholecystitis. Gall stones were risk factors for cholangitis and cholecystitis. Mechanical lithotripsy may also be a risk factor for stone recurrence. CONCLUSION: EST shows better results in early outcomes, but during long-term follow-up patients following EST experienced more number of late complications. Gall stones and mechanical lithotripsy may be risk factors for long-term complications.