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World Journal of Gastroenterology Jan 2016Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often... (Review)
Review
Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.
Topics: Adenomatous Polyps; Ampulla of Vater; Biopsy; Cholangiopancreatography, Endoscopic Retrograde; Duodenal Neoplasms; Duodenoscopes; Duodenoscopy; Endosonography; Equipment Design; Female; Humans; Intestinal Mucosa; Intestinal Polyps; Male; Middle Aged; Postoperative Complications; Sphincterotomy, Endoscopic; Treatment Outcome
PubMed: 26811610
DOI: 10.3748/wjg.v22.i2.600 -
EClinicalMedicine Aug 2020Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly...
BACKGROUND
Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly amongst published studies testing this subject. We aimed to estimate the contamination rate of reprocessed patient-ready duodenoscopes for endoscopic retrograde cholangio-pancreatography (ERCP) based on currently available data.
METHODS
We searched the PubMed and Embase databases from January 1, 2010 until March 10, 2020, for citations investigating contamination rates of reprocessed patient-ready duodenoscopes. Studies not assessing other types of endoscopes than duodenoscopes were excluded from the analysis. Study eligibility and data extraction was evaluated by three reviewers independently. A random-effects model (REM) based on the proportion distribution was used to calculate the pooled total contamination rate of reprocessed patient-ready duodenoscopes. Subgroup analyses were carried out to assess contamination rates when using different reprocessing methods by comparing single high-level disinfection (HLD) with double HLD and ethylene oxide (EtO) gas sterilization. Additionally, we investigated the contamination rate between studies conducted following an outbreak compared to non-outbreak-initiated studies.
FINDINGS
We identified 15 studies that fulfilled the inclusion, which included 925 contaminated duodenoscopes from 13,112 samples. The calculated total weighted contamination rate was 15.25% ± 0.018 (95% confidence interval [Cl]: 11.74% - 18.75%). The contamination rate after only using HLD was 16.14% ± 0.019 (95% Cl: 12.43% - 19.85%) and after using either dHLD or EtO the contamination rate decreased to 9.20% ± 0.025 (95% Cl: 4.30% - 14.10%). Studies conducted following an outbreak (n=4) showed a 5.72% ± 0.034 (95% Cl: 0.00% - 12.43%) contamination rate, and non-outbreak-initiated studies (n=11) revealed a contamination rate of 21.50% ± 0.031 (95% Cl: 15.35% - 27.64%).
INTERPRETATION
This is the first meta-analysis to estimate the contamination rate of patient-ready duodenoscopes used for ERCP. Based on the available literature, our analysis demonstrates that there is a 15.25% contamination rate of reprocessed patient-ready duodenoscopes. Additionally, the analysis indicates that dHLD and EtO reprocessing methods are superior to single HLD but still not efficient in regards to cleaning the duodenoscopes properly. Furthermore, studies conducted following an outbreak did not entail a higher contamination rate compared to non-outbreak-initiated studies.
FUNDING
The authors received no financial support for the research, authorship, and/or publication of this article.
PubMed: 32954234
DOI: 10.1016/j.eclinm.2020.100451 -
Gastrointestinal Endoscopy Dec 2022
Topics: Humans; Duodenoscopes; Equipment Contamination; Disinfection; Cholangiopancreatography, Endoscopic Retrograde
PubMed: 36253193
DOI: 10.1016/j.gie.2022.08.014 -
Current Opinion in Gastroenterology Sep 2021Given the growing concerns about infection transmission from use of contaminated reusable duodenoscopes, technological advancements have been made that vary from... (Review)
Review
PURPOSE OF REVIEW
Given the growing concerns about infection transmission from use of contaminated reusable duodenoscopes, technological advancements have been made that vary from modifications of existing designs to development of single-use devices.
RECENT FINDINGS
To circumvent mechanical limitations that preclude access to critical areas of a duodenoscope to perform thorough cleaning and disinfection, single-use disposable duodenoscopes have been developed. A thorough assessment of this technology is limited by the minimal published data that is currently available. This opinion assesses the current technical functionality of these devices, potential for further improvements, implications for healthcare economics and the future of gastrointestinal endoscopy.
SUMMARY
Currently available data suggest that majority of endoscopic retrograde cholangiopancreatography procedures can be safely performed using single-use duodenoscopes. The ability to improve technical functionality, incorporate futuristic technology and secure financial reimbursement from insurance carriers will largely define the future prospects of this recent innovation.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Disinfection; Duodenoscopes; Endoscopy, Gastrointestinal; Equipment Contamination; Humans
PubMed: 34010243
DOI: 10.1097/MOG.0000000000000755 -
World Journal of Gastrointestinal... Aug 2021Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most... (Review)
Review
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
PubMed: 34512875
DOI: 10.4253/wjge.v13.i8.260 -
Journal of Clinical Gastroenterology Apr 2024Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the endoscopic management of biliary disease. An average of 700,000 ERCPs are performed...
Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the endoscopic management of biliary disease. An average of 700,000 ERCPs are performed every year, and most are performed using a reusable flexible duodenoscope. The innovation of disposable duodenoscopes has changed the dynamic in the advanced endoscopy field of study to primarily reduce or eliminate the risk of cross-contamination between patients. Many factors affect whether institutions can convert from standard reusable duodenoscopes to single-use duodenoscopes including the cost of the devices, reimbursement from insurance companies for the new devices, and the overall environmental impact. However, the reduction of cross-contamination leading to active infection in patients, environmental waste produced with high-level disinfection procedures, staff and equipment required for reprocessing, and the inability to frequently upgrade duodenoscopes for optimal performance are all factors that favor transitioning to single-use duodenoscopes. As these devices are new to the field of gastroenterology, the purpose of this review is to analyze the advantages and disadvantages of transitioning to single-use devices and a brief mention of alternative options for institutions unable to make this change.
PubMed: 38567887
DOI: 10.1097/MCG.0000000000001994 -
Infectious Disease Clinics of North... Dec 2018Gastrointestinal endoscopes are used for diagnostic and therapeutic purposes and are the most common medical device implicated in health care-associated outbreaks.... (Review)
Review
Gastrointestinal endoscopes are used for diagnostic and therapeutic purposes and are the most common medical device implicated in health care-associated outbreaks. Infections can be divided into endogenous or exogenous. Exogenous infections were associated with lapses in reprocessing. Recent outbreaks have occurred despite compliance with reprocessing guidelines and highlight the challenges with clearance of all organisms from the duodenoscopes and the potential role of biofilms in hindering adequate reprocessing. This review provides an overview of recent developments and the current understanding of the key contributing factors related to gastrointestinal endoscope-related infections and current approaches to identify and prevent these complications.
Topics: Bacterial Infections; Disinfection; Endoscopes, Gastrointestinal; Endoscopy, Gastrointestinal; Humans; Virus Diseases
PubMed: 30241713
DOI: 10.1016/j.idc.2018.06.008 -
Der Gastroenterologe : Zeitschrift Fur... 2022Clinically relevant infections triggered by the use of flexible endoscopes and respective consumables have become the focus of clinical and scientific interest in the... (Review)
Review
Clinically relevant infections triggered by the use of flexible endoscopes and respective consumables have become the focus of clinical and scientific interest in the literature. Endoscopy-associated infections can be assigned to one of two groups: (i) endogenous infections are triggered by the spread of the patient's own local flora and (ii) exogenous infections result from transmission of contaminated material or endoscopes. The number of reported infectious complications in flexible endoscopy is low but likely underestimated due to inadequate surveillance strategies and lack of clinical symptoms. To prevent exogenous infections, single-use endoscopes were brought to the market. Single-use bronchoscope have been part of routine clinical care for years, while single-use duodenoscopes have only recently been approved. The increased patient safety and economic costs were clearly evaluated for the single-use bronchoscopes, but this still needs to be studied for single-use duodenoscopes. The use of single-use endoscopes-at first glance-represents an additional financial burden on the healthcare system. However, in addition to the material costs of disposable endoscopes, the costs that are avoided by them (e.g., prolonged hospitalization, intensive care treatment, and follow-up interventions) must also be included in the overall calculation.
PubMed: 35018195
DOI: 10.1007/s11377-021-00581-9 -
Visceral Medicine Feb 2016Since the late 1970s there have been sporadic reports of nosocomial infections linked to endoscopic procedures. Infections by multidrug-resistant organisms (MDRO) have... (Review)
Review
BACKGROUND
Since the late 1970s there have been sporadic reports of nosocomial infections linked to endoscopic procedures. Infections by multidrug-resistant organisms (MDRO) have an increasing impact on healthcare systems worldwide. Since 2010 outbreaks involving MDRO have been reported as a result of endoscopic retrograde cholangiopancreatography (ERCP) from the USA, France, Germany and the Netherlands.
METHODS
This article evaluates the recent outbreaks and developments and demonstrates a structural approach to how to prevent future infections. Current national and international guidelines were used as a basis for discussions.
RESULTS
In some cases insufficient cleaning or drying supported the outbreak. In the majority of cases, outbreaks occurred despite the apparently appropriate reprocessing protocols being in use. Microlesions were identified on a number of endoscopes, which supported the growth of bacteria and represented a vehicle for the transmission of infectious material. National official bodies responded with warnings. Manufacturers informed their customers accordingly. Separate, purpose-designed reprocessing rooms and a sufficient number of competent staff provide the structural quality for a safe reprocessing. The process quality includes a thorough cleaning of all endoscope channels and crucial instrument components, followed by an automated and validated reprocessing procedure. Strict adherence to manufacturers' recommendations is essential. The outcome quality should be evaluated by regular audits, validation of reprocessing procedures and microbiological surveillance. If outbreaks occur, a close co-operation with official bodies and manufacturers is essential.
CONCLUSION
Health care professionals and manufacturers should be aware of their responsibility to ensure patient safety. A structural approach is key in prevention of endoscopy-associated infections.
PubMed: 27588292
DOI: 10.1159/000443626 -
VideoGIE : An Official Video Journal of... Aug 2023Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary... (Review)
Review
BACKGROUND AND AIMS
Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10 mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques.
METHODS
The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk.
RESULTS
The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video.
CONCLUSIONS
A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.
PubMed: 37575136
DOI: 10.1016/j.vgie.2023.05.006