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Gut and Liver Mar 2021Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in... (Review)
Review
Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Choledochostomy; Cholestasis; Drainage; Endosonography; Gallbladder; Humans; Stents; Ultrasonography, Interventional
PubMed: 32694240
DOI: 10.5009/gnl20096 -
Journal of Microbiology, Immunology,... Apr 2024Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current... (Review)
Review
Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers.
Topics: Humans; Disinfection; Taiwan; Equipment Contamination; Endoscopes; Endoscopes, Gastrointestinal
PubMed: 38135645
DOI: 10.1016/j.jmii.2023.12.001 -
International Journal of Surgery Case... Apr 2022The papilla of Vater is situated in the second part of the duodenum. The current study aims to report a rare occurrence of an ectopic papilla of Vater in the pyloric...
INTRODUCTION
The papilla of Vater is situated in the second part of the duodenum. The current study aims to report a rare occurrence of an ectopic papilla of Vater in the pyloric region presenting with cholangitis.
CASE REPORT
A 59-year-old male patient presented with right upper quadrant pain, anorexia, nausea, and jaundice. He was feverish and exhibited tenderness in the right upper quadrant. Endoscopic retrograde cholangiopancreatography revealed an ectopic papilla of Vater on the pyloric canal. A gastroscope was used instead of a duodenoscope for better visibility of the opening, easier cannulation, and a less risky sphincterotomy. He returned one year after his last procedure with no symptoms and no recurrence of acute cholangitis.
DISCUSSION
It has been suggested that developmental defects are acquired during embryogenesis. If subdivision happens early in embryogenesis, leaving the pars hepatica above the zone of proliferation that divides the stomach from the duodenum, the pars hepatica will develop into a duct that empties into the pylorus area.
CONCLUSION
It is preferable to use a gastroscope rather than a duodenoscope to visualize and manipulate the common bile duct in the case of an ectopic papilla of Vater in the pylorus.
PubMed: 35305424
DOI: 10.1016/j.ijscr.2022.106887 -
Gut May 2021Single-use duodenoscopes have been recently developed to eliminate risk of infection transmission from contaminated reusable duodenoscopes. We compared performances of... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Single-use duodenoscopes have been recently developed to eliminate risk of infection transmission from contaminated reusable duodenoscopes. We compared performances of single-use and reusable duodenoscopes in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).
DESIGN
Patients with native papilla requiring ERCP were randomised to single-use or reusable duodenoscope. Primary outcome was comparing number of attempts to achieve successful cannulation of desired duct. Secondary outcomes were technical performance that measured duodenoscope manoeuvrability, mechanical-imaging characteristics and ability to perform therapeutic interventions, need for advanced cannulation techniques or cross-over to alternate duodenoscope group to achieve ductal access and adverse events.
RESULTS
98 patients were treated using single-use (n=48) or reusable (n=50) duodenoscopes with >80% graded as low-complexity procedures. While median number of attempts to achieve successful cannulation was significantly lower for single-use cohort (2 vs 5, p=0.013), ease of passage into stomach (p=0.047), image quality (p<0.001), image stability (p<0.001) and air-water button functionality (p<0.001) were significantly worse. There was no significant difference in rate of cannulation, adverse events including mortality (one patient in each group), need to cross-over or need for advanced cannulation techniques to achieve ductal access, between cohorts. On multivariate logistic regression analysis, only duodenoscope type (single-use) was associated with less than six attempts to achieve selective cannulation (p=0.012), when adjusted for patient demographics, procedural complexity and type of intervention.
CONCLUSION
Given the overall safety profile and similar technical performance, single-use duodenoscopes represent an alternative to reusable duodenoscopes for performing low-complexity ERCP procedures in experienced hands.
TRIAL REGISTRATION NUMBER
Clinicaltrials.gov number: NCT04143698.
Topics: Aged; Cholangiopancreatography, Endoscopic Retrograde; Cross Infection; Disposable Equipment; Duodenoscopes; Equipment Contamination; Equipment Design; Female; Humans; Infection Control; Male
PubMed: 32895332
DOI: 10.1136/gutjnl-2020-321836 -
Endoscopy Sep 2020A newly designed duodenoscope with detachable distal cap may reduce bacterial contamination by allowing better access to the elevator. We compared bacterial...
BACKGROUND
A newly designed duodenoscope with detachable distal cap may reduce bacterial contamination by allowing better access to the elevator. We compared bacterial contamination and organic residue evaluated by rapid adenosine triphosphate (ATP) test and culture from duodenoscopes with detachable vs. fixed distal caps after high-level disinfection (HLD).
METHODS
During December 2018-April 2019, 108 used newly designed duodenoscopes were enrolled. In group A (n = 54), the distal cap of the duodenoscope was detached before manual cleaning. In group B (n = 54), the distal cap was not detached. After HLD, samples were collected from the elevator, submitted for culture, and evaluated using the ATP test, using the cutoff value of 40 relative light units (RLUs).
RESULTS
After HLD, the proportion of potential bacterial contamination and organic residue in group A was significantly lower than in group B (37.0 % vs. 75.9 %; < 0.001; relative risk 0.49, 95 % confidence interval 0.33-0.71), and also confirmed by median ATP values (45.2 vs. 141.0 RLU; < 0.001). In group B, one sample culture was positive for nonpathogenic bacteria. Pathogenic bacteria were not found in any culture from either group.
CONCLUSIONS
The detachable distal cap was more effective at eliminating bacterial contamination and reducing organic residue than a fixed cap. Nonpathogenic bacteria were detected in the fixed cap group after reprocessing. The ATP test with 40 RLU cutoff is a practical method to ensure the cleanliness of duodenoscope reprocessing without the need to wait for bacterial culture results.
Topics: Adenosine Triphosphate; Bacteria; Disinfection; Duodenoscopes; Equipment Contamination; Humans
PubMed: 32299115
DOI: 10.1055/a-1145-3562 -
Clinical Endoscopy Jan 2022Multiple outbreaks of multidrug-resistant organisms have been reported worldwide due to contaminated duodenoscopes. In 2015, the United States Food and Drug...
BACKGROUND/AIMS
Multiple outbreaks of multidrug-resistant organisms have been reported worldwide due to contaminated duodenoscopes. In 2015, the United States Food and Drug Administration recommended the following supplemental enhanced surveillance and reprocessing techniques (ESRT) to improve duodenoscope disinfection: (1) microbiological culture, (2) ethylene oxide sterilization, (3) liquid chemical sterilant processing system, and (4) double high-level disinfection. A systematic review and meta-analysis was performed to assess the impact of ESRT on the contamination rates.
METHODS
A thorough and systematic search was performed across several databases and conference proceedings from inception until January 2021, and all studies reporting the effectiveness of various ESRTs were identified. The pooled contamination rates of post-ESRT duodenoscopes were estimated using the random effects model.
RESULTS
A total of seven studies using various ESRTs were incorporated in the analysis, which included a total of 9,084 post-ESRT duodenoscope cultures. The pooled contamination rate of the post-ESRT duodenoscope was 5% (95% confidence interval [CI]: 2.3%-10.8%, inconsistency index [I2]=97.97%). Pooled contamination rates for high-risk organisms were 0.8% (95% CI: 0.2%-2.7%, I2=94.96).
CONCLUSION
While ESRT may improve the disinfection process, a post-ESRT contamination rate of 5% is not negligible. Ongoing efforts to mitigate the rate of contamination by improving disinfection techniques and innovations in duodenoscope design to improve safety are warranted.
PubMed: 34974676
DOI: 10.5946/ce.2021.212 -
World Journal of Gastrointestinal... Aug 2014Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Several operative interventions of both the... (Review)
Review
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Several operative interventions of both the gastrointestinal tract and the biliary and/or pancreatic system lead to altered anatomy, rendering ERCP more difficult or even impossible with a conventional side-viewing duodenoscope. Adapted endoscopes are available to reach the biliopancreatic system and to perform ERCP in patients with altered anatomy. However, both technical difficulties and complications determine the procedure's success. Different technical approaches have been described and are highly dependent on local expertise and endoscopic equipment. Standardized practical guidelines are currently unavailable. This review focuses on the challenges encountered during ERCP in patients with altered anatomy and how to deal with them. The first challenge is reaching the papilla or the bilioenteric/pancreatoenteric anastomosis in the patient with postoperative altered anatomy. The second challenge is the cannulation of the biliopancreatic system and performing all conventional ERCP interventions and the third challenge is the control of possible complications. The available literature data on this topic is reviewed and illustrated with clinical cases.
PubMed: 25132917
DOI: 10.4253/wjge.v6.i8.345 -
Gastroenterology & Hepatology Mar 2021
PubMed: 34035774
DOI: No ID Found -
Internal Medicine (Tokyo, Japan) Jul 2021Objective It is difficult to insert a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatography in patients with esophagogastroduodenal...
Objective It is difficult to insert a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatography in patients with esophagogastroduodenal deformities. To evaluate the efficacy and safety of using a large balloon anchor technique for cases in which inserting side-viewing duodenoscopes is difficult. Methods We retrospectively examined patients with endoscopic retrograde cholangiopancreatography who required the large balloon anchor technique between April 2016 and October 2020. Patients with deformed superior duodenal angles, esophagogastric junctions and pyloric rings and those having a shortened lesser curve were included. Results The balloon as an anchor was safely used to insert the duodenoscopes in 17 patients, and this procedure was performed 21 times. The procedure was successful 20 out of 21 times (95.2%), including 12 cases with duodenal deformities, 5 with shortening of the lesser curve, 2 after duodenal stent placement and 1 with a deformity of the esophagogastric junction. In the remaining patient, the first ERCP was successful, but the second was unsuccessful with duodenal deformities. There were no complications throughout the course of the study. Conclusion The large balloon anchor technique is a safe and useful technique for patients when inserting side-viewing duodenoscopes is difficult for various reasons.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Duodenoscopes; Humans; Retrospective Studies; Stents; Treatment Outcome
PubMed: 33612682
DOI: 10.2169/internalmedicine.6624-20 -
Clinical Endoscopy May 2020Endoscopic retrograde cholangiopancreatography (ERCP) requires a unique skill set. Currently, there is no objective methodology to assess and train a professional to...
BACKGROUND/AIMS
Endoscopic retrograde cholangiopancreatography (ERCP) requires a unique skill set. Currently, there is no objective methodology to assess and train a professional to perform ERCP. This study aimed to develop and validate a novel ERCP simulator.
METHODS
The simulator consists of papillae presenting different anatomy and positioned in varied locations. Deep cannulation of the pancreatic duct, followed by the bile duct, was performed. The time allotted was 5 minutes. The content validity indexes (CVIs) for realism, relevance, and representativeness were calculated. Correlation between ERCP experience and simulator score was determined.
RESULTS
Twenty-three participants completed the simulation. The CVIs for realism were orientation of duodenoscope to papilla (1.00), angulation of papillotome to achieve cannulation (0.71), and haptic feedback during cannulation (0.80). The CVIs for relevance were use of elevator (1.00), wheels to achieve en face orientation (1.00), and papillotome for selective cannulation (1.00). Regarding CVI for representativeness, the results were as follows: basic cannulation (0.83), papilla locations (0.83), and papilla anatomies (0.80). The novice, intermediate, and experienced groups scored 6.7±8.7, 30.0±16.3, and 74.4±43.9, respectively (p<0.0001). There was a strong correlation between the ERCP experience level and the individual's simulator score (Pearson value of 0.77, R2 of 0.60).
CONCLUSION
This simulator appears to be realistic, relevant, and representative of ERCP cannulation techniques. Additionally, it is effective at objectively assessing basic ERCP skills by differentiating scores based on clinical experience.
PubMed: 32062958
DOI: 10.5946/ce.2019.105