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DEN Open Apr 2022Complete situs inversus viscerum (SIV) is a rare congenital condition, defined by a left-right transposition of all viscera with dextroposition of the heart. In patients...
Complete situs inversus viscerum (SIV) is a rare congenital condition, defined by a left-right transposition of all viscera with dextroposition of the heart. In patients with SIV that requires endoscopic intervention, namely endoscopic retrograde cholangiopancreatography (ERCP), the left-right coordination can be technically demanding even with skilled endoscopist. We report a case of a patient with underlying SIV who presented with septic shock secondary to ascending cholangitis compounded with a malaria infection. Despite the ascertainment of a relatively large Common Bile Duct (CBD) stone, ERCP and stenting were pursued as an initial treatment modality in view of the clinical presentation of cholangitis and COVID-19-related delays in surgical intervention at our center. This case is unique as the patient was maintained in a supine position throughout the procedure. The patient underwent a successful ERCP procedure followed by a CBD Exploration and cholecystectomy 2 weeks later. A key factor that contributed to the success of this procedure was the combined utilization of a rotatable sphincterotome and extractor balloon which assisted with cannulation and shortening manoeuvre of the duodenoscope to facilitate biliary stenting.
PubMed: 35310748
DOI: 10.1002/deo2.17 -
DEN Open Apr 2022Although patients with ampullary cancers frequently experience obstructive jaundice and tumor bleeding, there have been few reports on efficient management of refractory...
Although patients with ampullary cancers frequently experience obstructive jaundice and tumor bleeding, there have been few reports on efficient management of refractory hemorrhage after conservative treatment. In this report, we describe a case of refractory bleeding from a 15-mm ampullary adenocarcinoma. A Japanese woman in her 60s was urgently hospitalized for cholangitis, pancreatitis, and sepsis treatment. Investigation with a side-viewing duodenoscope revealed an ulcerated ampullary adenocarcinoma. After the patient underwent anticoagulation therapy for pulmonary thromboembolism, the tumor bleeding gradually increased, resulting in severe anemia. Because the anemia did not improve with fasting or discontinuation of the anticoagulation therapy, the patient underwent repeated red blood cell transfusions. As no hemobilia was observed in the bile juice aspirated during endoscopic retrograde cholangiography, we supposed that the bleeding originated from the ulcerative cancer surface. We did not perform thermal therapy because we considered that it would worsen the bleeding. Abdominal angiography showed no pseudoaneurysms or extravasation. Ultimately, we performed transpapillary placement of a fully covered self-expandable metallic stent (SEMS) with an anchoring double pigtail plastic stent that resulted in successful hemostasis. In this case, the mechanism of hemostasis was not presumably explained by direct compression of the bleeding point but by indirect compression. When tumor volume is small, the radial force of the SEMS may cause compression of the tumor volume, leading to shrinkage of the bleeding blood vessels. In conclusion, covered SEMS placement could be an efficient treatment for refractory ampullary cancer bleeding, even from an ulcerated cancer surface.
PubMed: 35310691
DOI: 10.1002/deo2.23 -
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 -
BMC Gastroenterology Mar 2022While techniques for extracting large stones from dilated bile ducts are increasing, options for small stones impacted in non-dilated bile ducts are limited.
BACKGROUND
While techniques for extracting large stones from dilated bile ducts are increasing, options for small stones impacted in non-dilated bile ducts are limited.
CASE PRESENTATION
We report the case of an impacted biliary balloon dilator in a choledocholithiasis patient with a non-dilated bile duct and multiple anatomical variations, including low insertion of the cystic duct. After unsuccessful attempts with a stone extraction basket and balloon, a biliary balloon dilator with a sharp catheter tip was advanced into the bile duct. The balloon could not be removed from the bile duct even when deflated. The duodenoscope fell back into the stomach, causing the shaft of the dilator to break near the ampulla. We then removed the broken tip with a snare, which caused the balloon sheath to separate from the shaft and remain in the bile duct. Finally, we removed the sheath with rat-tooth forceps, leading to successful extraction of the stone-and-balloon complex.
CONCLUSIONS
The exceedingly rare possibility of balloon impaction should be kept in mind when using biliary balloon dilators in non-dilated bile ducts.
Topics: Ampulla of Vater; Bile Ducts; Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Gallstones; Humans
PubMed: 35303802
DOI: 10.1186/s12876-022-02196-y -
Infection Control and Hospital... Dec 2022Several clinical procedures utilize duodenoscopes, which are processed for reuse after the procedures are completed. However, infection outbreaks due to improper...
OBJECTIVE
Several clinical procedures utilize duodenoscopes, which are processed for reuse after the procedures are completed. However, infection outbreaks due to improper duodenoscope processing occur frequently. To address this, we aimed to assess the contamination rates of duodenoscopes after reprocessing in nonoutbreak settings.
DESIGN AND SETTING
Prospective study in 16 clinical sites in the United States.
METHODS
We sampled and cultured reprocessed duodenoscopes following the FDA/CDC/ASM guideline; "Duodenoscope Surveillance Sampling and Culturing - Reducing the Risks of Infection." High-concern (HC) organisms were those highly associated with disease, including gram-negative rods, , β-hemolytic , spp, and yeasts. We evaluated duodenoscopes with ≥1 CFU of organisms after reprocessing. The reprocessing environments were also sampled and cultured.
RESULTS
We assessed 859 newer-model (NM) duodenoscopes (TJF-Q180V) and 850 older-model (OM) duodenoscopes (TJF-160F/VF); of these, 35 NM samples (4.1%) and 56 OM samples (6.6%) were contaminated with HC organisms. We detected and classified the HC organisms as gastrointestinal (45.4%), human origin (16.7%), environmental (24.1%), waterborne (13.0%), and unidentified (0.9%).
CONCLUSIONS
We detected an overall HC contamination rate of 5.3% in nonoutbreak settings. Although the relationship between endoscopic contamination and the occurrence of infections remains unclear, attempts should continue to be made to further reduce contamination rates. Additional improvements to the manufacturer's instructions for use, human factors during the reprocessing procedure, ongoing training programs, cleanliness of reprocessing environments, and the design of the distal end of the duodenoscope should be considered.
Topics: Humans; Duodenoscopes; Prospective Studies; Equipment Contamination; Disease Outbreaks; Gram-Negative Bacteria; Disinfection
PubMed: 35300743
DOI: 10.1017/ice.2021.525 -
Case Reports in Gastroenterology 2021The Food and Drug Administration (FDA) has recently released a safety communication recommending transition to duodenoscopes with innovative designs that facilitate or...
The Food and Drug Administration (FDA) has recently released a safety communication recommending transition to duodenoscopes with innovative designs that facilitate or eliminate the need for reprocessing. Thus, there has been a significant amount of development into disposable duodenoscope components and single-use duodenoscopes, with variable tactile feedback. We describe a case of esophageal perforation after using a single-use disposable duodenoscope (EXALT Model D; Boston Scientific Corporation, Marlborough, MA, USA). To our knowledge, this is the first reported case of an esophageal perforation since FDA approval of this device in December 2019. ERCP was performed with the EXALT Model D single-use duodenoscope (Boston Scientific Corporation) by an experienced gastroenterologist. During the procedure, gentle force applied through the gastroesophageal junction caused a liner perforation in the distal esophagus. An esophageal stent was placed with satisfactory wound healing and no fistula formation. There have been a few reports in the last 2 years showing promising results using this device; however, the differences in the tactile feedback, navigation, and pushability of the device may make it prone to unintended consequences.
PubMed: 35110984
DOI: 10.1159/000519685 -
Revista Espanola de Enfermedades... Feb 2022The performance of an endoscopic procedure involves introducing an endoscope through the mouth or the anus, which may potentially lead to lethal infection. The risk...
The performance of an endoscopic procedure involves introducing an endoscope through the mouth or the anus, which may potentially lead to lethal infection. The risk increases when complex and difficult-to-clean scopes are used, as in the case of duodenoscopes. Side-viewing duodenoscopes are complex in design, with the camera and working channel exit located on one side of the endoscope's distal end, and with an elevator nail also located at this point for catheter redirection. This complex design may facilitate the presence of blind areas not easy to access for cleaning, resulting in suboptimal disinfection of the duodenoscope and therefore a higher risk of bacterial infection. This is of particular importance in particularly vulnerable patients like those who are immunosuppressed (e.g., transplanted patients) or have a malignant disease and are receiving chemotherapy. Moreover, in the era of ¨superbugs¨, like carbapenem-resistant Enterobacteriaceae, infection outbreaks related to endoscopic retrograde cholangiopancreatography (ERCP) have been reported with a significant mortality rate.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Costs and Cost Analysis; Delivery of Health Care; Disinfection; Duodenoscopes; Humans
PubMed: 35045718
DOI: 10.17235/reed.2022.8570/2021 -
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 -
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 -
Antimicrobial Resistance and Infection... Dec 2021Duodenoscopy-associated infections occur worldwide despite strict adherence to reprocessing standards. The exact scope of the problem remains unknown because a... (Review)
Review
Duodenoscopy-associated infections occur worldwide despite strict adherence to reprocessing standards. The exact scope of the problem remains unknown because a standardized sampling protocol and uniform sampling techniques are lacking. The currently available multi-society protocol for microbial culturing by the Centers for Disease Control and Prevention, the United States Food and Drug Administration (FDA) and the American Society for Microbiology, published in 2018 is too laborious for broad clinical implementation. A more practical sampling protocol would result in increased accessibility and widespread implementation. This will aid to reduce the prevalence of duodenoscope contamination. To reduce the risk of duodenoscopy-associated pathogen transmission the FDA advised four supplemental reprocessing measures. These measures include double high-level disinfection, microbiological culturing and quarantine, ethylene oxide gas sterilization and liquid chemical sterilization. When the supplemental measures were advised in 2015 data evaluating their efficacy were sparse. Over the past five years data regarding the supplemental measures have become available that place the efficacy of the supplemental measures into context. As expected the advised supplemental measures have resulted in increased costs and reprocessing time. Unfortunately, it has also become clear that the efficacy of the supplemental measures falls short and that duodenoscope contamination remains a problem. There is a lot of research into new reprocessing methods and technical applications trying to solve the problem of duodenoscope contamination. Several promising developments such as single-use duodenoscopes, electrolyzed acidic water, and vaporized hydrogen peroxide plasma are already applied in a clinical setting.
Topics: Anti-Bacterial Agents; Cross Infection; Disinfection; Drug Resistance, Multiple, Bacterial; Duodenoscopes; Enterobacteriaceae; Enterobacteriaceae Infections; Equipment Contamination; Equipment Reuse; Humans; Infection Control; United States; United States Food and Drug Administration
PubMed: 34949217
DOI: 10.1186/s13756-021-01037-z