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World Journal of Gastroenterology Oct 2020The management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to...
BACKGROUND
The management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.
AIM
To assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.
METHODS
We enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.
RESULTS
Hybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.
CONCLUSION
Hybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.
Topics: Adenoma; Duodenal Neoplasms; Duodenoscopes; Endoscopic Mucosal Resection; Humans; Intestinal Mucosa; Treatment Outcome
PubMed: 33088160
DOI: 10.3748/wjg.v26.i37.5673 -
JAMA Oct 2014Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the...
IMPORTANCE
Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities.
OBJECTIVE
To identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital.
DESIGN, SETTING, AND PARTICIPANTS
Outbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed.
MAIN OUTCOMES AND MEASURES
Association between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing.
RESULTS
In total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producing Escherichia coli was recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008], P < .001). After the hospital changed its reprocessing procedure from automated high-level disinfection with ortho-phthalaldehyde to gas sterilization with ethylene oxide, no additional case patients were identified.
CONCLUSIONS AND RELEVANCE
In this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producing E coli among patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.
Topics: Adult; Aged; Aged, 80 and over; Carbapenems; Case-Control Studies; Cohort Studies; Cross Infection; Disease Outbreaks; Disinfection; Drug Resistance, Bacterial; Duodenoscopes; Enterobacteriaceae Infections; Equipment Contamination; Escherichia coli; Female; Hospitals; Humans; Illinois; Male; Middle Aged; beta-Lactamases
PubMed: 25291580
DOI: 10.1001/jama.2014.12720 -
The American Surgeon Apr 2024The use of endoscopic retrograde cholangiography (ERCP) for diagnostic and therapeutic interventions on the pancreaticobiliary system has steadily increased, but the...
The use of endoscopic retrograde cholangiography (ERCP) for diagnostic and therapeutic interventions on the pancreaticobiliary system has steadily increased, but the standard approach through the oropharynx is prohibited after Roux-en-Y (RYGB) gastric bypass surgery. Laparoscopic access to the gastric remnant allows for the completion of ERCP using the standard side-viewing duodenoscope to facilitate the completion of standard and advanced endoscopic maneuvers. Here, we describe our experience with the technical aspects of safe and effective performance of laparoscopic-assisted ERCP.
PubMed: 38587416
DOI: 10.1177/00031348241244651 -
The Journal of Hospital Infection May 2024Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved... (Observational Study)
Observational Study
BACKGROUND
Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved multidrug-resistant micro-organisms (MDROs), outbreaks involving non-MDROs are also likely to occur. Detection challenges arise as these infections often resolve before culture or because causative strains are not retained for comparison with duodenoscope strains.
AIM
To identify and analyse DAIs spanning a seven-year period in a tertiary care medical centre.
METHODS
This was a retrospective observational study. Duodenoscope cultures positive for gastrointestinal flora between March 2015 and September 2022 were paired with duodenoscope usage data to identify patients exposed to contaminated duodenoscopes. Analysis encompassed patients treated after a positive duodenoscope culture and those treated within the interval from a negative to a positive culture. Patient identification numbers were cross-referenced with a clinical culture database to identify patients developing infections with matching micro-organisms within one year of their procedure. A 'pair' was established upon a species-level match between duodenoscope and patient cultures. Pairs were further analysed via antibiogram comparison, and by whole-genome sequencing (WGS) to determine genetic relatedness.
FINDINGS
Sixty-eight pairs were identified; of these, 21 exhibited matching antibiograms which underwent WGS, uncovering two genetically closely related pairs categorized as DAIs. Infection onset occurred up to two months post procedure. Both causative agents were non-MDROs.
CONCLUSION
This study provides crucial insights into DAIs caused by non-MDROs and it highlights the challenge of DAI recognition in daily practice. Importantly, the delayed manifestation of the described DAIs suggests a current underestimation of DAI risk.
Topics: Humans; Retrospective Studies; Duodenoscopes; Tertiary Care Centers; Microbial Sensitivity Tests; Male; Female; Bacteria; Equipment Contamination
PubMed: 38447805
DOI: 10.1016/j.jhin.2024.02.015 -
Endoscopy International Open Nov 2016Endoscopic retrograde cholangiopancreatography-related infections are of increasing global concern due to the emergence of multidrug-resistant bacteria such as...
Endoscopic retrograde cholangiopancreatography-related infections are of increasing global concern due to the emergence of multidrug-resistant bacteria such as carbapenem-resistant enterobacteriaceae (CRE), with bacterial biofilm production postulated as one cause of persistent infection from such virulent organisms. Because N-acetylcysteine (NAC) has been shown to possess antibacterial and biofilm-disruption properties, we aimed to evaluate if NAC would demonstrate clinical utility in reducing the colony forming units (CFU) at the elevator end of a duodenoscope, one of the hardest areas to clean. This was a pilot study of 16 procedures involving the use of a duodenoscope. After use, the elevator tip of a duodenoscope was cultured and submerged for 30 minutes, either in 20 % NAC (200 mg/mL, intervention) or in sterile water (control). After 30 minutes, the elevator tip was re-cultured. Submersion of the distal end of a duodenoscope in 20 % NAC (200 mg/mL) for 30 minutes resulted in a statistically significant reduction in bacterial colony forming units compared to control (average reduction 41.6 % vs 8.8 %, = 0.001). There was no visible damage and no optical distortion to the duodenoscope after submersion in NAC. In summary, NAC may be a safe, simple, and useful adjunct to currently available methods of duodenoscope reprocessing. Further research may better define NAC's role in duodenoscope reprocessing, either broadly or specifically after procedures suspected to produce a high risk of bacterial contamination (e. g. choledocholithiasis).
PubMed: 27853743
DOI: 10.1055/s-0042-116490 -
Endoscopy International Open Jun 2022The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and...
The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.
PubMed: 35692911
DOI: 10.1055/a-1794-0331 -
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 -
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 -
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 -
Frontiers in Public Health 2019Duodenoscopes have been described as potential vehicles of patient-to-patient transmission of multi-drug resistant organisms. Carbapenem-resistant duodenoscope related...
Duodenoscopes have been described as potential vehicles of patient-to-patient transmission of multi-drug resistant organisms. Carbapenem-resistant duodenoscope related infections have been described by the Center for Disease Control and the US Food and Drug Administration consequently to outbreaks occurring in the United States. These evidences suggested that improved microbiological surveillance and endoscope design optimization could represent valid tools to improve infection control. At this aim, in this study an example of duodenoscope microbiological surveillance and reprocessing improvement analyzing strains component of bacterial biofilm by phylogenetic analysis has been proposed. From September 2016 to December 2017, duodenoscope instruments were subjected to microbial surveillance by post-reprocessing cultures of liquid collected by internal channels of instruments after injection and aspiration cycles and membrane filtration. During surveillance seventeen , of which 10/17 (58.8%) MDR and KPC strains were collected from duodenoscope instruments plus one MDR strain from the rectal swab performed before ERCP procedure in an inpatient. The surveillance allowed evidencing potential failure of reprocessing procedure and performing consequent reprocessing improvements including the contaminated instruments quarantine until their negativity. Phylogenetic analysis of whole genome sequence of duodenoscope strains plus inpatients MDR strains, showed intermixing between duodenoscopes and inpatients, as evidenced by minimum spanning tree and time-scale Maximum Clade Credibility tree. In minimum spanning tree, three groups have been evidenced. Group I including strains, isolated from inpatients before microbiological surveillance adoption; group II including intermixed strains isolated from inpatients and strains isolated from duedonoscopes and group III including strains exclusively from duedonoscope instruments. In the Maximum Credibility Tree, a statistically supported cluster including two strains from duedonoscope instruments and one strains isolated from an inpatient was showed. From the first microbiologic surveillance performed on September 2016 and after the reprocessing improvement adoption, none MDR or susceptible strain was isolated in the following surveillance periods. In conclusion, these results should encourage hospital board to perform microbiological surveillance of duodenoscopes as well as of patients, by rectal swabs culture, and rapid molecular testing for antimicrobial resistance before any endoscopic invasive procedure.
PubMed: 31448253
DOI: 10.3389/fpubh.2019.00219