Laparoscopy-assisted ERCP (LA-ERCP) following bariatric gastric bypass surgery: initial experience of a single UK centre.
ABSTRACT: Bariatric gastric bypass surgery is being increasingly performed, but endoscopic retrograde cholangiopancreatography (ERCP) in these patients poses a unique challenge because of a lack of per-oral access to the stomach. Small series suggest a higher technical success rate using laparoscopy-assisted ERCP (LA-ERCP) than with an enteroscopic approach via the Roux-en-Y anastomosis. We present initial experience of LA-ERCP in our unit.Retrospective case series of consecutive patients undergoing LA-ERCP in our unit between September 2011 and July 2014. Data was retrieved from electronic, clinical and endoscopy records.Seven LA-ERCPs were performed. All seven patients were female, with median age 44 years (range 36-71). Indications included symptomatic bile duct stones (5/7), benign papillary fibrosis (1/7) and retained biliary stent (1/7). 5/7 (71%) patients had had a prior cholecystectomy. To facilitate LA-ERCP, laparoscopic gastrostomy ports were created in all patients. Duodenal access, biliary cannulation and completion of therapeutic aim were achieved in all patients. 6/7 (86%) patients required endoscopic sphincterotomy. The median duration of procedures was 94 min (range 70-135). Median postoperative length of stay was 2 days (range 1-9). One patient developed mild postprocedural acute pancreatitis, and another patient developed a mild port-site infection. Otherwise, no procedure-related complications were seen. All patients remained well on follow-up (median 14 months (range 1-35) from date of ERCP), with no evidence of further biliary symptoms.Our early experience of LA-ERCP is that it is safe and effective. The technique may require particular consideration, as bariatric surgery is increasingly performed, in a patient group at significant risk of bile duct stones.
Project description:Acute pancreatitis is a common diagnosis worldwide, with gallstone disease being the most prevalent cause (50%). The American College of Gastroenterology recommends urgent endoscopic retrograde cholangiopancreatography (ERCP) (within 24 h) for patients with biliary pancreatitis accompanied by cholangitis. Most international guidelines recommend that ERCP be performed within 72 h in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, but the optimal timing for endoscopy is controversial. We investigated the optimal timing for ERCP in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, and whether performing endoscopy within 24 h is superior to performing it after 24 h. We analyzed the clinical data of 505 patients with newly diagnosed acute pancreatitis, from January 1, 2005 to December 31, 2014. We divided the patients into two groups according to the timing of ERCP: < 24 h (urgent) and 24-72 h (early).Among the 505 patients, 73 were diagnosed with biliary pancreatitis and a bile duct obstruction without cholangitis. The mean age of the patients was 55 years (range: 26-90 years). Bile duct stones and biliary sludge were identified on endoscopy in 45 (61.6%) and 11 (15.0%) patients, respectively. The timing of ERCP within 72 h was not associated with ERCP-related complications (P = 0.113), and the total length of hospital stay was not different between urgent and early ERCP (5.9 vs. 5.7 days, P = 0.174). No significant differences were found in total length of hospitalization or procedural-related complications, in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, according to the timing of ERCP (< 24 h vs. 24-72 h).
Project description:Background and study aims? After stone removal in endoscopic retrograde cholangiopancreatography (ERCP), an occlusion cholangiogram (OC) is performed to confirm bile duct clearance. OC can miss residual stones that can lead to recurrent biliary symptoms. The aim of this study was to assess if digital peroral cholangioscopy (POC) increased the diagnostic yield of residual biliary stones that are missed with OC. Patients and methods? Patients having ERCP performed for choledocholithiasis were enrolled into the study only if they had one of the following criteria: dilated bile duct ? 12?mm and/or if lithotripsy was being performed. An OC was performed to confirm duct clearance after removal of stones followed by POC, based on inclusion criteria. The incremental yield of biliary stones missed by OC but confirmed by POC was then measured. A total of 96 POC procedures were performed on 93 patients in two tertiary care centers. Results? Residual biliary stones were found in 34?% of cases. The average bile duct size in cases with residual stones was 15.1?mm?±?0.7?mm. One- to three-mm stones were found in 41?% of cases, 4- to 7-mm stones in 45?% of cases, and ??8-mm stones in 14?% of cases. Lithotripsy was performed in 13?% of cases and was significantly associated with residual stones (30?% vs. 3?%, P ?<?0.001). Conclusions? Occlusion cholangiogram can miss residual stones in patients with dilated bile ducts and those receiving lithotripsy. Digital POC can increase the yield of residual stone detection in these patients and should be considered to confirm clearance of stones. (ClinicalTrials.gov-NCT03482375).
Project description:Background and aims ?Treatment of biliary neoplasms often involves multiple endoscopic retrograde cholangiopancreatography (ERCP)-related procedures. Endoscopic sphincterotomy (ES) may prevent post-ERCP pancreatitis (PEP). This retrospective, multicenter cohort study aimed to investigate the effectiveness of ES for prevention of PEP in patients with biliary neoplasm. Methods ?Patients with biliary duct neoplasm who underwent ERCP between January 2006 and December 2016 were enrolled. The frequency of PEP was compared between the ES and non-ES groups using propensity score analysis. The effectiveness of ES in subgroups of patients who underwent biliary duct stent placement, intraductal ultrasound (IDUS), and transpapillary biliary duct biopsy was analyzed by logistic regression. Results ?Of the 362 patients enrolled, 84 (23.2?%) developed PEP. Propensity score matching for PEP risk factors in 172 ERCP procedures showed that the frequency of PEP in the ES group was lower than that in the non-ES group (19.7?% vs. 33.7?%). Non-ES was also an independent risk factor for PEP in patients who underwent intraductal ultrasound and transpapillary biliary duct biopsy (RR?=?4.54 and 5.26), but was not an independent risk factor for PEP in patients with biliary duct stents. In addition, there was no evidence that the frequency of PEP was statistically different between patients with plastic stents and metal stents in the ES and non-ES groups ( P ?=?0.14 and 0.10). Conclusions ?ES is an effective technique to prevent PEP in patients with biliary neoplasms. In particular, ES is a safe technique to prevent PEP when performing IDUS and transpapillary biliary duct biopsy.
Project description:BACKGROUND AND STUDY AIMS: Bile stones represent a highly prevalent condition and abnormalities of the biliary tree predispose to stone recurrence due to development of biliary stasis. In our study, we assessed the importance of an altered bile duct course for stone formation. PATIENTS AND METHODS: 1,307 patients with choledocholithiasis in the absence of any associated hepatobiliary disease who underwent endoscopic retrograde cholangiopancreatography (ERCP) between 2002 and 2009 were analysed. The angle enclosed between the horizontal portion of the common bile duct (CBD) and the horizontal plane was measured (angle ?). Oblique common bile duct (OCBD) was defined as a CBD with angle ? < 45°. RESULTS: 103 patients (7.9%) were found to harbour OCBD and these were compared to 104 randomly selected control subjects. Compared to controls, OCBD patients were (i) significantly older (72 ± 13 vs. 67 ± 13, p<0.00001); (ii) more frequently underwent a cholecystectomy (p = 0.02) and biliary surgery (p = 0.003) prior to the diagnosis and (iii) more often developed chronic pancreatitis (p = 0.04) as well as biliary fistulae (p = 0.03). Prior to and after ERCP, OCBD subjects displayed significantly elevated cholestatic parameters and angle ? negatively correlated with common bile duct diameter (r = -0.29, p = 0.003). OCBD subjects more often required multiple back-to-back ERCP sessions to remove bile stones (p = 0.005) as well as more ERCPs later on due to recurrent stone formation (p<0.05). CONCLUSION: OCBD defines a novel variant of the biliary tree, which is associated with chronic cholestasis, hampers an efficient stone removal and predisposes to recurrence of bile duct stones.
Project description:Although various endoscopic techniques in situs inversus have been reported, endoscopic retrograde cholangiopancreatography (ERCP) in patients with situs inversus is always challenging even for an experienced endoscopist. We performed ERCP using two different techniques, and compare the merits of each technique.A 74-year-old woman presented with epigastric pain and jaundice for 3 days. Computed tomography revealed diffuse dilatation of the biliary tree, with multiple intrahepatic duct and common bile duct (CBD) stones, in addition to situs inversus totalis. ERCP was performed twice for CBD stone to remove the CBD stones using two techniques. For the first technique used, the patient was placed in a prone position with the endoscopist on the right side of the table. First, the endoscope was rotated 180° counterclockwise in the stomach, and was then shortened by turning 180° the counterclockwise again in the duodenum. For the second technique, we assessed the second portion of the duodenum by following the lesser curvature, while slowly turning the endoscope clockwise.We present an unusual case of biliary stones in a patient with situs inversus who was treated using modified ERCP techniques.
Project description:The Endoscopic retrograde cholangiopancreatography (ERCP) Quality Network is a voluntary system for submission of data to generate individual report cards and benchmarking. The aim of this study was to compare aspects of ERCP practice between USA and UK participants.Analysis was limited to USA and UK based endoscopists who had each entered more than 30 cases. A number of practice and performance measures were studied including, rates of deep biliary cannulation, sedation use and success in bile duct stone removal.Patients attending for routine and emergency ERCP in participating tertiary and secondary care units in the UK and USA.61 US endoscopists performed 18 182 procedures and 16 UK endoscopists 3172, respectively. The UK participants performed less complex procedures as judged by the accepted complexity grading system, 8% versus 35% at grade 3, p<0.001. There was a significantly greater use of sedation as opposed to anaesthesia in the UK 97% versus 34%, p<0.001. UK deep biliary cannulation rate was 93% versus 97%, p<0.001. For small bile duct stones (<10 mm) the UK success rate was 96% compared with 99%, p<0.001.The present data, while not purporting to be an accurate representation of practice in either country, documents good technical success in both cohorts, albeit significantly better in the USA. The inexorable drive to greater accountability and transparency of outcomes in endoscopic practice is likely to lead to increased participation in subsequent benchmarking projects.
Project description:Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) for bile duct stone extraction has a major role in the treatment of cholangitis. It is well known that certain risk factors predispose to recurrence of such stones. The aims of this study were to evaluate the correlation between angulation of the common bile duct (CBD), right hepatic duct (RHD), and left hepatic duct (LHD) with recurrent cholangitic attacks and to elucidate other risk factors that may be associated with these attacks.This is retrospective study included 62 patients who had undergone therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. Their medical records were followed until May 1, 2009. The RHD, LHD, and CBD angulation and CBD diameter were measured on cholangiography prior to any endoscopic procedures.Among these 62 patients, 6 (9.7 %) had recurrence of cholangitis. Both angles of the RHD and the CBD were significantly smaller in the group with recurrence (P = 0.001, P = 0.004). A CBD angle ≤ 130(o) and RHD angle ≤ 125(o) were found to be significantly associated with an increased risk of recurrence (RR = 10.526, P = 0.033; RR = 24.97, P = 0.008) in multivariate analysis. Cholecystectomy was not a protective factor against recurrence of cholangitis (P = 0.615).Angulation of the CBD (≤ 130°) and RHD (≤ 125°) on ERCP are independent risk factors for recurrent cholangitis. Further prospective studies using these data may be warranted for a more accurate estimation and verification of the risk factors predisposing to recurrent cholangitis.
Project description:Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP.A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively.Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days).Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.
Project description:Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for identifying biliary pathology is unclear, with studies reporting false positive rates between 30% and 60%.Evaluate the sensitivity of IOC for biliary pathology, using ERCP with sphincterotomy and balloon sweep as gold standard.Retrospective cohort study.Tertiary medical centre.130 consecutive patients (age 51.3±1.7 years, 69.2% women) who underwent ERCP for the evaluation of abnormalities identified on IOC between 2005 and 2013.Endoscopic retrograde cholangiopancreatography.Sensitivity of IOC, identify predictors of positive postoperative ERCP and ERCP-related complications.ERCP was successful in all 130 subjects. ERCP-related adverse events occurred in six (4.3%) patients, including self-limited post-sphincterotomy bleeding in three (2.3%) and mild post-ERCP pancreatitis in three (2.3%). Overall, 41 (31.5%) patients had normal cholangiogram at time of ERCP. Finding of a filling defect on IOC was the only predictor for the presence of common bile duct stones on postoperative ERCP (OR 3.3, 95% CI 1.0 to 10.8, p=0.05).Retrospective study design.Nearly one-third of patients with abnormal IOC had a normal postoperative ERCP. Significant pathology could have been missed in 1/130 patients. Based on these findings, we believe the use of less-invasive diagnostic modalities may be used in place of ERCP in patients with suspected choledocholithiasis on IOC.
Project description:BACKGROUND: Laparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed. METHOD: A total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholithiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient,who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequelae of bile duct transection requiring staged operations. CONCLUSIONS: It is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed.