Tomazo Franzini

CHOLANGIOSCOPY IN BILE DUCT DISEASE: a case series

CONTEXT Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology. METHODS We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention. RESULTS Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation. CONCLUSION The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies.

Advances in Therapeutic Cholangioscopy

Nowadays, cholangioscopy is an established modality in diagnostic and treatment of pancreaticobiliary diseases. The more widespread use and the recent development of new technologies and accessories had renewed the interest of endoscopic visualization of the biliary tract, increasing the range of indications and therapeutic procedures, such as diagnostic of indeterminate biliary strictures, lithotripsy of difficult bile duct stones, ablative techniques for intraductal malignancies, removal of foreign bodies and gallbladder drainage. These endoscopic interventions will probably be the last frontier in the near future. This paper presents the new advances in therapeutic cholangioscopy, focusing on the current clinical applications and on research areas.

DOUBLE-BALLOON ENTEROSCOPY IN THE DIAGNOSIS OF AN ADENOCARCINOMA OF THE FOURTH PORTION OF THE DUODENUM: REPORT OF A CASE

due to a coincident bariatric jejunum-ileal bypass sur-gery at that time.Upper gastrointestinal endoscopy showed antral ery-thematous gastritis, and no alteration was noted in the firstor second portions of the duodenum. Fecal stool occultblood testing was positive (3+), but colonoscopy showedno alterations. Scintigraphy with 99 Tc and marked eryth-rocytes was performed and revealed positivity for intesti-nal bleeding, probably at the proximal small bowel.DBE demonstrated first, second and third portions ofthe duodenum with no abnormalities. In the fourth portionof the duodenum a vegetative, infiltrative and friable le-sion was noted, extending about 10 cm, involving almostall the circumference and the lumen of the organ, allow-ing however the transposition of the double-balloonenteroscope. Multiple biopsies were performed. Histologi-cal examination demonstrated moderately differentiatedadenocarcinoma of the duodenum. The immunohistochemi-cal evaluation was consistent with adenocarcinoma. Afterthe diagnosis, the patient and his family elected treatmentat a private hospital and we lost the follow-up.

Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial

Background and study aims  Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % – 90 %). However, there is no study comparing these 2 techniques. Patients and methods  From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. Results  The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P  > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, – 25.2 min (CI95 % – 12.48 to – 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. Conclusion  Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.

SpyGlass percutaneous transhepatic cholangioscopy-guided lithotripsy of a large intrahepatic stone

Occasionally, biliary stone management can be really challenging, depending on location, size, number, altered anatomy, and presence of strictures [1]. Although different approaches can be used in this setting, such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and extracorporeal shock wave lithotripsy or surgery [2], more complex cases may require management using a combination of techniques [3–5]. A 40-year-old woman presented with recurrent cholangitis due to right hepatolithiasis (▶Fig. 1). Past history included a failed ERCP, and subsequent cholecystectomy with biliary exploration at another hospital. First, left PTBD was performed to improve the patient’s clinical status. A multidisciplinary team then decided in favor of surgical bile duct exploration with hepaticojejunostomy; however, the right intrahepatic stone could not be identified, even with intraoperative ultrasound. Biliary exploration through the PTBD drain was scheduled for the postsurgical recovery period. Meanwhile, cholangitis recurred, and the patient underwent urgent right PTBD following discovery of a 1.7 cm biliary stone, which had impacted in the confluence of the right anterior and posterior sectoral biliary ducts (▶Fig. 2). Balloon fragmentation was attempted, but was not successful. In addition, a basket was not considered to be a safe method of retrieval because of the size of the stone. ▶ Fig. 1 Intrahepatic stone (arrow) observed at magnetic resonance cholangiopancreatography.

Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones: A systematic review and meta-analysis based on randomized controlled trials

AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy (ML), perforation and cholangitis. RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding [FE RD-0.02, CI (-0.03, -0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI (-0.25, -0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI (-0.38, -0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI (-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI (-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI (-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI (-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI (-0.02, 0.07), I2 = 11%, P = 0.31]. CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.

Common bile duct intussusception during ERCP for stone removal

Figure 2. Basket with the gallstone captured in the middle third of the mortality in 0.33%. The most common adverse events are pancreatitis (3.47%), bleeding (1.34%), sepsis (1.44%), and perforation (0.6%). Rare adverse events after ERCP occur in 1% of cases and could put the patient in critical condition requiringurgent surgical intervention.We report the first case of a common bile duct (CBD) intussusception during ERCP for stone removal in a patient with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC). A 66-year-old man was referred for a second ERCP attempt at stone removal a week after cannulation of the CBD had failed. He had experienced jaundice and abdominal pain for the previous month, and US and CT showed cholecystolithiasis, choledocholithiasis, and dilatation of the intrahepatic bile ducts. His medical history included UC, rheumatoid arthritis, type 2 diabetes, and placement of a coronary stent after a myocardial infarction. The CBD was cannulated with a guidewired sphincterotome (Video 1, available online at www.VideoGIE.org). The intrahepatic bile ducts showed segmental strictures and

Metallic vs plastic stents to treat biliary stricture after liver transplantation: a systematic review and meta-analysis based on randomized trials

Background and study aims  The first-line approach to anastomotic biliary stricture after orthotopic liver transplantation (OLTX) involves endoscopic retrograde cholangiopancreatography (ERCP). The most widely used technique is placement of multiple plastic stents, but discussions are ongoing on the benefits of fully-covered self-expandable metallic stents (FCEMS) in this situation. This study aimed to compare results from use of plastic and metal stents to treat biliary stricture after transplantation. Patients and methods  Searches were performed in the Medline, EMBASE, SciELO/LILACS, and Cochrane databases, and only randomized studies comparing the two techniques were included in the meta-analysis. Results  Our study included four randomized clinical trials totaling 205 patients. No difference was observed between the stricture resolution rate (RD: 0.01; 95 %CI [−0.08 – 0.10]), stricture recurrence (RD: 0.13; 95 %CI [−0.03 – 0.28]), and adverse events (RD: −0.10; 95 %CI [−0.65 – 0.44]) between the plastic and metallic stent groups. The metallic stent group demonstrated benefits in relation to the number of ERCPs performed (MD: −1.86; 95 %CI [−3.12 to −0.6]), duration of treatment (MD: −105.07; 95 %CI [−202.38 to −7.76 days]), number of stents used (MD: −10.633; 95 %CI [−20.82 to −0.44]), and cost (average

Single-guidewire double-tip cannulation for difficult biliary access: the DTC technique

 8,288.50 versus

Large biliary stone: Lessons from a difficult case

 18,580.00, P  < 0.001). Conclusions  Rates of resolution and recurrence of stricture are similar, whereas the number of ERCPs performed, number of stents used, duration of treatment, and costs were lower in patients treated with FCEMS, which shows that this device is a valid option for initial treatment of post-OLTX biliary stricture.