Search Results (15)

Type 1 autoimmune pancreatitis (AIP), IgG4-related sclerosing cholangitis (IgG4-SC), and IgG4-related cholecystitis are recognized as IgG4-related pancreatobiliary diseases. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are crucial diagnostic modalities for these conditions. In the diagnosis of AIP, EUS-guided tissue acquisition plays an important role in obtaining histological confirmation and excluding pancreatic cancer (PC). EUS, including contrast-enhanced harmonic imaging and elastography, is used to differentiate focal-type AIP from PC. Endoscopic retrograde pancreatography (ERP) is utilized to obtain a pancreatogram when it is challenging to distinguish AIP from pancreatic cancer. Duodenal papilla biopsy may serve as a supplementary tool, particularly in cases involving the pancreatic head. Cholangiographic classification is essential for differentiating IgG4-SC from PC, primary sclerosing cholangitis (PSC), and cholangiocarcinoma (CCA). ERCP is commonly performed for additional ERCP-related procedures. Intraductal ultrasonography (IDUS) is useful for distinguishing IgG4-SC from CCA or PSC. The primary role of bile duct biopsy is exclusion of malignant biliary strictures; EUS-guided tissue acquisition may also provide histological evidence of IgG4-SC. In the diagnosis of IgG4-related cholecystitis, EUS is helpful to differentiate it from gallbladder cancer. EUS-guided tissue acquisition can aid in confirming IgG4-related cholecystitis and excluding gallbladder cancer or xanthogranulomatous cholecystitis. Transpapillary gallbladder cytology or biopsy may also be considered. Overall, endoscopic modalities play a critical role in diagnosing IgG4-related pancreatobiliary diseases. Full article

Background/Objectives: Pancreatitis is the most frequent and serious complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence between 2 and 10% and a mortality rate of 1 in 500 patients. Etiopathogenesis remains poorly understood. The aim of this study was to analyze the incidence of post-ERCP pancreatitis (PEP) and to identify potential patient- and procedure-related risk factors (RF) in a cohort of patients from a tertiary referral center in Romania. Methods: We conducted a retrospective, observational, single-center study in which we analyzed ERCP procedures performed in the Gastroenterology Department of Colentina Clinical Hospital, Bucharest, Romania, between January 2019 and September 2024. All patients received intrarectal diclofenac before the ERCP and were hydrated with at least 1500 mL of Ringer’s solution after the procedure in the absence of contraindications, according to the latest international recommendations. Results: In total, 2743 ERCPs were performed in the given time period, while 2350 procedures were analyzed in the study. PEP occurred in 350 cases (14.9%). Of these, 191 (54.6%) occurred in males with a mean age of 66.5 years. Procedural RF with adjusted odds ratios (OR) were as follows: difficult cannulation of the common bile duct, OR = 3.734, p < 0.001, main pancreatic duct catheterization, OR = 1.454, p = 0.022, and endoscopic papillary balloon dilatation, with an OR of 3.258, p < 0.001. Pancreatic duct stent placement was shown to prevent PEP in this study group (p < 0.001). Conclusions: PEP remains a serious complication of ERCP, associated with significant morbidity and occasional mortality. While some proven risk factors, such as age, gender, or comorbidities, are unmodifiable, avoiding Wirsung duct cannulation and pancreatography, or prophylactic pancreatic duct stent placement, could play a significant role in PEP prevention. Full article

The long-term efficacy of endoscopic treatment of pancreas divisum is controversial. This review focuses on recent literature on the role of endoscopic ultrasonography (EUS) as effective clinical support in the diagnosis and management of pancreas divisum. A challenging case study in a patient with pancreas divisum affected by recurrent acute pancreatitis and chronic pain is also reported. Our methodology was developed from a search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive electronic search across multiple databases, including Medline/PubMed, EMBASE, Medline/Metacrawler and the Cochrane Library, to identify relevant publications for this systematic review was conducted. A total of 308 articles were found. According to EMBASE grouping criteria, 31 articles were considered major clinical studies and were analysed, reporting for each study the relevant clinical features. In the majority of studies examined, EUS proved useful in diagnosing a pancreatic divisum. The EUS diagnostic yield was reported to have a sensitivity ranging from 51% to 95% and high diagnostic accuracy up to 97%. EUS has shown high sensitivity and specificity in diagnosing pancreas divisum. Studies indicate that EUS can achieve sensitivity rates ranging from 80% to 100% and specificity rates around 97% to 100% for detecting pancreas divisum. Based on these figures, EUS is the most reliable imaging system in terms of diagnostic capability compared with other imaging systems. Full article

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the “sequential approach”. The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien–Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation. Full article

Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m², p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort. Full article

The need for cholecystectomy during pediatric age has significantly increased in the last two decades. As biliary pathology increases, the probability of complicated cholecystectomies increases too. The aim of this article is to analyze our experience with difficult laparoscopic pediatric cholecystectomy, focusing on the importance of an accurate pre-operative imaging study. We retrospectively analyzed all patients affected by cholelithiasis who underwent laparoscopic cholecystectomy at the Pediatric Surgery Department of San Camillo Forlanini hospital of Rome and Santa Maria alle Scotte University Hospital of Siena from 2017 to 2022. Demographic data, body mass index (BMI), recovery data, laboratory tests, imaging exams, surgical findings, post operative management and outcome were taken into account. Overall, 34 pediatric patients, with a mean age of 14.1 years (6–18 years) were included, with a mean BMI of 29. All patients underwent abdominal ultrasonography and a liver MRI with cholangiography (cMRI). We identified five cases as “difficult cholecystectomies”. Two subtotal cholecystectomies were performed. Cholecystectomy in pediatric surgery can be difficult. The surgeon must be able to find alternative strategies to total cholecystectomy to avoid the risk of possible bile duct injury (BDI). Pre-operative imaging study trough ultrasound and especially cMRI is crucial to recognize possible difficulties and to plan the surgery. Full article

Endoscopic ultrasound guided—pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed. Full article

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification. Full article

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I²: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I²: 0%) and 99.1% (95%CI: 98.6–99.7; I²: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I²: 86.9%) and 69.1% (95%CI: 65.3–72.9; I²: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I²: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I²: 0%) and 98.5% (95%CI: 97.8–99.2; I²: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I²: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I²: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I²: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events. Full article

Background and objectives: Factors predictive of severe non-iatrogenic acute pancreatitis have been investigated, but few studies have evaluated prognostic markers of severe post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The neutrophil–lymphocyte ratio (NLR) has been studied for predicting severe acute pancreatitis. We examined the predictive value of NLR in patients with PEP. Materials and Methods: From January 2012 to August 2021, 125 patients who developed PEP were retrospectively evaluated. The NLR was measured before, and on days 1 and 2 after, ERCP. PEP was categorized as mild, moderate, or severe according to consensus guidelines, based on the prolongation of planned hospitalization. Patients were divided into two groups, mild-to-moderate vs. severe PEP. Results: We analyzed 125 patients with PEP, 18 (14.4%) of whom developed severe PEP. The baseline NLR was similar between the two groups (2.26 vs. 3.34, p = 0.499). The severe PEP group had a higher NLR than the mild/moderate PEP group on days 1 (11.19 vs. 6.58, p = 0.001) and 2 (15.68 vs. 5.32, p < 0.001) post-ERCP. The area under the curve of the NLR on days 1 and 2 post-ERCP for severe PEP was 0.75 (95% confidence interval (CI), 0.64–0.86)) and 0.89 (95% CI, 0.81–0.97), respectively; NLR on day 2 had greater power to predict severe PEP. The optimal cutoff value of the NLR on days 1 and 2 after ERCP for prediction of severe PEP was 7.38 (sensitivity, 72%; specificity, 69%) and 8.17 (sensitivity, 83%; specificity, 83%), respectively. In a multivariate analysis, a Bedside Index of Severity in Acute Pancreatitis score ≥3 (odds ratio (OR) 9.07, p = 0.012) and NLR on day 2 > 8.17 (OR 18.29, p < 0.001) were significantly associated with severe PEP. Conclusions: The NLR on day 2 post-ERCP is a reliable prognostic marker of severe PEP. Full article

Background: Malignant gastric outlet obstruction (MGOD) is an extremely rare expression of advanced extra-gastrointestinal cancer, such as squamous cell carcinoma (SCC) of the cervix, and only sixcases are described in the literature.Because of the short life expectancyand the high surgical risk involving these patients, less invasive approaches have been developed over time, such asthe use of an enteral stent or less invasive surgical techniques (i.e., laparoscopic gastrojejunostomy). However, MGOD could make it difficult to perform an endoscopic retrograde cholangio-pancreatography (ERCP) for standard endoscopic drainage, so in this case a combined endoscopic-percutaneous technique may be performed. This article, therefore, aims to highlight the presence in the doctor’s armamentarium of the “rendezvous technique”, few case reports of whichare described in the literature, and, moreover, this article aims to underline the technique’sfeasibility. Case Presentation: The case is that of a 38-year-old woman who presented with MGOD three years after the diagnosis of SCC of the cervix, who successfully underwent the rendezvous technique with the resolution of duodenal obstruction. Endoscopic enteral stenting treatment with the placement of a metal stent (SEMSs) represents the mainstay of MGOD treatment compared withsurgery due to its lower morbidity, mortality, shorter hospitalization and earlier symptom relief. However, in patients with both duodenal and biliary obstruction, a combined endoscopic–percutaneous approach may be necessary because of the difficulty in passing the duodenal stricture or in accessing the papilla through the mesh of the duodenal SEMS. Conclusion: The rendezvous procedure is a technicallyfeasible and minimally invasive approach to the double stenting of biliary and duodenal strictures. It achieves the desired therapeutic result while avoiding the need to perform more invasive procedures that could have a negative impact on the patient’sprognosis. Full article

Background: Bacterobilia is associated with postoperative morbidity after pancreaticoduodenectomy (PD), mostly due to infectious complications. The aim of this study was to investigate the prevalence of bacteria species isolated from intraoperative biliary cultures, and related complications after PD. Methods: An ANOVA test was used to assess the prevalence of isolated bacterial species and postoperative complications. The odds ratio was computed to evaluate the association between biliary cultures and each complication, Endoscopic Retrograde CholangioPancreatography (ERCP) and each complication, ERCP and biliary cultures, Delayed Gastric Emptying (DGE) and Postoperative Pancreatic Fistula (POPF). Results: Positive biliary cultures were found in 162/244 (66%) PDs. Different prevalences of polymicrobial biliary culture were detected in patients with postoperative complications. In SSIs, a significant prevalence of biliary culture positive for E. coli, Klebsiella pneumoniæ and Enterococcus fæcalis (p < 0.001) was detected. Prevalences of polymicrobial biliary cultures with Escherichia coli, Klebsiella pneumoniæ, Enterococcus fæcalis and Enterococcus fæcium were significantly associated with POPF (p < 0.001). Biliary culture positive for Escherichia coli, Enterococcus fæcalis and Enterococcus fæcium showed a higher prevalence of intra-abdominal collection and DGE (p < 0.001). Notably, Escherichia coli was significantly associated with DGE as a unique complication (OR = 2.94 (1.30–6.70); p < 0.01). Conclusions: Specific prevalences of polymicrobial bacterobilia are associated with major complications, while monomicrobial Escherichia coli bacterobilia is associated with DGE as a unique complication after PD. Full article

Background: Failure in the reprocessing of thermolabile flexible endoscopes has been reported as one of the most important threats to patient health. Method: A case report and observational study was conducted, from August 2014 to December 2019, in the Digestive Endoscopy Unit of a University Hospital in Italy, where two cases of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae infections in patients undergoing endoscopic retrograde cholangio-pancreatography were observed. Following the risk/safety management practices, an epidemiological investigation was started, duodenoscopes were removed from use and the reprocessing practices reviewed. Moreover, microbiological surveillance of endoscopes was carried out according to the CDC guidelines. Results: In the first phase of sampling, 10/10 (100%) endoscopes were found to be non-compliant, of which 7 showed results for high-concern organisms (HCOs), such as KPC-K. pneumoniae, P. aeruginosa and E. coli. After implementing corrective actions, 12 out of 17 endoscopes were found to be non-compliant (70.5%), of which 8 showed results for HCOs, such as KPC-K. oxytoca and P. aeruginosa. During the last year of regular microbiological surveillance, only 23% of endoscopes (35/152) were found to be non-compliant, of which 7 showed results for HCOs, such as NDM-K. pneumoniae, P. aeruginosa and A. baumannii. The crucial issues were related to samples collected from the internal channels of duodenoscopes. Conclusion: Managing the risk associated with the reprocessing of digestive endoscopes, through risk assessment at every stage of the process, is important for the prevention of infections associated with the use of these device. Full article

Endotherapy is a recognized, widely available, and minimally invasive treatment method for pancreatic fluid collections (PFCs) formed in the course of acute pancreatitis (AP). The use of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption due to AP remains unclear. In this article, a comprehensive review of current literature referencing our observations was performed to identify publications on the role of MPD stenting in patients undergoing endoscopic drainage of PFCs resulting from AP. In this paper, we attempt to clarify this most controversial aspect of endotherapy for PFCs based on existing knowledge and our own experience regarding the endoscopic treatment of AP sequelae. Endoscopic retrograde pancreatography should be performed in all patients undergoing endoscopic drainage of walled-off pancreatic necrosis to assess the integrity of the main pancreatic duct and to implement endotherapy if pancreatic duct disruption is detected. Passive transpapillary drainage is an effective method for treating MPD disruption in the course of necrotizing AP and is one of the key components of endoscopic therapy for local pancreatic necrosis. Conversely, in patients with pancreatic pseudocysts, passive transpapillary drainage reduces the effectiveness of endoscopic treatment and should not be used even in cases of MPD disruption during transmural drainage of pancreatic pseudocysts. In conclusion, the use of transpapillary drainage should depend on the type of the PFC. This conclusion is of great clinical importance, as it can help improve the results of pancreatic endotherapy for fluid collections resulting from AP. Full article

Perforation is a known but rare complication to Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). Most of the perforations are located in the periampullary area due to ES. This report presents an unusual perforation in the third part of the duodenum following ES. The patient an eigthy-sixt-year-old man underwent ERCP with ES. The patient had Magnetic Resonance Cholangio-pancreatography (MRCP) and Computerized Tomography (CT) verified cholelithiasis and intra- and extrahepatic cholestasis. The perforation was not found under the ERCP procedure but was clinically revealed when the patient developed pneumoscrotum after the procedure. A CT-scan with oral contrast later confirmed the duodenal perforation. Full article