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Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is a first-line diagnostic modality for suspected malignant biliary stricture (MBS), the diagnostic yield of ERCP-based tissue sampling is insufficient. Peroral cholangioscopy-guided forceps biopsy (POC-FB) and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) are evolving as reliable diagnostic procedures for inconclusive MBS. This study aimed to evaluate the usefulness of a diagnostic approach using POC-FB or EUS-FNAB according to the stricture location in patients with suspected MBS.Methods: Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with transpapillary forceps biopsy (TPB) was performed initially. When malignancy was not confirmed by TPB, POC-FB using a SpyGlass direct visualization system or direct POC using an ultraslim endoscope was performed for proximal strictures, and EUS-FNAB was performed for distal strictures as a follow-up biopsy.Results: Among a total of 181 patients, initial TPB showed malignancy in 122 patients, and the diagnostic accuracy of initial TPB was 71.8 % (95 % confidence interval [CI] 65.3 % - 78.4 %]. Of the 59 patients in whom TPB was negative for malignancy, 32 had proximal biliary strictures and underwent successful POC. The remaining 27 patients had distal strictures and underwent successful EUS-FNAB. The accuracy of malignancy detection using POC-FB for proximal biliary strictures and EUS-FNAB for distal biliary strictures was 93.6 % (95 %CI 84.9 %-100 %) and 96.3 % (95 %CI 89.2 %-100 %), respectively. The overall diagnostic accuracy for the combination of TPB with either POC-FB for proximal strictures and EUS-FNAB for distal strictures was 98.3 % (95 %CI 95.9 %-100 %) and 98.4 % (95 %CI 95.3 %-100 %), respectively.Conclusions: An approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS. [ABSTRACT FROM AUTHOR]

Background and study aims I-SCAN is a computed virtual chromoendoscopy (CVC) system designed to enhance surface and vascular patterns. In this study, we evaluated the usefulness of direct peroral cholangioscopy (POC) using I-SCAN compared with a conventional white-light image (WLI) to diagnose bile duct lesions. Patients and methods Patients with mucosal lesions in the bile duct detected during direct POC were enrolled prospectively. The quality of endoscopic visualization and the visual diagnosis were assessed using I-SCAN and WLI modes, respectively, during direct POC. Results A total of 20 patients (9 malignant and 11 benign lesions) underwent I-SCAN to evaluate lesions in the bile duct using direct POC. The quality of endoscopic visualization using direct POC with I-SCAN was significantly higher than that of WLI for surface structure (P = 0.04), surface microvascular architecture (P = 0.01), and margins (P = 0.02). Overall diagnostic accuracy of the visual diagnosis was not different between I-SCAN and WLI (90.0 % vs. 75.0 %; P = 0.20). Conclusion Direct POC using CVC by I-SCAN seems to be helpful for evaluating mucosal lesions of the bile duct, without the interference from bile.Clinical Trial Registration: UMIN000021009. [ABSTRACT FROM AUTHOR]

Background and study aim: Endoscopic stent-instent (SIS) placement of multiple metal stents is technically demanding. In the present study, we explored the technical feasibility and efficacy of endoscopic deployment of a third metal stent to create a triple SIS placement in patients with a bilateral SIS configuration for inoperable high grade malignant hilar biliary stricture (HBS) that had failed clinically. Methods: Eighteen patients with histologically proven inoperable HBS underwent deployment of an additional third metal stent as a revisionary method after early clinical failure following technically successful bilateral SIS placement using cross-wired metal stents. The main outcome measures were the technical and clinical success rates, and adverse events. Results: The overall technical and clinical success rates were 88.9% (16/18) and 87.5% (14/16), respectively. The early and late complications were cholangitis (n=2) and cholecystitis (n=1). Stent occlusion developed in 35.7% (5/14) of patients in whom a third metal stent for revision of a bilateral SIS configuration was clinically successful. The median (range) times for stent patency and patient survival were 176 days (49-372) and 216 days (52-384), respectively. Conclusions: Endoscopic deployment of an additional third metal stent into a bilateral SIS configuration was technically feasible and effective in patients with inoperable high grade malignant HBS in whom bilateral SIS placement had failed clinically. [ABSTRACT FROM AUTHOR]

Background and Study Aim: The nonflared ends of fully covered, self-expandable, metal stents (FCSEMSs) may minimize stent-induced ductal injury. Suprapapillary intraductal placement of nonflared FCSEMSs for malignant biliary stricture might reduce duodenobiliary reflux and pancreatitis. The aim of this study was to evaluate the efficacy of a newly modified, nonflared FCSEMS for intraductal placement in patients with malignant biliary stricture.Patients and Methods: A total of 51 patients with nonhilar, extrahepatic, malignant biliary stricture were enrolled prospectively. The nonflared FCSEMS is 12 mm in diameter, and has a central saddle and a distal lasso of 7 cm in length. An FCSEMS was placed above the papilla in all patients, with the central saddle positioned at the stricture to prevent stent migration.Results: The technical and clinical success rates were 100 % and 98 %, respectively. Early adverse events occurred in one patient (2.0 %; mild pancreatitis). A total of 12 patients underwent surgery with curative intent, one of whom (8.3 %) experienced a postoperative adverse event. No stent migration occurred in any of the patients. Cholecystitis developed in one patient (2.0 %) as a late adverse event. Stent occlusion occurred in 44.7 % (17/38), and endoscopic removal of the stent was successful in 87.5 % of patients. The mean stent patency was 297 days (95 % confidence interval, 211 - 383).Conclusions: Intraductal placement of the nonflared FCSEMS, 12 mm in diameter, was feasible for the palliative and preoperative management of patients with malignant biliary stricture. Long-term follow-up and prospective comparative studies are needed to evaluate the usefulness of intraductal placement of this stent. [ABSTRACT FROM AUTHOR]

The article looks at studies on technological developments in endoscopic retrograde cholangiopancreatography (ERCP) that were presented at the 2014 Digestive Disease Week in Chicago, Illinois. Retrospective results of prophylactic rectal indomethacin with pancreatic duct stenting were presented. Impact of probe-based confocal laser endomicroscopy on patients with indetermine biliary structures was reported.

Background and study aims: After endoscopic papillectomy, pancreatic duct stenting is important in preventing pancreatitis, but duct cannulation can be difficult following conventional snare resection. Pancreatic duct wire-guided endoscopic snaring before resection can reduce the post-procedure stenting failure rate. We evaluated the usefulness of this approach. Patients and methods: Pancreatic duct wire-guided endoscopic papillectomy was performed in 72 patients with ampullary adenoma. The snare loop was passed over a guide wire inserted into the pancreatic duct. After resection, a pancreatic stent was immediately placed along or alongside the guide wire. Results: Pancreatic duct stentingwas successful in all patients after endoscopic papillectomy. Postprocedure pancreatitis occurred in 6/72 (8 %), but was mild and resolved with conservative treatment. Complete endoscopic resection of ampullary adenoma was achieved in 65/72 (90 %), with en bloc resection in 60/72 (83 %). There was no procedure-associated mortality. Follow-up (mean 23.7 months) showed recurrence in 5/65 (8 %) who had undergone complete resection. Conclusions: Pancreatic duct wire-guided endoscopic snare papillectomy for ampullary adenoma effectively facilitated pancreatic duct stenting to prevent severe post-procedure pancreatitis. [ABSTRACT FROM AUTHOR]

Background and study aims: Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is rare but can cause high mortality. Our aim was to assess the clinical outcomes of these events. Method: A total of 59 patients who were diagnosed as having ERCP-related duodenal perforation at six institutions between 2000 and 2007 were enrolled in this multicenter retrospective study. We evaluated complications and mortality associated with ERCP-related duodenal perforation according to injury detection time (IDT), peritoneal irritation signs (PIS), systemic inflammation signs (SIS), and treatment modality in these patients. Results: Of the 59 patients, 41 (69.5 %) and 18 (30.5 %) underwent medical and surgical treatment, respectively. Duodenal perforation-related death was observed in five patients, who had received medical therapy (n=2) and surgical therapy (n=3). Among medically treated patients, seven patients (17.1 %) underwent endoscopic clipping immediately after the injury; surgery was not required as a salvage therapy and there were no complications or deaths among these patients. The remaining 34 patients received antibiotics combined with therapeutic fasting and intravenous hydration. Duodenal perforation-related complications depended significantly on IDT (P=0.0001), treatment modality (P=0.008), PIS (P=0.003), and SIS (P=0.010). The duodenal perforation- related mortality was significantly related to IDT (P=0.008) and PIS (P=0.001). Conclusions: IDT, PIS, and SIS appear to be important prognostic factors following ERCP-related duodenal perforation. Medical therapy can be suggested as an initial treatment strategy for ERCP-related duodenal perforation, and if possible, endoscopic clipping is strongly recommended. However, surgical treatment should be considered if the perforation is not expected to seal spontaneously, or if the continuing leakage causes PIS or SIS. [ABSTRACT FROM AUTHOR]

The authors reflect on the viability of the endoscopic ultrasound (EUS)-guided bile duct drainage to replace the traditional endoscopic retrograde cholangiopancreatography (ERCP). They compare EUS studies that use self-expanding metallic stent in treatment of patients with distal malignant biliary obstruction. The authors believe that replacement of the conventional ERCP-guided transpapillary bile duct drainage could only be possibly with standardized echoendoscope and specialized stents.

The article presents a case study of a 57-year-old man who has undergone endoscopic retrograde cholangiopancreatography (ERCP) for multiple bile duct and gallbladder stones. The case outlines various endoscopic techniques that have been introduced for removing a proximally migrated pancreatic stent. It also notes the delayed removal following insertion of an additional stent that can help to make more space for inserting removal devices.

The article presents a case study of a 52-year-old woman with a history of epigastric pain and jaundice. She was administered with abdominal computed tomography and magentics resonance cholangiopancreatograph that reveals bile duct dilation and hepatic duct with impact to cystic duct. It highlights the use of an ultraslim upper endoscope to treat Mirizzi syndrome type II with laser lithotripsy.