Rendezvous Technique Versus Endoscopic Retrograde Cholangiopancreatography to Treat Bile Duct Stones Reduces Endoscopic Time and Pancreatic Damage (original) (raw)
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Laparoendoscopic rendezvous reduces perioperative morbidity and risk of pancreatitis
Surgical Endoscopy, 2012
Background The ideal management of cholelithiasis and common bile duct stones still is controversial. Although the two-stage sequential approach remains the prevalent management, several trials have concluded that the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, such as a reduced risk of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. This study aimed to compare the single-stage LERV technique with the two-stage endoscopic sphincterotomy followed by laparoscopic cholecystectomy. Methods A search for randomized controlled trials (RCTs) comparing LERV and the two-stage sequential approach was conducted. The outcomes considered were overall complications and pancreatitis. Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1998 to July 2012. Odds ratios (ORs) were extracted and pooled using a fixed or random-effect model depending on I 2 used as a heterogeneity measure. Results Four RCTs, including a total of 430 patients, met the inclusion criteria. The incidence of overall complications was lower in the LERV group (11.2 %) than in the two-stage intervention group (18.1 %) (OR, 0.56; 95 % confidence interval [CI], 0.32-0.99; P = 0.04; I 2 = 45 %). The findings showed that LERV was associated with less clinical pancreatitis (2.4 %) than the two-stage technique (8.4 %) (OR, 0.33; 95 % CI, 0.12-0.91; P = 0.03; I 2 = 33 %). Conclusions Despite the limitation of a small number of studies completed, the evidence of RCTs shows that LERV is superior to two-stage treatment due to a reduction in overall complications, particularly pancreatitis. Keywords Common bile duct Gallbladder Laparoendoscopic rendezvous Metaanalysis Stones Systematic review An erratum to this article can be found at http://dx.doi.org/10.1007/s00464-013-3397-2\. The prevalence of common bile duct stones (CBDS) in patients with gallstones varies widely depending on several clinical and radiologic findings, but usually ranges from 11 to 20 % [1-3]. About half of the asymptomatic CBDS discovered accidentally at intraoperative cholangiography would pass the papilla of Vater spontaneously within the following 6 weeks [4]. However, stones might be retained and cause cholangitis, hepatic abscess, and pancreatitis, justifying an invasive approach. Since the introduction of laparoscopic cholecystectomy (LC) in the early 1990s, given the large number of possible strategies, the ideal management of CBDS for patients affected by gallstones
Acta Endoscopica, 1979
Risk factors of acute pancreatiUs after endoscopic retrograde cholangiopancreatography (E.R.C,P,) and endoscopic papillotomy (E,P.T.) RESUME L'616vation du taux d'amylase s6rique apr~s C.P.R.E. et S.E. a 6t6 6tudi6e afin de d6terminer les circonstances d'un accroissement du risque de pancr6atite aigu~ apr~s manipulation endoscopique. Ce risque est significativement sup6rieur chez les patients 5. taux d'amylase s6rique basal 61ev6, aprb~s douleur ~_ l'injection du produit de contraste, opacification dense des canaux pancr6atiques, et retard d'6vacuation du produit de contraste sur pancr6atogrammes normaux ou r6v61ateurs d'alt6rations mineures. L'opacification du canal pancr6atique principal lors de la sphinct~rotomie endoscopique expose un risque identique ~. celui de la C.P.R.E., si la section est effectu6e avec catheter en place dans la voie biliaire principale (V.B.P.). S UMMA R Y The rise o[ serum amylase /ollowing E.R.P. and E.P.T. was studied in order to determine which conditions couM increase the risk o/ acute pancreatitis. This risk is signi/icantly higher in patients with high basal amylase levels, pain during contrast medium injection, high degree o] opaci/ication, normal pancreatogram or Minor Alteration and with delay in output o/ contrast medium. Opaci/ication o[ the main pancreatic duct during E.P.T. has the same risk o/ E.R.P. i/ cutting is made when in the C.B.D. lumen. On the other side, precutting is a very hazardous procedure.
Background: There is still some controversy regarding the optimal timing and best method for the removal of common bile duct stones (CBDS). Intraoperative endoscopic retrograde cholangiopancreaticography (IO-ERCP) is an alternative method that should be considered for this procedure. The aim of our study was to investigate the clinical outcome of a single-step procedure (IO-ERCP) to remove CBDS, thereby combining two existing high-volume clinical modalities-i.e., laparoscopic cholecystectomy (LC) and ERCP. Methods: Between January 2000 and December 2001, 674 patients, 192 male and 482 female, underwent cholecystectomy at our hospital. Therewere 612 LC (90.8%), 37 converted procedures (5.5%), and 25 open operations (3.7%). In 592 of the patients, (87.8%) intraoperative cholangiography (IOC) was performed. In 34 (5.7%) of those who had and IOC, an IO-ERCP was performed. While the surgeon waited for the endoscopist, care was taken to introduce a thin guidewire through the IOC catheter and pass it through the sphincter of Oddi, out into the duodenum. This complementary procedure greatly facilitated the subsequent cannulation of the bile ducts. Results: The cannulation frequency of the CBD was 100%. Common bile duct stones were successfully extracted in 93.5%. Endoscopic sphincterotomy (EST), followed by the insertion of a plastic endoprosthesis, was performed in two patients with remaining stones. The CBD of these two patients was cleared by postoperative ERCP. None of the patients developed postoperative pancreatitis. The operating time was prolonged as compared with the time for LC (192 vs 110 mins; p < 0.05). The length of hospitalization for IO-ERCP patients did not differ from that for patients undergoing cholecystectomy alone (2.6 vs 2.1. days; NS).
Archives of Surgery, 1996
Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography. To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP). Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy. Two ERCP units in adjacent teaching hospitals. Three hundred seventeen patients with gallstones and in situ gallbladders. Common bile duct imaging at ERCP. Abnormalities justifying ERCP. Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P &amp;amp;amp;amp;amp;amp;amp;lt; .001), jaundice (P &amp;amp;amp;amp;amp;amp;amp;lt; = .001), a dilated CBD on ultrasound (P &amp;amp;amp;amp;amp;amp;amp;lt; .001), or CBD stones on ultrasound (P &amp;amp;amp;amp;amp;amp;amp;lt; .001). On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P = .003) or elevated results of individual liver function tests (P &amp;amp;amp;amp;amp;amp;amp;lt; .001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors. The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.
Annals of the Royal College of Surgeons of England, 2004
T he technique of endoscopic biliary sphincterotomy was first reported in 1974 1 and has become the accepted method for management of retained or recurrent bile duct stones. This is particularly applicable to frail and elderly patients who are poor surgical candidates. Since the late 1970s, numerous reports within the literature advocated that endoscopic retrograde cholangiopancreatography (ERCP) was more appropriate for the elderly where avoidance of general anaesthesia and laparotomy is desirable -reflected in high mortality rates for the open surgical approach. Over the last two decades, there have been several advances within the surgical domain. It has long been recognised that open cholecystectomy and bile duct clearance with 'T' tube placement is associated with a high morbidity and mortality rateparticularly in the elderly. This has largely been superseded by laparoscopic cholecystectomy and, in some centres, with laparoscopic bile duct exploration. Reported mortality for open surgical common bile duct exploration range from 5.5-12.8% in patients over the age of 60 years, 2,3 and as high as 29% in a British series of patients over the age of 70 years. 4 Despite the criticism that the initial data from Vellacott and Powell 4 arose from inexperienced surgical technique, more recent data still show a high mortality and morbidity in the elderly population. 5 In comparison, mortality rates related to ERCP and sphincterotomy are much lower being between 0-2.3%. 6
Surgical Endoscopy, 2019
Introduction For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both twosession endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP). Methods An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire. Results Thirty-seven patients (27 female, age 19-77, BMI 21-50 kg/m 2) underwent intraoperative ERCP via AWRC technique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a postoperative subhepatic abscess requiring drainage. Conclusion AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or postsphincterotomy bleeding.
European Journal of Biomedical and Pharmaceutical sciences, 2023
Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively complex procedure, with pancreatitis being this procedure's most commonly reported complication. Many randomized clinical trials (RCTs) have been conducted to assess the best prevention modality of post-ERCP pancreatitis (PEP). This systematic review aims to collate evidence from RCTs on the best modality for the prevention of PEP. Methods: A systematic search was conducted across the following databases: PubMed, Cochrane library, EBSCO, and Web of Science. Relevant articles were located between January 2012 through August 2022. The following keywords were used: ERCP, post-endoscopic retrograde cholangiopancreatography pancreatitis, prevention, and post-ERCP. Duplicates were manually removed. This systematic review was conducted adhering to PRISMA statement 2020 guidelines. The reference lists were additionally searched (umbrella methodology). Results: Of the 2482 studies that were identified, 2010 were reviewed for titles and abstracts. Finally, 28 articles were assessed for full-text eligibility, of which 13 RCTs met the inclusion criteria. The most commonly used prevention technique was Pancreatic Stent Placement (PSP) (n=977), which had a statistically significant reduced incidence of PEP. The second most commonly used methodology was Wire-Guided Biliary Cannulation (WGC) (n=1329), which showed overall protective findings. With Endoscopic Nasobiliary Drainage (ENBD) (n=153), there was an independent risk of patients acquiring PEP with the procedure. Lastly, Needle Knife Sphincterotomy (NKS) (n=73) showed no improvement in PEP. Conclusion: There are multiple modalities of preventing PEP. Patients at high risk of post-ERCP complications must undergo both pharmacological and surgical prevention. In this systematic review, pancreatic stent placement was found to be the most effective technique to prevent PEP. It is, however, recommended that the administration of pharmacological agents, diagnostic procedures of PEP, and procedural techniques be optimized to reduce the patient burden of PEP.
Pancréatite après cholangiopancréatographie rétrograde par voie endoscopique (CPRE)
Acta Endoscopica, 1994
La frEquence des pancrEatites apr~s CPRE est surtout fonction de l'Eventuel geste de sphinctErotomie associ6 et de I'expErience de I'endoscopiste. Le diagnostic est habituellement facile ~t condition d'6carter la perforation rEtro-duodEnale. La tomodensitomEtrie constitue le progr~s majeur de ces derni~res annEes. La chirurgie n'a pratiquement plus sa place dans le traitement curatif qui est medical mais reste le plus souvent symptomatique et contemplatif. C'est dire l'int6rEt de la prevention. Celle-ci depend des facteurs de risque :