CPRE em Portugal: Inquérito sobre a profilaxia de pancreatite e estratégias de canulação

Background/Aims: Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods: A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results: Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions: There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message: There is a significant gap between guidelines and routine clinical practice(undefined)info:eu-repo/semantics/publishedVersio

Endoscopic Treatment of Post-Cholecystectomy Biliary Leaks

Postcholecystectomy leaks may occur in 0.3-2.7% of patients. Bile leaks associated with laparoscopy are often more complex and difficult to treat than those occurring after open cholecystectomy. Furthermore, their incidence has remained unchanged despite improvements in laparoscopic training and technological developments. The management of biliary leaks has evolved from surgery into a minimally invasive endoscopic procedural approach, namely, endoscopic retrograde cholangiopancreatography (ERCP), which decreases or eliminates the pressure gradient between the bile duct and the duodenum, thus creating a preferential transpapillary bile flow and allowing the leak to seal. For simple leaks, the success rate of endotherapy is remarkably high. However, there are more severe and complex leaks that require multiple endoscopic interventions, and clear strategies for endoscopic treatment have not emerged. Therefore, there is still some debate regarding the optimal time point at which to intervene, which technique to use (sphincterotomy alone or in association with the placement of stents, whether metallic or plastic stents should be used, and, if plastic stents are used, whether they should be single or multiple), how long the stents should remain in place, and when to consider treatment failure. Here, we review the types and classification of postoperative biliary injuries, particularly leaks, as well as the evidence for endoscopic treatment of the latter.publishersversionpublishe

A Series of 3 Cases

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Endoscopic retrograde cholangiopancreatography performed through a temporary lumen-apposing metal stent in a patient with a benign gastric outlet obstruction

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Cholangioscopy-guided holmium laser lithotripsy of a stone trapped in a mechanical lithotripter

Large common bile duct (CBD) stones can be removed with mechanical lithotripsy, although over-the-basket techniques such as electrohydraulic or pulsed dye laser lithotripsy can be necessary in cases of stone impaction.1 We report the case of a 42-year-old woman with a 30-mm stone in the CBD in whom mechanical lithotripsy was attempted after wide sphincterotomy. However, during the procedure, a rupture occurred in the traction wire of the basket, next to the handle. Emergency lithotripsy (EL) with use of an external-type system was immediately attempted, but wire fracture occurred again (2 times), turning its length shorter than the metallic sheath of the EL and rendering EL impossible(undefined)info:eu-repo/semantics/publishedVersio

An Unexpected Diagnosis

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Esophageal laceration after percutaneous endoscopic gastrostomy tube removal attempt: alternative route of extraction

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NOTES Híbrido: ressecção endoscópica completa da parede gástrica assistida por laparoscopia no tratamento de um tumor do estroma gastrointestinal do fundo gástrico

[Excerpt] Laparoscopic wedge resection with a linear stapler is widely accepted in the treatment of gastric gastrointestinal stromal tumors (GISTs) [1, 2]. Although not complex [3], this procedure has some major drawbacks, namely failure in identifying the lesion, possible rupture of the capsule with the linear stapler, excessive normal tissue removal, and technical difficulties in reaching areas such as the cardia, fundus, lesser curvature, or peri-pyloric areas [1–5].[...](undefined)info:eu-repo/semantics/publishedVersio

Resultados da utilização da colangioscopia de operador único na litotrícia de cálculos difíceis biliares e pancreáticos

"Published online: May 16, 2018"Background and Aims: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. Methods: This is a prospective clinical study – conducted at two affiliated university hospitals – of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. Results:Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.Introdução: A CPRE é o exame preferencial para a remoção de cálculos biliares e pancreáticos. Em situações de cálculos difíceis foram propostas novas modalidades terapêuticas como a litotrícia electro-hidráulica (LEH) e a litotrícia por laser (LL). Recentemente a disponibilidade da colongioscopia de operador-único tornaram estas técnicas mais acessíveis e fáceis de realizar. Procuramos avaliar a eficácia clínica de litotrícia guiada por colangioscopia recorrendo à LEH ou à LL em doentes com cálculos biliares e pancreáticos difíceis. Métodos: Estudo prospetivo, conduzido em 2 Hospitais associados à Universidade e englobando 17 doentes consecutivos com cálculos difíceis biliares e pancreáticos, estes doentes foram tratados com litotrícia guiada por colangioscopia recorrendo a LEH ou LL. Analisamos a limpeza completa dos ductos, bem como o impato do número de pedras e localização no sucesso clínico, associada à avaliação das 2 técnicas de litotrícia e complicações desta abordagem terapêutica. Resultados: Doze doentes (70.6%) tinham cálculos no colédoco/hepático comum, 2 doentes (17.6%) tinham um cálculo único no coto do cístico e 3 doentes (17.6%) apresentavam cálculos pancreáticos. Dezasseis (94.1%) doentes foram tratados com sucesso numa única sessão e o restante (5.9%) doente necessitou de 3 sessões incluído LEH, LL e litotrícia mecânica para obter limpeza dos ductos. Onze doentes foram tratados com LL e obtiveram sucesso clínico numa única sessão com uma fibra única de laser. Seis doentes foram tratados com LEH: 4 doentes obtiveram sucesso clínico numa única sessão com 1 fibra; 1 doente necessitou de 2 fibras para obter limpeza ductal numa sessão única. O último doente falhou a limpeza dos ductos com duas fibras de LEH e necessitou de sessão adicional com Laser (uma fibra) para obter fragmentação adequada dos cálculos. As complicações foram ligeiras em 6/17 (35.2%) doentes e incluíram febre (n = 4), dor (n = 1) e pancreatite ligeira (n = 1). Conclusões: A litotrícia guiada por colangioscopia com recurso a LEH ou LL em doentes com cálculos difíceis biliares e pancreáticos é muito eficaz e está associada a complicações transitórias e ligeiras. Existe clara necessidade de realizar estudos comparativos entre LEH e LL.(undefined)info:eu-repo/semantics/publishedVersio

Suboclusão intestinal causada por um lipoma gigante: Polipectomia assistida por laço endoscópico

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