[Fiber duodenoscopic examination. A preliminary investigation of the diagnostic possibilities of the Olympus duodenoscope].
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Adult↗
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Endoscopic examination with the duodenoscope at ERCP: frequency of lesions and accuracy of detection.
BACKGROUND: Little is known about the yield and accuracy of endoscopic examination with the duodenoscope after ERCP, and there appears to be no uniform standard of practice for endoscopic examination in this setting. METHODS: Over a 1-year period, all patients undergoing ERCP also underwent endoscopic examination of the duodenum, stomach, and esophagus with the duodenoscope upon completion of ERCP. Patients were then placed in the left lateral decubitus position and upper endoscopy was performed with a standard forward-viewing endoscope. The same investigator performed both endoscopic examinations. Patients were queried about prior ulcer disease, upper GI symptoms, and use of antisecretory medication as well as nonsteroidal anti-inflammatory drugs. RESULTS: During the 12-month study, 368 patients (mean age 53 years) underwent 474 procedures. The most frequent indication for ERCP was suspected choledocholithiasis (24%). Endoscopic examination was normal in 42% of patients, and the most frequent endoscopic finding was hiatal hernia (132 patients, 36%). The lesions most frequently missed with the duodenoscope were trauma at the upper esophageal sphincter (12 patients) and small benign gastric polyps (3 patients). Examination with the duodenoscope was superior to the forward-viewing endoscope for identification of Schatzki's ring. No carcinoma, gastric varices, or severe esophagitis were missed with the duodenoscope. CONCLUSIONS: Given the frequency of endoscopic lesions, a yield of positive findings similar to that obtained with the forward-viewing endoscope, and the ease of performing endoscopy with the duodenoscope, endoscopic examination of the esophagus, stomach, and duodenum with the duodenoscope should become standard practice after ERCP.
Cholangiopancreatography, Endoscopic Retrograde↗
Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope.
BACKGROUND AND STUDY AIMS: A prospective, randomized study was carried out to compare the success and complication rates associated with the forward-viewing endoscope and side-viewing duodenoscope in conducting endoscopic retrograde cholangiopancreatography (ERCP) and needle-knife sphincterotomy in patients with a Billroth II gastrectomy. PATIENTS AND METHODS: The study included 45 patients with a Billroth II gastrectomy who required ERCP and endoscopic sphincterotomy (EST) for evaluation and management of pancreaticobiliary disease. The patients were randomly assigned to receive ERCP and EST with either a forward-viewing endoscope or a side-viewing duodenoscope. RESULTS: Cannulation of the papilla was successful in 68% (15 of 22) in the side-viewing duodenoscope group, and in 87% (20 of 23) in the forward-viewing endoscope group. Failures of cannulation occurred in seven patients in the side-viewing duodenoscope group, caused by jejunal perforation during insertion (n = 4), by a long afferent loop (n = 1), by a complaint of severe abdominal pain (n = 1), and by failure to enter the afferent loop (n = 1). In the forward-viewing endoscope group, failure occurred in three patients due to the long afferent loop (n = 2) and to an inability to cannulate despite identification of the papilla (n = 1). Sphincterotomy was successfully completed in eight of ten patients (80%) in the side-viewing duodenoscope group, and in ten of twelve patients (83%) in the forward-viewing endoscope group. CONCLUSIONS: For ERCP and EST in patients with Billroth II gastrectomy, the forward-viewing endoscope is as effective as the side-viewing duodenoscope, but it may be the safer of the two instruments. The forward-viewing endoscope can be recommended for ERCP and EST in patients with a Billroth II gastrectomy.
Abdominal Pain↗
Predictive value of Rectal and Throat-nose Screening for the presence of Multidrug-Resistant Organisms in Duodenal Fluid as a Risk of Duodenoscope Contamination: A Multicenter Study.
BACKGROUND: Duodenoscopes have been implicated in patient-to-patient transmission of multidrug-resistant organisms (MDROs). Current gastrointestinal MDRO surveillance relies on rectal screening, yet the duodenum is the primary site of duodenoscope exposure. This study evaluated the predictive value of rectal and throat-nose screening for detecting duodenal MDROs as a marker of duodenoscope contamination risk. METHODS: Adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at tertiary care centers in the Netherlands and India were included. Rectal swabs, throat-nose swabs, and duodenal aspirates were analyzed for MDROs. The detected MDROs were compared using species identification, antibiotic susceptibility patterns, and whole-genome sequencing. RESULTS: Among 512 participants (Netherlands: 339; India: 173), rates of duodenal and rectal MDRO carriage were higher in India (56.6% (98/173); 79.8% (138/173), respectively) than in the Netherlands (5.6% (19/339); 10.3% (35/339)). Given the low prevalence of throat-nose carriage, only the predictive value of rectal screening was assessed. Rectal screening sensitivity for genetically related strains in duodenal fluid was 32.7% in India and 68.4% in the Netherlands . For detecting any duodenal MDRO, sensitivity reached 91.8% in India and 84.2% in the Netherlands, with specificities of 36.0% and 94.1%. Positive predictive value (PPV) was low (India: 65.2%; Netherlands: 45.7%), while negative predictive value was 77.1% and 99%, respectively. CONCLUSIONS: Rectal screening is unreliable for detecting strain-specific duodenal MDROs and overestimates true carriage due to low PPV values. However, it provides excellent rule-out value in low-prevalence settings. Consequently, its utility for guiding infection prevention strategies for duodenoscope contamination is greatest in low-MDRO-prevalence regions.
Bacterial↗
Esophageal intubation with duodenoscope in the presence of pharyngeal pouch by a guidewire and catheter-guided technique.
Esophageal perforation can occur during blind intubation with a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatogram (ERCP) in patients with pharyngeal or esophageal anomalies. We describe a case of difficult intubation during an ERCP due to an asymptomatic and unsuspected pharyngeal pouch (Zenker's diverticulum). The side-viewing duodenoscope was withdrawn once resistance was encountered during intubation, and a forward-viewing gastroscope was inserted carefully under direct vision to evaluate the upper esophagus. After the diagnosis was made, intubation of the duodenoscope was performed by exchanging scopes over a guidewire. Subsequent ERCP with sphincterectomy and stone removal was uneventful. We caution that a side-viewing duodenoscope should be withdrawn once resistance is encountered during blind intubation during ERCP. Our technique minimizes patient discomfort and is rapid and easy to perform. In addition, no extra device such as an overtube is required.
Aged↗
[Duodenoscopic interventions on the terminal part of the choledochus].
The results of various methods of duodenoscopic interventions on the terminal choledochus in 261 patients with papilla stenosis and choledocholithiasis were analysed. Endoscopic papillosphincterotomy by the cannulation method was performed in 107 patients, endoscopic papillosphincterotomy with preincision of the major duodenal papilla in 31, and endoscopic suprapapillary choledochoduodenostomy in 123 patients. The performance of various methods of duodenoscopic interventions according to indications made it possible to increase the possibility of conducting the operation to 98% and its efficacy to 95%. Complications after duodenoscopic interventions occurred in 10% of cases with 1.2% lethality. The late results of duodenoscopic interventions were good in 85.5% of cases irrespective of the mode of the operation.
Choledochostomy↗
In-hospital evaluation of contamination of duodenoscopes: a quantitative assessment of the effect of drying.
A prospective, quantitative assessment was undertaken of the effect of drying on the bacterial load in duodenoscopes that had been used for endoscopic retrograde cholangiopancreatography procedures. The endoscopes were washed and disinfected using an automatic washer and samples were taken through the suction channel at 2, 24 and 48 h post-disinfection. Twenty-one of the 42 duodenoscopes tested were contaminated. The ratio of Gram-negative bacilli to Gram-positive cocci increased from 70:1 at 2 h up to 4000:1 at 48 h for those duodenoscopes that were contaminated. Pseudomonas species (6 of 12 contaminated endoscopes) and Acinetobacter species (7 of 21 contaminated endoscopes) were the most common isolates. There was visible moisture remaining in the suction channel despite the use of the complete recommended automatic washer cycle. Bacterial concentrations reached as high as 1 x 10(7) colony forming units (cfu) ml-1. An additional 10 min of drying using either an 'in house' air line or the manual machine dry prevented bacterial overgrowth of all 19 endoscopes tested 48 h post-disinfection. If the additional 10 min of drying was used, then no alcohol rinse was required. Although no infections related to use of contaminated endoscopes were reported, it was apparent that Gram-negative bacilli were multiplying to unacceptably high concentrations and that this could be prevented by an additional 10 min of drying. The additional drying was only required at the end of the endoscopy list and not between patients.
Cholangiopancreatography, Endoscopic Retrograde↗
Use of a double-channel duodenoscope for diagnostic and therapeutic ERCP.
BACKGROUND: A double-channel duodenoscope has the potential to shorten ERCP procedure time or improve procedure success rates because tasks can be done in parallel through variably situated accessory channels. METHODS: We prospectively evaluated a prototype double-channel duodenoscope in 102 patients, recording findings, procedural success, and potential advantages or problems associated with the instrument. RESULTS: Both channels were used in 79 cases (77%) and a single-channel in the remainder. Ninety-nine percent (101 of 102) of diagnostic and 95% (87 of 92) of therapeutic ERCPs were successful. Instrument advantages included decreased procedure time (23%), cannulation/procedural ease (16%), and miscellaneous (6%). Disadvantages were noted in 15% of the patients and were related to instrument diameter and diameter of the accessory channels. CONCLUSIONS: Additional study of second generation dual-channel duodenoscopes appears warranted.
Bile Duct Diseases↗
A survey of reprocessing methods, residual viable bioburden, and soil levels in patient-ready endoscopic retrograde choliangiopancreatography duodenoscopes used in Canadian centers.
OBJECTIVES: To obtain information about current reprocessing practices and to obtain samples from the biopsy channel to quantitate soil levels and bioburden in patient-ready flexible duodenoscopes used for endoscopic retrograde choliangiopancreatography (ERCP). DESIGN: Participating centers were sent a questionnaire and a kit for on-site collection of samples from the biopsy channel of the duodenoscope. SETTING: Thirty-seven hospitals from across Canada participated. The only criterion was that they currently used and reprocessed flexible duodenoscopes for ERCP procedures. METHODS: The questionnaire obtained information on reprocessing practices. The kit included a detailed instruction booklet outlining sample collection and all of the tubes, sterile water, and brushes needed for it. Samples were collected on-site from all ERCP scopes in each center on Monday morning and shipped by overnight courier on ice to the research center. Each sample was assayed by routine microbiologic methods for total viable count and protein, blood, carbohydrate, and endotoxin levels. RESULTS: Microbial overgrowth was present in 7% of 119 scope samples. Cleaning appeared to be reasonably well done in most of the centers, and 43% of the centers were in total compliance with basic national guidelines. The data from the scope samples indicated that there was significantly greater buildup of protein, carbohydrate, and endotoxin associated with ERCP scopes from centers using glutaraldehyde, compared with those using peracetic acid. Carbohydrate was the soil component detected most frequently and in the highest concentration in scope channels. CONCLUSIONS: Although cleaning was generally well done, areas for improvement included ensuring the availability of written reprocessing protocols, immersion of scopes during manual cleaning, use of adequate fluid volume for rinsing, adequate drying of scopes prior to storage, and the separation of ERCP valves from scopes during storage.
Canada↗
British experience with duodenoscopic sphincterotomy for removal of bile duct stones.
Duodenoscopic sphincterotomy is rapidly becoming popular in Britain. Representatives of 14 British centres met in January 1980 to discuss progress and problems with the technique. This report summarizes current experience, with particular reference to hazards. Duodenoscopic sphincterotomy is mainly being used in patients who have previously undergone cholecystectomy and who no longer have a T tube drain in place. Sphincterotomy was achieved in 87 per cent of 679 patients attempted, and the common duct was cleared of stones in 87 per cent of these. Immediate complications followed in 8.5 per cent; 1.6 per cent required urgent surgery and 7 patients (1 per cent) died. Centres with the greatest experience had better results and fewer complications. Those performing duodenoscopic sphincterotomy believe it to be a major advance in the management of high risk patients with common duct stones, after cholecystectomy. Its use remains controversial in high risk patients who still have gallbladders and in low risk patients after cholecystectomy; long term follow-up studies are essential.
Aged↗
Endoscopic cholangiopancreatography in the infant: evaluation of a new prototype pediatric duodenoscope.
The usefulness of a new pediatric duodenoscope PJF in the diagnosis of neonatal cholestasis was studied in 23 infants with ages ranging from 19 to 150 days. In 22 of 23 infants the papilla was cannulated. In 13 of 14 neonates (93%) with neonatal hepatitis, the common bile duct was opacified and biliary atresia was excluded. In one of two neonates with choledochal cyst, the common bile duct was demonstrated. In six of seven neonates (86%) with biliary atresia, only the pancreatic duct was demonstrated and the diagnosis was suspected. Although absence of a common bile duct opacification does not rule out biliary atresia, ERCP with the new duodenoscope proved to be most useful in the diagnosis of normal biliary tree and served to avoid unnecessary surgery in most infants with neonatal cholestasis.
Biliary Atresia↗
Use of a duodenoscope to manage complications at the ureteroileal anastomotic site after total urinary bladder resection and the Bricker procedure.
BACKGROUND: A novel flexible endoscopic technique is described for the treatment of ureteroileal strictures and leaks after the Bricker procedure. METHODS: Seventeen patients with 24 ureteroileal complications (strictures, 22; leaks, 2) were treated under conscious sedation with a side-viewing duodenoscope. The ureter was cannulated and stent insertion, dilation, or both were performed. RESULTS: Immediate technical success was achieved in 19 of the 24 (79.2%) ureteroileal complications. Treatment included stent placement alone in 12, dilation plus stent in 4, intraileal ureter resection plus stent with or without dilation in 3, and removal of ureteral calculi in 1. The procedure was unsuccessful in 5 (20.8%; failure to visualize ureteroileal anastomosis 4, unsuccessful cannulation 1). No major complications occurred. The 14 patients treated successfully were followed (mean 43 months, range 2-132 months) and a satisfactory outcome was observed in all. Partial stent displacement occurred in 2 patients and ureteral calculi developed in 2 patients. Three patients died with a stent in situ; no death was stent-related. Eleven patients are alive and asymptomatic, 5 with a stent in situ. In 6 patients, the stent was extracted after a mean of 36 months and all remained asymptomatic during a mean further follow-up of 41 months. CONCLUSION: Treatment of ureteroileal anastomotic complications with a flexible duodenoscope and endoscopic techniques is safe, simple, and noninvasive with good success and excellent long-term results. This approach can be recommended as first-line therapy in patients with ureteroileal anastomotic complications.
Adult↗
Duodenoscopic sphincterotomy in the treatment of the "sump syndrome".
The "sump syndrome" is recognized as a complication of a choledochoenterostomy (choledochoduodenostomy or choledochojejunostomy) performed for recurrent stone disease. A sump (a pit or well) develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate. This results in obstruction of the enterostomy stoma producing either cholangitis, pancreatitis pain, and/or cholestasis. It is thought that dysfunction of the sphincter mechanism contributes to the development of this syndrome. Filling defects in the bile duct are appreciated on gastrointestinal series when barium reflexes into the biliary tree through the patent stoma. Treatment has largely been surgical, but, more recently, the availability of ERCP has enabled the endoscopist to make a major contribution to the management of this syndrome. A nonsurgical alternative to treatment is duodenoscopic sphincterotomy which has been performed in 11 patients presenting with the sump syndrome. There have been no recurrences of stones in 10 patients while stones were found in one patient with an open sphincterotomy. In follow-ups of 3-30 months, there was satisfactory relief of symptoms in all patients. Because of these results, duodenoscopic sphincterotomy is recommended as a primary treatment modality in the sump syndrome.
Adult↗
Non-operative removal of bile duct stones by duodenoscopic sphincterotomy in the elderly.
Between January 1975 and December 1979, 71 patients over the age of 70 underwent attempted duodenoscopic sphincterotomy for stones in the common bile duct. Fifteen patients still had gall bladders in situ. Sphincterotomy was possible in 69 of the patients and in 65 of these duct clearance was achieved, giving an overall success rate of 92%. Failure to achieve sphincterotomy in two cases was due to substantial peripapillary diverticula. Duct clearance failed in four patients, mostly due to the size of the retained stones. The largest stone extracted was 24 mm diameter. There were no deaths but complications occurred in nine patients (13%); these were haemorrhage in four (requiring surgery in one), cholangitis in four (two of whom required surgical extraction of stones), and pancreatitis in one. The average duration of hospital stay in successful cases was 11 days (range three to 30). Clinical follow-up of 55 patients one to five years after sphincterotomy showed no evidence of stones or of stenosis of the sphincter. Duodenoscopic sphincterotomy is a major advance in the management of elderly patients with stones in the common bile duct.
Aged↗
Duodenoscopic sphincterotomy for removal of bile duct stones in patients with gallbladders.
Duodenoscopic sphincterotomy was attempted in 71 elderly patients with gallbladders who presented with acute symptoms caused by common bile duct stones. Sphincterotomy was possible in all but one patient, and duct clearance was achieved in 61 (86%); failures were usually due to the size of the stones. Two patients required blood transfusions for immediate bleeding, and two underwent cholecystectomy for acute cholecystitis developing within 7 days of sphincterotomy. One patient with a retained stone was judged to be unfit for surgery and died 6 weeks after sphincterotomy. Eleven patients had elective cholecystectomy. Forty-eight patients (mean age 75 years) were discharged with their gallbladders in place; clinical follow-up (mean 19 months) had been possible in 44. None have suffered cholangitis or jaundice, and only five have so far needed cholecystectomy for recurrent biliary pains. Duodenoscopic sphincterotomy is recommended for acutely ill patients with symptoms caused by duct stones, even patients with gallbladders. Longer follow-up is required to judge the indications for subsequent cholecystectomy, but present evidence suggests that it is reasonable to postpone cholecystectomy indefinitely for many elderly and frail patients.
Adult↗
Duodenoscopic sphincterotomy and gallstone removal.
Duodenoscopic sphincterotomy was attempted in 265 patients. The procedure was successful in 243 patients (92%). Indications for sphincterotomy were: 185 patients with choledocholithiasis, 52 patients with papillary stenosis, and 6 patients with ampullary carcinoma. The clinical and biochemical evidence of cholestasis resolved in 222 of the 243 successful patients (91%). Complications consisting of hemorrhage, perforation, pancreatitis, cholangitis, and instrumental injury resulted in three deaths, an over-all mortality of 1.2%. Emergency laparotomy was required in 6 cases (2.5%). Duodenoscopic sphincterotomy is a relatively safe and effective means of relieving certain instances of extrahepatic cholestasis. The complication and mortality rates appear lower than those with equivalent conventional surgical techniques.
Adult↗
EUS and K-ras analysis of pure pancreatic juice collected via a duodenoscope after secretin stimulation for diagnosis of pancreatic mass lesion: a prospective study.
BACKGROUND: The early diagnosis of pancreatic cancer remains problematic. This prospective study assessed the utility of a combination of endoscopic ultrasound (EUS) and genetic analysis of pure pancreatic juice in the diagnosis of pancreatic mass lesions. METHODS: One hundred seventy-six patients with suspected pancreatic disease were enrolled and underwent ultrasonography (US), computed tomography (CT), endoscopic retrograde choleangiopancreatography (ERCP), and EUS. Pure pancreatic juice was collected endoscopically after secretin stimulation. K-ras point mutations at codon 12 in the juice were assayed by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: Thirty-six (20%) patients were found to have solid pancreatic masses including 19 with cancer (7 patients, </= 2 cm) and 17 patients with an inflammatory mass (13 patients, </= 2 cm). US and CT were both less sensitive, particularly in patients with small masses. In 13 patients, small masses (4 cancer and 9 inflammatory masses) were not delineated until EUS. The combination of EUS and K-ras analysis had a high sensitivity (100%; p < 0.05 vs. US) and its accuracy reached 94% (p < 0.01 vs. US). CONCLUSIONS: EUS and K-ras determination in pure pancreatic juice collected via a duodenoscope may be useful for the diagnosis of pancreatic mass lesions.
Adenocarcinoma↗
Short-channel duodenoscope: innovations in selective biliography.
The selective cannulation of the intrahepatic branches of the biliary system is made possible by the use of torsion-stabilized angiographic catheters passed via short-channel duodenoscopes. Other feasible applications are the endoscopic selective positioning of biliary endoprosthesis, and the cannulation of the gall bladder using a cysto-nasal catheter through which a litholytic fluid can be installed directly into the gall bladder.
Bile Ducts, Intrahepatic↗