Main Recommendations
ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.
Strong ...recommendation, low quality evidence.
ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.
Strong recommendation, moderate quality evidence.
ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.
Strong recommendation, moderate quality evidence.
ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:
– severe, as soon as possible and within 12 hours for patients with septic shock
– moderate, within 48 – 72 hours
– mild, elective.
Strong recommendation, low quality evidence.
ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.
Strong recommendation, moderate quality of evidence.
ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones.
Strong recommendation, high quality evidence.
ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.
Strong recommendation, moderate quality evidence.
ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events.
Strong recommendation, moderate quality evidence.
Background The Swedish Registry for Gallstone Surgery and ERCP (GallRiks) is the first nationwide Web-based quality registry for gallstone surgery and ERCP in the world. In this article we report ...data from 11,074 ERCPs performed in 2007 and 2008. Objective The aim of this study is to present outcomes, safety data, and success rates of ERCPs performed in Sweden. Design Data gathering from a medical record database. Patients This study reviewed 11,074 ERCPs performed in 2007 and 2008. Methods In GallRiks, data concerning surgery performed for gallstone disease as well as all ERCPs are recorded. The registry is approved by the Swedish Surgical Society and is based on an Internet platform with online data registration. The online program includes 30-day follow-up information as well as the opportunity to retrieve electronic reports on demand. The present data represent 76% of all ERCPs performed in Sweden in 2007 and 95% of those performed in 2008. The database also has been validated, indicating a complete match between the medical records and the database in 97.3% of ERCP cases. Main Outcome Measurements Cannulation success and perioperative and postoperative complications. Results A successful bile duct cannulation was achieved in 92% of the ERCPs performed. The presence of common bile duct stones was the predominant finding and was seen in 36.8% of examinations. Perioperative and postoperative complication rates were 2.5% and 9.8%, respectively. The rate of ERCP-induced pancreatitis was 2.7%, and the total 30-day mortality rate in the database was 5.9% but varied significantly among the different diagnostic groups. The indications for ERCP differed between high-volume and low-volume centers, indicating an adequate referral pattern of complex cases in Sweden. Limitations GallRiks registration is voluntary and thus not 100%. This makes selection bias a possibility. Conclusion ERCP is widely used at Swedish hospitals, with acceptable cannulation success rates and perioperative and postoperative complication rates similar to established standards. GallRiks is a population-based nationwide registry with good data validity and high inclusion rates regarding ERCPs.
MAIN RECOMMENDATIONS
1
ESGE/EASL recommend that, as the primary diagnostic modality for PSC, magnetic resonance cholangiography (MRC) should be preferred over endoscopic retrograde ...cholangiopancreatography (ERCP).
Moderate quality evidence, strong recommendation.
2
ESGE/EASL suggest that ERCP can be considered if MRC plus liver biopsy is equivocal or contraindicated in patients with persisting clinical suspicion of PSC. The risks of ERCP have to be weighed against the potential benefit with regard to surveillance and treatment recommendations.
Low quality evidence, weak recommendation.
6
ESGE/EASL suggest that, in patients with an established diagnosis of PSC, MRC should be considered before therapeutic ERCP.
Weak recommendation, low quality evidence.
7
ESGE/EASL suggest performing endoscopic treatment with concomitant ductal sampling (brush cytology, endobiliary biopsies) of suspected significant strictures identified at MRC in PSC patients who present with symptoms likely to improve following endoscopic treatment.
Strong recommendation, low quality evidence.
9
ESGE/EASL recommend weighing the anticipated benefits of biliary papillotomy/sphincterotomy against its risks on a case-by-case basis.
Strong recommendation, moderate quality evidence.
Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation.
Strong recommendation, low quality evidence.
16
ESGE/EASL suggest routine administration of prophylactic antibiotics before ERCP in patients with PSC.
Strong recommendation, low quality evidence.
17
EASL/ESGE recommend that cholangiocarcinoma (CCA) should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion.
Strong recommendation, moderate quality evidence.
19
ESGE/EASL recommend ductal sampling (brush cytology, endobiliary biopsies) as part of the initial investigation for the diagnosis and staging of suspected CCA in patients with PSC.
Strong recommendation, high quality evidence.
Background and Aim
The rendezvous postoperative endoscopic retrograde cholangiopancreatography (ERCP) technique has been introduced as a modification of the single‐session rendezvous intraoperative ...ERCP procedure in the management of concurrent common bile duct stones during cholecystectomy. There are no reports on the impact of this modified technique on post‐ERCP morbidity. The objective of the present study was to study and compare the rendezvous techniques in terms of procedure‐associated morbidities, such as post‐ERCP pancreatitis and postoperative infections.
Methods
The Swedish National Registry for Gallstone Disease and ERCP was searched for ERCP procedures cross‐matched with cholecystectomies for the same patient carried out for gallstone indications between 2008 and 2014. A total of 1770 rendezvous ERCP procedures were retrieved and included in this study. The ERCP procedures were considered rendezvous intraoperative or rendezvous postoperative, depending on whether the ERCP procedure was carried out during or after completing the cholecystectomy.
Results
There were 1205 and 565 ERCP procedures in the rendezvous intraoperative and the rendezvous postoperative groups, respectively. The cohorts were similar in age and gender distribution. Overall complication rates were higher in the rendezvous postoperative group compared with the rendezvous intraoperative group (19.7% vs 14%, P = 0.004), involving specifically post‐ERCP pancreatitis (6.4% vs 3.2% P = 0.003) and postoperative infections (4.4% vs 2.3% P = 0.028). Despite similar stone clearance rates, there were higher rates of retained stones in the rendezvous postoperative group (5.5% vs 0.6%, P < 0.001).
Conclusions
Single‐session rendezvous intraoperative ERCP is superior to the rendezvous postoperative ERCP technique in terms of post‐ERCP pancreatitis and postoperative infections.
Abstract Background and objective Even when advanced cross-sectional imaging modalities have been employed, endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMN) is often required ...in order to assess the final character and extent of lesions. The current study addresses the use of SpyGlass single-operator peroral pancreatoscopy in suspected IPMN. Design A prospective, non-randomized exploratory cohort study. Setting Single-center. Patients and intervention A prospective study-cohort of 44 consecutive patients in a single tertiary referral center who underwent ERCP and peroral pancreatoscopy, was prospectively collected between July 2007 and March 2013 because of a radiological signs of IPMN. These IPMN-findings were discovered incidentally in 44% of the cases. Main outcome measurements Diagnostic accuracy (specificity & sensitivity) and complications. Results The targeted region of the pancreatic duct was reached with the SpyGlass system in 41 patients (median age 65 years, 41% female). Three patients were excluded from analysis because of failed deep cannulation of the pancreatic duct. Brush cytology was taken in 88% and direct biopsies in 41%. IPMN with intermediate or high-grade dysplasia was the main final diagnosis (76%) in 22 patients who had surgery. Out of the 17 patients with a final diagnosis of MD-IPMN, 76% were correctly identified by pancreatoscopy. Of the 9 patients with a final diagnosis of BD-IPMN, the pancreatoscopy identified 78% of the cases correctly.The incidence of post-ERCP pancreatitis was 17%. Pancreatoscopy was found to have provided additional diagnostic information in the vast majority of the cases and to affect clinical decision-making in 76%. Limitations Single-center study. Conclusions Single-operator peroral pancreatoscopy contributed to the clinical evaluation of IPMN lesions and influenced decision-making concerning their clinical management. The problem of post-procedural pancreatitis needs further attention.
Gastrointestinal complaints without obvious organic causes confirmed by clinical laboratory analyses, endoscopy or radiology are often referred to functional entities. Irritable bowel syndrome (IBS) ...is the most common functional disorder in the gut. Careful examination of these patients may reveal other diagnoses of defined etiologies, e.g., enteric neuropathy, microscopic colitis, and primary Sjögre’s syndrome. The present case describes a young patient with incapacitating gastrointestinal symptoms presumed to be IBS, who underwent endoscopic full-thickness biopsy in sigmoid colon. Histopathological examination revealed degenerative enteric neuropathy, possibly secondary to chronic ischemia.
This pilot study aimed to evaluate safety and tissue sampling from subepithelial lesions (SEL) in the upper gastrointestinal tract with a novel electric motor driven endoscopic ultrasonography ...(EUS)-guided 17-gauge (G) size core needle biopsy (CNB) instrument.
An investigator-led prospective open label, performance and safety control study, including seven patients (female
= 4, median 71 y, range 28-75) with a determined SEL (median size 30 mm, range 17-150 mm) in the upper digestive tract (stomach
= 6, duodenum
= 1) were eligible and later followed up 14 days after index procedure. All investigations were completed according to protocol with three FNB 22-G passes with four fanning strokes and two EndoDrill
17-G passes with three fanning strokes.
Quality of samples as 'visible pieces' (>5 mm): FNB (
= 5/7) (fragmented/blood imbibed
= 1, poor tissue quantity
= 1) compared with 17-G CNB (
= 7/7). Histological result which led to final diagnosis (leiomyoma
= 2, adenocarcinoma
= 1, schwannoma
= 1, neuroendocrine tumour
= 1, desmoid tumour
= 1 and gastrointestinal stromal tumour (GIST)
= 1) could be obtained with the 17-G CNB instrument in all seven patients. FNB technique reached correct diagnosis in six patients. No serious adverse event were recorded.
By using an electric driven 17-G biopsy device, a true cylinder of core tissue can be obtained in one single puncture from the area of interest reducing the need for a second sampling. The absolute benefit of EUS-guided CNB is that the sample can be handled and histologically prepared in the same manner as standard percutaneous core needle sample, e.g., breast and prostate cancer.
Endoscopic retrograde cholangiopancreatography (ERCP) with failed biliary cannulation is associated with a high rate of adverse events, but the role of prophylactic antibiotics remains unclear. The ...primary aim was to investigate if prophylactically administered antibiotics affect the frequency of overall adverse complications in patients where biliary cannulation fails during ERCP. The secondary aim was to investigate if specific infectious complications, also were affected by the antibiotic prophylaxis.
We analysed data from 96,818 ERCPs (2006-2018), from the Swedish National Quality Registry of Cholecystectomy and ERCP (GallRiks), excluding ERCPs with successful cannulation (n = 88,743), missing data (n = 2,014), or on-going antibiotic therapy (n = 1,062).
In total 4,996 procedures were included, 2,124 received (42.5%) and 2,872 (57.5%) did not receive antibiotic prophylaxis. There were fewer overall complications in the group receiving prophylaxis (13.6% vs. 17.1%, p < .001), which corresponded to a 24% adjusted odds reduction in the multivariable analysis (odds ratio OR 0.76; 95% confidence interval CI 0.65-0.89). In the prophylaxis group, there was a lower overall rate of infectious complications (2.1% vs. 3.2%; p = .038; OR 0.68; 95% CI 0.47-0.98) and abscesses (0.8% vs. 1.4%; p = .040; OR 0.54; 95% CI 0.31-0.96). However, no significant differences were seen in the rate of cholangitis (1.3% vs. 1.7%; p = .182; OR 0.74; 95% CI 0.46-1.18).
This national quality registry study of ERCPs with failed cannulation showed a significant reduction in overall and infectious complications when prophylactic antibiotics were administered.
Summary This guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and of the European Association for the Study of the Liver (EASL) on primary sclerosing ...cholangitis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1. ESGE/EASL recommend that, as the primary diagnostic modality for PSC, magnetic resonance cholangiography (MRC) should be preferred over endoscopic retrograde cholangiopancreatography (ERCP). Moderate quality evidence, strong recommendation. 2. ESGE/EASL suggest that ERCP can be considered if MRC plus liver biopsy is equivocal or contraindicated in patients with persisting clinical suspicion of PSC. The risks of ERCP have to be weighed against the potential benefit with regard to surveillance and treatment recommendations. Low quality evidence, weak recommendation. 6. ESGE/EASL suggest that, in patients with an established diagnosis of PSC, MRC should be considered before therapeutic ERCP. Weak recommendation, low quality evidence. 7. ESGE/EASL suggest performing endoscopic treatment with concomitant ductal sampling (brush cytology, endobiliary biopsies) of suspected significant strictures identified at MRC in PSC patients who present with symptoms likely to improve following endoscopic treatment. Strong recommendation, low quality evidence. 9. ESGE/EASL recommend weighing the anticipated benefits of biliary papillotomy/sphincterotomy against its risks on a case-by-case basis. Strong recommendation, moderate quality evidence. Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation. Strong recommendation, low quality evidence. Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation. Strong recommendation, low quality evidence. 16. ESGE/EASL suggest routine administration of prophylactic antibiotics before ERCP in patients with PSC. Strong recommendation, low quality evidence. 17. EASL/ESGE recommend that cholangiocarcinoma (CCA) should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion. Strong recommendation, moderate quality evidence. 19. ESGE/EASL recommend ductal sampling (brush cytology, endobiliary biopsies) as part of the initial investigation for the diagnosis and staging of suspected CCA in patients with PSC. Strong recommendation, high quality evidence.
PDF
