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Endoscopic salvage therapy after failed biliary cannulation using advanced techniques:A concise review

World Journal of Gastroenterology 2022年第29期28卷 3803-3813页

作者： yung-kuan tsou kuang-Tse Pan Mu Hsien Lee Cheng-Hui Lin Department of Gastroenterology and Hepatology Chang Gung Memorial HospitalTaoyuan 333Taiwan Department of Medicine Chang Gung UniversityTaoyuan 333Taiwan Department of Medical Imaging and Intervention Chang Gung Memorial HospitalTaoyuan 333Taiwan

Therapeutic endoscopic retrograde cholangiopancreatography(ERCP)begins with successful biliary cannulation.However,it is not always be successful.The failure of the initial ERCP is attributed to two main aspects:the papilla/biliary orifice is endoscopically accessible,or it is inaccessible.When the papilla/biliary orifice is accessible,bile duct cannulation failure can occur even with advanced cannulation techniques,including double guidewire techniques,transpancreatic sphincterotomy,needle-knife precut papillotomy,or fistulotomy.There is currently no consensus on the next steps of treatment in this setting.Therefore,this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation.These options include interval ERCP,percutaneous-transhepatic-endoscopic rendezvous procedures(PTE-RV),and endoscopic ultrasound-assisted rendezvous procedures(EUS-RV).The overall success rate for interval ERCP was 76.3%(68%-79% between studies),and the overall adverse event rate was 7.5%(0-15.9% between studies).The overall success rate for PTE-RV was 88.7%(80.4%-100%between studies),and the overall adverse event rate was 13.2%(4.9%-19.2% between studies).For EUS-RV,the overall success rate was 82%-86.1%,and the overall adverse event rate was 13%-15.6%.Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise,facilities,or other specialists,it can be considered the first choice for salvage therapy.EUS-RV can also be considered if local experts are available.For patients in urgent need of biliary drainage,PTE-RV should be considered.

关键词： Difficult biliary cannulation Endoscopic ultrasound Rendezvous Endoscopic retrograde cholangiopancreatography Percutaneous transhepatic biliary drainage Interval

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Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

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World Journal of Clinical Cases 2023年第29期11卷 6984-6994页

作者： yung-kuan tsou Yi-Tse Su Cheng-Hui Lin Nai-Jen Liu Department of Gastroenterology and Hepatology Chang Gung Memorial HospitalTaoyuan 333TaiwanChina

BACKGROUND Whether clinical outcomes of acute cholangitis(AC)vary by etiology is unclear.AIM To compare outcomes in AC caused by malignant biliary obstruction(MBO)and common bile duct stones(CBDS).METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography(ERCP)due to AC caused by MBO(MBO group,n=56)and CBDS(CBDS group,n=460).Clinical and laboratory parameters were compared between the groups.Propensity score matching(PSM)created 55 matched pairs.Confounders used in the PSM analysis were age,sex,time to ERCP,and technical success of ERCP.The primary outcome comparison was 30-d mortality.The secondary outcome comparisons were intensive care unit(ICU)admission rate,length of hospital stay(LOHS),and 30-d readmission rate.RESULTS Compared with the CBDS group,the MBO group had significantly lower body temperature,percentage of abnormal white blood cell counts,and serum levels of aspartate aminotransferase,alanine aminotransferase,and creatinine.Body temperature,percent abnormal white blood cell count,and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis.Platelet count,prothrombin time/international normalized ratio,and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group.The MBO group had a significantly higher percentage of severe AC(33.9%vs 22.0%,P=0.045)and received ERCP later(median,92.5 h vs 47.4 h,P<0.001).However,the two differences were not found in the PSM analysis.The 30-d mortality(5.4%vs 0.7%,P=0.019),ICU admission rates(12.5%vs 4.8%,P=0.028),30-d readmission rates(23.2%vs 8.0%,P<0.001),and LOHS(median,16.5 d vs 7.0 d,P<0.001)were significantly higher or longer in the MBO group.However,only LOHS remained significant in the PSM analysis.Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality.CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS

关键词： Malignant biliary obstruction Common bile duct stones Endoscopic retrograde cholangiopancreatography Acute cholangitis Mortality Etiology

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Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

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World Journal of Gastroenterology 2022年第38期28卷 5602-5613页

作者： Yao-Chi Huang Chi-Huan Wu Mu Hsien Lee Sheng Fu Wang yung-kuan tsou Cheng-Hui Lin Kai-Feng Sung Nai-Jen Liu Department of Medicine College of MedicineChang Gung UniversityTaoyuan 333Taiwan Department of Gastroenterology and Hepatology Chang Gung Memorial HospitalTaoyuan 333Taiwan

BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography(ERCP)in acute cholangitis(AC) is uncertain,especially in patients with AC of varying severity.AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.METHODS According to the 2018 Tokyo guidelines,683 patients who met the definite diagnostic criteria for AC were retrospectively identified.The results were first compared between patients receiving ERCP ≤ 24 h and>24 h and then between patients receiving ERCP ≤ 48 h and>48 h.Subgroup analyses were performed in patients with grade Ⅰ,Ⅱ or Ⅲ AC.The primary outcome was 30-d mortality.Secondary outcomes were intensive care unit(ICU) admission rate,length of hospital stay(LOHS) and 30-d readmission rate.RESULTS Taking 24 h as the critical value,compared with ERCP>24 h,malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group(5.2% vs 11.5%).The proportion of cardiovascular dysfunction(11.2% vs 2.6%),respiratory dysfunction(14.2% vs 5.3%),and ICU admission(11.2% vs 4%)in the ERCP ≤ 24 h group was significantly higher,while the LOHS was significantly shorter(median,6 d vs 7 d).Stratified by the severity of AC,higher ICU admission was only observed in grade Ⅲ AC and shorter LOHS was only observed in grade Ⅰ and Ⅱ AC.There were no significant differences in 30-d mortality between groups,either in the overall population or in patients with grade Ⅰ,Ⅱ or Ⅲ AC.With 48 h as the critical value,compared with ERCP>48 h,the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group(81.5% vs 68.3%).The ERCP ≤ 48 h group had significantly lower 30-d mortality(0 vs 1.9%) and shorter LOHS(6 d vs 8 d).Stratified by AC severity,lower 30-d mortality(0 vs 6.1%) and higher ICU admission rates(22.2% vs 10.2%) were only observed in grade Ⅲ AC,and shorter LOHS was only observed in grade I and Ⅱ AC.In the multivariate analysis,cardiovascular dysfunction and time to ERCP were two

关键词： Acute cholangitis Endoscopic retrograde cholangiopancreatography severity Timing Thirtyday mortality Length of hospital stay

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Treating delayed endoscopic sphincterotomy-induced bleeding:Epinephrine injection with or without thermotherapy

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World Journal of Gastroenterology 2009年第38期15卷 4823-4828页

作者： yung-kuan tsou Nai-Jen Liu Jui-Hsiang Tang Kai-Feng Sung Chi-Liang Cheng Ching-Song Lee Department of Hepato-Gastroenterology Division of Therapeutic EndoscopyChang Gung Memorial Hospital & Chang Gung University College of Medicine

AIM:To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed post-endoscopic sphincterotomy (ES) bleeding.METHODS: Cases with delayed post-ES bleeding undergoing epinephrine injection alone (epinephrine injection group, n=26) or epinephrine combined with thermotherapy (combination therapy group, n=33) in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements wereRESULTS: The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy (P=0.44). There were four patients with re-bleeding in each group (16.0% vs 12.1%, P=0.72). There was only one complication of pancreatitis from the combination therapy group. Three patients (11.5%) in the epinephrine injection group and one patient (3%) in the combination therapy group required angiographic embolization or surgery (P=0.31). The total number of blood transfusions was not significantly different between the two groups (3.5±4.6 U vs 3.5±4.5 U, P=0.94). There was no bleeding-related death in either group.CONCLUSION: Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post-ES bleeding.

关键词：肾上腺素结合治疗注射出血热疗延迟内镜括约肌

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Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth Ⅱ gastrectomy

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World Journal of Gastroenterology 2010年第36期16卷 4594-4598页

作者： Jui-Hsiang Tang yung-kuan tsou Hao-Tsai Cheng Mu-Hsien Lee Ching-Song Lee Nai-Jen Liu Division of Digestive Therapeutic Endoscopy Department of Gastroenterology and HepatologyChang Gung Memorial Hospital College of Medicine Chang Gung University

AIM:To evaluate the effect of double balloon endoscope(DBE)on the endoscopic retrograde cholangio-pancreatography(ERCP)success rate in patients with a history of BillrothⅡ(BⅡ)gastrectomy.METHODS:From April 2006 to March 2007,32 patients with a BⅡgastrectomy underwent 34 ERCP attempts.In all cases,the ERCP procedures were started using a duodenoscope.If intubation of the afferent loop or reaching the papilla failed,we changed to DBE for the ERCP procedure(DBE-ERCP).We assessed the success rate of afferent loop intubation,reaching the major papilla,selective cannulation,possibility of therapeutic approaches,procedure-related complications,and the overall success rate.RESULTS:Among the 32 patients with a history of BⅡgastrectomy,the duodenoscope was successfully passed up to the papilla in 22 patients(69%),and cannulation was successfully performed in 20 patients(63%).Six patients(2 with failure in afferent loop intubation and 4 with failure in reaching the papilla)underwent DBE-ERCP.The DBE reached the papilla in all the 6 patients(100%)and selective cannulation was successful in 5 patients(83%).Four patients(67%)who had common bile duct stones were successfully treated.One patient underwent diagnostic ERCP only and the other one,in whom selective cannulation failed,was diagnosed with papilla cancer proven by biopsy.There were no complications related to the DBE.The overall ERCP success rate increased to 88%(28/32).CONCLUSION:The overall ERCP success rate increases with DBE in patients with a previous BⅡgastrectomy.

关键词： Double balloon endoscopy Endoscopic retrograde cholangiopancreatography BillrothⅡgastrectomy

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Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

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World Journal of Gastroenterology 2012年第19期18卷 2396-2401页

作者： Chi-Liang Cheng yung-kuan tsou Cheng-Hui Lin Jui-Hsiang Tang hien-Fu Hung Kai-Feng Sung Ching-Song Lee Nai-Jen Liu Division of Therapeutic Endoscopy Department of Gas-troenterology and Hepatology Chang Gung Memorial HospitalCollege of Medicine Chang Gung University Taoyuan 333Taiwan China Division of Radiology Department of Gastro-enterology and Hepatology College of Medicine Chang GungUniversity Taoyuan 333 Taiwan China

AIM:To describe characteristics of a poorly expandable(PE) common bile duct(CBD) with stones on endoscopic retrograde cholangiography.METHODS:A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment.Between 2003 and 2006,endoscopic retrograde cholangiography(ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital.Patients with characteristic PE bile duct on ERC were identified from the database.Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS:A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study.The median patient age was 45 years(range,20 to 92 years);66.7% of the patients were men.The diameters of the widest non-PE CBD segment,the PE segment,and the largest stone were 14.3 ± 4.9 mm,5.8 ± 1.6 mm,and 11.2 ± 4.7 mm,respectively.The length of the PE segment was 39.7 ± 15.4 mm(range,12.3 mm to 70.9 mm).To remove the CBD stone(s) completely,mechanical lithotripsy was required in 25(83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature.The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy.Post-ERC complications occurred in 4 cases:pancreatitis in 1,cholangitis in 2,and an impacted Dormia basket with cholangitis in 1.Two(6.7%) of the 28 patients developed recurrent CBD stones at follow-up(50 ± 14 mo) and were successfully managed with therapeutic ERC.CONCLUSION:Patients with a PE duct frequently require mechanical lithotripsy for stones extraction.To retrieve stones successfully and avoid complications,these patients should be identified during ERC.

关键词：胆总管结石胆管内镜计算机数据库生物多样性公约 APE 数据收集管理资源

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Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

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World Journal of Gastroenterology 2013年第30期19卷 4966-4972页

作者： Shu-Wei Huang Cheng-Hui Lin Mu-Shien Lee yung-kuan tsou Kai-Feng Sung Department of Gastroenterology and Hepatology Division of Digestive Therapeutic EndoscopyChang Gung Memorial HospitalChang Gung University College of Medicine

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

关键词： Balloon-occluded cholangiography Common bile duct stones Endoscopic retrograde cholangiography Peroral cholangioscopy Residual stones

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Esophagogastroduodenoscopy with conscious sedation does not interfere with catheter-based 24-h pH monitoring

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World Journal of Gastroenterology 2013年第11期19卷 1805-1810页

作者： yung-kuan tsou Jau-Min Lien Chin-Kuo Chen Cheng-Hui Lin Hsing-Yu Chen Mu-Shien Lee Department of Gastroenterology and Hepatology Chang Gung Memorial HospitalChang Gung University College of MedicineTaoyuan 333Taiwan Department of Otolaryngology Chang Gung Memorial HospitalChang Gung University College of MedicineTaoyuan 333Taiwan Center for Traditional Chinese Medicine Chang Gung Memorial HospitalChang Gung University College of MedicineTaoyuan 333Taiwan

AIM:To investigate the impact of esophagogastroduodenoscopy with conscious sedation on the subsequent 24-h catheter-based pH monitoring.METHODS:Fifty patients with extra-esophageal symptoms of gastroesophageal reflux disease undergoing ambulatory dual-probe 24-h pH monitoring were enrolled from March 2010 to August 2011.All of the data were collected prospectively and analyzed retrospectively.Thirty-six patients(72%,group A) underwent pH monitoring shortly after esophagogastroduodenoscopy(EGD) with conscious sedation,and 14 patients(28%,group B) underwent pH monitoring without conscious sedation.The 24-h pH data from two time periods were analyzed:the first 4 h(Period Ⅰ) and the remaining time of the study(Period Ⅱ).RESULTS:The mean age of the patients was 49.6 ± 12.5 years;20 patients(40%) were men.The baseline data,including age,sex,body mass index,reflux esophagitis,the Reflux Symptom Index,and the Reflux Findings Score,were comparable between the two groups.The percentage of total time with a pH < 4 and the frequency of acid reflux during Period Ⅰ were not significantly different between the two groups,as measured using both pharyngeal(0.03% ± 0.10% vs 0.07% ± 0.16%,P = 0.32;and 0.07 ± 0.23 episodes/h vs 0.18 ± 0.47 episodes/h,P = 0.33,respectively) and esophageal probes(0.96% ± 1.89% vs 0.42% ± 0.81%,P = 0.59;and 0.74 ± 1.51 episodes/h vs 0.63 ± 0.97 episodes/h,P = 0.49,respectively).The percentage of total time with a pH < 4 and the frequency of acid reflux were also not significantly different between Periods I and Ⅱ in group A patients,as measured using both pharyngeal(0.03% ± 0.10% vs 0.23% ± 0.85%,P = 0.21;and 0.07 ± 0.23 episodes/h vs 0.29 ± 0.98 episodes/h,P = 0.22,respectively) and esophageal probes(0.96% ± 1.89% vs 1.11% ± 2.57%,P = 0.55;and 0.74 ± 1.51 episodes/h vs 0.81 ± 1.76 episodes/h,P = 0.55,respectively).CONCLUSION:EGD with conscious sedation does not interfere with the results of subsequent 24-h pH monitoring in patients with extra-esophageal symptoms of gastroesophageal reflux disease.

关键词： Esophagogastroduodenoscopy Conscious sedation pH monitoring Gastroesophageal reflux disease Extraesophageal symptoms

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Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

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World Journal of Gastroenterology 2016年第11期22卷 3196-3201页

作者： Mu-Hsien Lee yung-kuan tsou Cheng-Hui Lin Ching-Song Lee Nai-Jen Liu Kai-Feng Sung Hao-Tsai Cheng Department of Gastroenterology and Hepatology Chang Gung Memorial Hospital and Chang Gung University College of Medicine

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

关键词： Delayed bleeding Endoscopic hemostasis Endoscopic sphincterotomy Predictors Re-bleeding

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Altered heart rate variability and pulse-wave velocity after spinal cord injury

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World Journal of Clinical Cases 2022年第27期10卷 9680-9692页

作者： Hsi-Kai tsou kuan-Chung Shih Yueh-Chiang Lin Yi-Ming Li Hsiao-Yu Chen Functional Neurosurgery Division Neurological InstituteTaichung Veterans General HospitalTaichung 404Taiwan Department of Rehabilitation Jen-Teh Junior College of MedicineNursing and ManagementMiaoli County 356Taiwan College of Health National Taichung University of Science and TechnologyTaichung 403Taiwan College of Medicine National Chung Hsing UniversityTaichung 402Taiwan Research Assistant The Rong Sing Medical FoundationTaichung 404Taiwan Research Assistant Neurological InstituteTaichung Veterans General HospitalTaichung 404Taiwan Research Assistant Department of NursingNational Taichung University of Science and TechnologyTaichung 403Taiwan Graduate Institute of Applied Science and Technology National Taiwan University of Science and TechnologyTaipei 106Taiwan Department of Nursing National Taichung University of Science and TechnologyTaichung 403Taiwan

BACKGROUND Heart rate variability(HRV) and pulse-wave velocity(PWV),indicators of cardiac function,are altered in patients with spinal cord injury(SCI),suggesting that autonomic cardiac function and arterial stiffness may underlie the high risk of cardiovascular complications in these patients.No study has simultaneously investigated HRV and PWV in the same patients.AIM To evaluate cardiovascular complications in SCI patients by comparing HRV and PWV between patients with and without SCI.METHODS In this cross-sectional pilot study,patients with(n = 60) and without SCI(n = 60) were recruited from December 7,2019 to January 21,2020.Each participant received a five-minute assessment of HRV and the cardiovascular system using the Medicore HRV Analyzer SA-3000 P.Differences in HRV and PWV parameters between participants with and without SCI were statistically examined.RESULTS We observed a significant difference between participants with and without SCI with respect to the standard deviation of all normal-to-normal intervals,square root of the mean sum of squared successive risk ratio interval differences,physical stress index,total power,very-low frequency,low frequency,high frequency,and arterial elasticity.CONCLUSION Patients with SCI have weaker sympathetic and parasympathetic activity as well as lower arterial elasticity compared to those without,suggesting that SCI may increase cardiac function loading.

关键词： Acceleration plethysmography Cardiac function Heart rate variability Pulse wave velocity Spinal cord injury

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