ERCP is undergoing its 50th anniversary with a steady conversion from a diagnostic procedure to a therapeutic procedure. This paper shows a reflection of my 42 years of experience in the accession of biliary and pancreatic ducts and how the techniques have evolved to achieve a high rate of primary duct cannulation. There has been an increase in the primary approach to cannulation involving different cannulation catheters and guidewires, and we will review some of those available, realizing that the selection may vary depending on operator preference and team approach. Different views and experiences with these techniques will be presented. ERCP has evolved from a diagnostic to primarily a therapeutic procedure. This has resulted in the development of a variety of devices and techniques to access the ducts of interest. I have presented several of the techniques and my team approach that has evolved over a number of years. A more prospective evaluation of devices and wires is needed to see if one is superior to the other.

Patients with acute relapsing or chronic pancreatitis and main pancreatic duct pathology may benefit from endoscopic therapy with stenting. Polyethylene pancreatic stents are commonly used but have limited patency and are associated with stent-related complications within several weeks. The aim of this multi-center retrospective case series was to evaluate use of a long multi-perforated, soft plastic stent without flanges (Johlin®) in patients with pancreatitis undergoing endotherapy with pancreatic stenting.

In this report, a patient had a previous diagnosis of cholangiocarcinoma with an extended cholecystectomy. Three years later, he was evaluated for recurrent ascites. The patient had several large volume paracentesis, without evidence of malignant cells. Subsequently, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of both lymph and omental nodules was utilized. While the lymph nodes were negative for malignancy, the omental nodule was interrogated with multiple antibodies and was found to be positive for neoplasia. EUS with FNA can safely be used in patients with cirrhosis to spare the patient invasive evaluation such as exploratory laparotomy (ex-lap) for diagnosis and staging of cholangiocarcinoma.

Introduction There are a number of factors which can influence the accuracy of EUS FNA but the presence of an in-room cytotechnician (IRC) has been shown to be one of the important factors. The aim of this study was to establish if the introduction of an IRC improved the diagnostic accuracy of EUS guided FNA of solid pancreatico biliary lesions Methods This is a prospective study and includes all patients with solid pancreatico biliary lesions who underwent EUS FNA from April 2009 to September 2010. We have been performing EUS FNA since 2003 but did not have an IRC till this period. The IRC attended 2 of the 4 EUS lists and therefore there were two groups identified: Group 1 – Cytotechnician absent; Group 2 – Cytotechnician present. Final diagnosis was based on a positive diagnosis on cytology, other forms of tissue acquisition and/or a year9s follow up for the benign/indeterminate cases. Only patients with a final diagnosis were included in the study. Results The final results are shown in table 1. We compared our data to the 6 months prior to this study (October 2008–March 2009) when there was no IRC available. The accuracy, sensitivity, specificity, PPV and NPV during this period were 86%, 82%, 100%, 100% and 57.6% respectively. The inadequate aspirate rate during this period was 14.2%. There was no statistical difference when this data was compared to either Groups 1 or 2. Conclusion This study shows that the presence of an IRC does not necessarily improve the diagnostic accuracy of EUS FNA of pancreatobiliary lesions. There are a number of factors which influence the results but experience of the cytopathologist/cytotechnician has shown to be one of the important factors. By keeping the number of inadequate aspirates low and reducing the number of highly suspicious samples the accuracy of the test can be improved. Large studies may be required to show a significant difference. Cost effectiveness and experience of the cytopathologist/cytotechnician should be taken into consideration when setting up this service.

In this report, a patient was exposed to an herbal remedy for hypercholesterolemia. She became acutely jaundiced while taking the remedy and presented for medical care. Endoscopic ultrasound was utilized, and found a distal common bile duct mass. Endoscopic retrograde cholangiopancreatography guided bile duct biopsies revealed that the mass was cholangiocarcinoma (CCA). This case highlights a unique association between autoimmune hepatitis and CCA. It also highlights that EUS can be safely used in patients with cirrhosis to spare invasive evaluation such as exploratory laporotomy for diagnosis and staging of cholangiocarcinoma.

BrC has a notoriously low yield in MBO, adding bile duct biopsy has been demonstrated to improve the yield. Studies reporting a higher yield include a “suspicious for malignancy” as a positive result. Most programs want “positive for malignancy” to consider therapy, especially chemo/XRT. We performed a periodic review with our pathologists to see what can be done to improve yield. At about our 50th case stopped submitting the brushing on a slide and submitted the brush in cytolite and the biopsy for block cytology (BxC) rather than surgical pathology. The sequence was brush first and biopsy second. At case 127 we altered the sequence doing biopsy first then cytology.

Background: The utility and safety of endoscopic biliary orifice balloon dilation (EBD) for bile duct stone removal (with use of large-diameter balloons) after biliary endoscopic sphincterotomy (BES) is currently not well established.Objective: Our purpose was to evaluate the efficacy and complications of BES followed by >= 12 mm diameter EBD for bile duct stone removal.Design: Retrospective, multicenter series.Setting: Five ERCP referral centers in the United States.Patients and Interventions: Patients who underwent attempted removal of bile duct stones by BES followed by EBD with >= 12 mm diameter dilating balloons were identified by searching the prospectively recorded endoscopic databases from 1999 to 2007. Clinical parameters, endoscopic data, and outcomes were collected and analyzed.Results: One hundred three patients, mean age 70 +/- 17 years (range 23-98 years), with 56 (54%) women, underwent 107 procedures. Eleven patients (11%) had a prior history of acute pancreatitis. Pancreatogram was performed in 15 (14%) patients. Median stone size and median balloon diameter used was 13 mm. Complete stone removal in the first session of EBD was accomplished in 102 (95%) procedures, and mechanical lithotripsy was required in 29 (27%). Six patients (5.4%) had documented procedure-related complications including one patient with severe bleeding and one with severe cystic duct perforation. No acute pancreatitis occurred.Conclusion: EBD with a large-diameter balloon in conjunction with BES for bile duct stone removal is effective and relatively safe. This technique appears to be a reasonable alternative option when standard BES and basket or balloon sweep are inadequate to remove bile duct stones.

Background and Aim: The yield of brush cytology (Cyt) in malignant bile duct (BD) strictures is low, multiple sampling methods have given variable results. Our database has been prospectively recording our experience with intraductal sampling with biopsy block Cyt (B x C) and brush Cyt (BrC) as part of a QA exercise. We report our experience with our last 43 cases of non pancreatic MBO. Materials and Methods: Once a suspicious bilary stricture is identified @ ERCP and a 0.035” guidwire inserted, a 9.6 French (Fr) biliary cannulation sleeve (Cook Medical, Winston Salem) with its 6 Fr inner guide catheter are advanced over the wire and through the stricture. The guide catheter and wire removed. Through the sleeve a pediatric Bx forceps (Boston Scientific, Boston) and a cytology brush with a 5 or 6 Fr covering catheter are inserted and the sleeve repositioned in the duct to allow sampling. 4 bx specimens from within the stricture and the brush are sent in preservative for Cyt evaluation. For this study pathology reading of malignancy is our only positive recording, while suspicious and atypical diagnoses are considered negative. Results: 110 strictures were evaluated, 16 were benign, 51 were primary pancreatic and 43 non pancreatic (cholangioCa-27, gallbladder-8, metastatic 8)and they are reported here. Each sampling method was compared to both in combination using a Chi Square analysis in the table below. 37/43 cases were positive by @ least one sample. Of the 6 negatives (3 suspicious and 3 negative)were confimed cancers by EUS, PTC or surgery. After sampling is completed the sleeve system could be used to insert a 10 Fr plastic stent, or a metal inserted over the wire. Combined sampling was stastically superior to either method alone. Conclusions: 1). Combining BrC and BxC is statistically superior to either alone. 2). Using the sleeve system for multiple sampling gives a high overall yield. 3). This sampling method would not confer the risk of seeding the biopsy tract like percutaneous or EUS sampling in surgical candidates Tabled 1 Method # positive (%) cumulative (BrC + BxC) (%) P value BrC 27/43 (63%) 37/43 (86%) p = 0.01 BxC 29/43 (67%) 37/43 (86%) P = 0.05 Open table in a new tab

Background and Aim: Long term patency of partially covered self-expandable metal stents has not been shown to be superior to uncovered stents. Fully CSEMS may provide longer patency but may be associated with a higher rate of migration and cholecystitis. The aim of this multicenter study is to evaluate the efficacy and complication rates of CSEMS in malignant biliary obstruction. Methods: Between Oct 2003 and May 2007, 84 patients (50 males, 66 ± 15 y/o) underwent ERCP with placement of an 8 mm (7) or 10 mm (77) diameter CSEMS (VIABIL , ConMed) for the palliation of distal biliary obstruction: pancreatic (61), ampullary (11), biliary (6), metastatic (5) and duodenal neoplasia (1). Survival, stent patency, complications, and cause of dysfunction were analyzed retrospectively. Results: At the end of the study period, 42 patients were alive, 88% died with a patent stent. 8 CSEMS malfunctioned; 1 migrated distally and 7 occluded secondary to debris (n = 4), tumor overgrowth (n = 2) and unclear reasons (n = 1). CSEMS were left in place and remained patent for a mean of 106 ± 90 days (range: 6-498). Patency at 90, 180 and 360 days were 96, 80 and 53 % respectively (see Figure). Technical difficulty during insertion included 2 proximal stents deployments repositioned endoscopically. Complications (7%) post placement included: post ERCP pancreatitis (2), cholecystitis (2), self limited wire perforation (1) and subcapsular liver hematoma (1). Six patients underwent curative resection. A total of 10 patients had their CSEMS removed uneventfully; 1 received an uncovered metal stent and 9 received a second CSEMS (5 for tissue sampling, 3 for occlusion and 1 for pancreatic drainage). Conclusion: Fully CSEMS have acceptable patency and complication rate. Decreased long term patency appears related mainly to biliary debris. Further long term prospective data is required to confirm this observation.

To date, antegrade intussusception involving a Roux-en-Y reconstruction has been reported only once.We report a case of acute bowel obstruction due to an intussusception involving two Roux-en-Y limbs in a 40-year-old woman with a history of chronic pancreatitis due to pancreas divisum.Four years preceding this event, the patient had undergone a Whipple procedure, and three years prior to that, a Puestow operation.The patient was successfully treated with bowel resection and a sideto-side anastomosis between the most distal aspect of the bowel and the most distal Roux-en-Y reconstruction, which preserved both Roux-en-Y reconstructions.

Background and Objectives: At the time of endoscopic retrograde cholangiopancreatography, deep cannulation of the bile duct is a prerequisite to be able to provide endoscopic therapy. We describe a simple technique to assist in difficult bile duct cannulation. Methods: If the pancreatic duct is easily entered but the bile duct cannot be accessed, a guidewire is advanced into the pancreatic duct, and the cannulating catheter is removed leaving the tip of the wire in the mid pancreatic duct. Alongside the pancreatic wire, a catheter, preloaded with a second wire, is advanced via the channel of the endoscope. With the first wire in the pancreatic duct, the second wire is advanced above it in the anticipated bile duct axis. Results: We have used this technique in 12 cases and succeeded in 10. No complications occurred. Discussion: Inserting a pancreatic wire can assist in bile duct cannulation, by straightening and stabilizing the papilla. The use of this new technique can reduce the need for precut sphincterotomy, with its inherent increased risks of pancreatitis, bleeding, and perforation. The approach proposed by us can assist in any difficult bile duct cannulation, but it can be particularly useful when dealing with a papilla that is very prominent with a tortuous intraduodenal segment or a papilla located in a duodenal diverticulum.

Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.

Background: Bleeding as a complication of endoscopic sphineterotomy is influenced by several factors. The objective of this study was to compare rates of bleeding after sphincterotomy performed with two different electrosurgical current generators (Valleylab SSE2L and ERBE ICC200).Methods: A total of 6179 consecutive reports of ERCP were analyzed to compare the frequency of endoscopically and clinically evident bleeding after sphincterotomy when using the Valleylab SSE2L generator (from February 1994 to November 1997) and the ERBE ICC200 generator (from December 1997 to September 2000). Relevant risk factors were assessed by univariate analysis and significant predictors were included in a multiple logistic regression model.Results: A total of 2711 sphincterotomies were performed in 2309 patients (1749 biliary, 962 pancreatic). Endoscopically observed bleeding occurred in 68 patients (5.5%) in the ValleyLab group and 13 (1.2%) in the ERBE group. The ValleyLab generator was independently associated with an increase in endoscopically observed bleeding (OR 4.02: 95% CI[2.13, 7.61], p < 0.001). There was no significant difference in clinically evident bleeding between the two groups.Conclusions: Use of the microprocessor-controlled ERBE electrosurgical generator for endoscopic sphineterotomy was associated with a significantly lower frequency of endoscopically observed bleeding but not clinically evident bleeding.

BACKGROUND:Biliary stricture is one of the most common complications of liver transplantation. A number of treatment options are available, but a standard approach has not been established.METHODS:A total of 25 patients with post-liver transplantation anastomotic strictures were treated endoscopically by stent placement. Long-term outcomes (bile duct patency, morbidity, and mortality) were reviewed retrospectively.RESULTS:Placement of a stent was attempted in 25 patients with anastomotic stricture. Successful stent placement with stricture resolution at the time of stent removal was noted in 22 patients (technical success 88%). In those 22 patients, long-term success (mean follow-up after all stents removed, 54 months) was observed in 20 patients (90%) and partial success in two (10%). Long term, failure did not occur in any patient. There was no procedure- or disease-related mortally. Three mild episodes of cholangitis occurred during the period while the stents were in place, in relation to 79 endoscopic interventions for a procedure-related complication rate of 3.7%.CONCLUSIONS:The long-term outcome for patients with post-liver transplantation biliary anastomotic strictures treated with endoscopic stent placement is excellent, with no therapy- or disease-associated mortality and minimal morbidity.

Background and Study Aims: Unexplained pancreatitis represents a diagnostic challenge. The aim of this study was to determine the diagnostic utility of endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry (SOM), bile analysis, and endoscopic ultrasound (EUS) in evaluating such patients. Patients and Methods: Of 162 patients referred for evaluation of pancreatitis, 72 with a known cause were excluded. The remainder (n=90) was classified as having prior acute (n=24) or recurrent acute pancreatitis (n=66). Bile sampling and SOM were performed at the time of ERCP. EUS was used to assess for tumors and for chronic pancreatitis. Clinical outcomes were evaluated by questionnaire. Results: ERCP was successful in 88/89 patients (99 %). Manometry was successful in 63/67 patients (94 %), and 56 patients underwent EUS. Findings were categorized into five distinct etiologies: sphincter of Oddi dysfunction (SOD) (n=28; 31 %), pancreas divisum (n=18; 20 %), biliary (n=18; 20 %), idiopathic (n=18; 20 %) and tumor-related (n=8; 9 %). Features of moderate or severe chronic pancreatitis by EUS and ERCP criteria were found in 18 patients (21 %); an additional nine patients had chronic pancreatitis by EUS criteria alone. EUS identified all the tumors. The condition was improved in 96 % of all patients undergoing endoscopic therapy. Conclusion: An etiology was identified in the majority of patients with unexplained pancreatitis. SOD represented the most common finding. Moderate to severe chronic pancreatitis was found in over one-fifth of these patients. Bile analysis, SOM, and EUS are useful tools in the evaluation of unexplained acute pancreatitis.

Eosinophilic gastroenteritis is a rare gastrointestinal disorder of undetermined etiology that is characterized by eosinophilic infiltration of the gut wall. The presenting symptoms depend on the site and depth of intestinal involvement and varies from nausea, vomiting, and abdominal pain to acute bowel obstruction. Pancreaticobiliary obstruction caused by eosinophilic gastroenteritis is rare. We report a 39-year-old man who presented with abdominal pain, vomiting, abnormal liver tests, and a duodenal mass on upper endoscopy. Blood tests showed peripheral eosinophilia. Abdominal computed tomography scan showed a suspected mass in ampullary region. At endoscopic retrograde cholangiopancreatography, both pancreatic and common bile duct were dilated with no obvious ductal strictures. Biopsies from the duodenal mass showed evidence of eosinophilic gastroenteritis. He was successfully treated with prednisone, and his liver test results returned to normal. In conclusion, this unusual case of eosinophilic gastroenteritis presented with duodenal mass that was masquerading as an ampullary adenoma causing pancreaticobiliary obstruction.

Background: Patients with intraductal papillary mucinous tumors of the pancreas (IPMT) present with symptoms similar to those of chronic pancreatitis. This study assessed the accuracy of EUS for detection of IPMT and identified features that discriminate IPMT from chronic pancreatitis. Methods: EUS accuracy for detecting IPMT was determined with characteristic findings by endoscopic retrograde pancreatography as the reference standard. To determine EUS features characteristic of IPMT, EUS images from patients with IPMT were compared with those from patients (similar age, gender) with chronic pancreatitis. Results: Thirty-eight patients (23 men, 15 women; age range 40-90 years) with IPMT were identified between 1994 and 2001. For EUS, the sensitivity was 86%, specificity 99%, positive predictive value 78%, and negative predictive value 99% for detection of IPMT. When compared with patients with chronic pancreatitis, the EUS features of dilation of pancreatic duct (89% vs. 42%, p < 0.0001), cysts (45% vs. 11%, p = 0.002), and pancreatic atrophy (32% vs. 3%, p = 0.002) were more common, whereas parenchymal features of chronic pancreatitis were less common with IPMT (21% vs. 97%, p < 0.0001). By multivariate analysis, the presence of no more than one parenchymal feature of chronic pancreatitis suggested the diagnosis of IPMT (odds ratio 43.84; 95% CI [4.13, 465.74]). Conclusions: EUS may be useful in the initial evaluation of patients suspected to have IPMT. Paucity of parenchymal features of chronic pancreatitis is important in differentiating IPMT from other causes of chronic pancreatitis. (Gastrointest Endosc 2002;56:701-7.)