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Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients.
The study was a retrospective observational study and includ...
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Citations
... A meta-analysis of four RCTs showed increased bleeding with pure cut compared to mixed current with similar rates of pancreatitis [65]. Compared to blended current, endocut and pulsecut mode produces fewer uncontrolled cuts and bleeding though rates of perforation and PEP do not differ [66][67][68][69]. ...
Purpose of Review
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common adverse event following ERCP. The purpose of this review is to highlight prevention strategies and recent developments in this area and summarize current recommendations to reduce PEP rates.
Recent Findings
PEP prevention continues to rely heavily on use of peri-procedural rectal non-steroidal anti-inflammatory drugs (NSAIDs) and intravenous aggressive hydration (AH) while shying away from more invasive maneuvers such as pancreatic stents except in high-risk cases. Comparative studies of medical therapy, AH, and pancreatic stents are beginning to emerge.
Summary
Acute pancreatitis remains the most common adverse event following ERCP. Prevention continues to evolve and requires a multi-disciplinary approach of careful risk assessment and procedural planning, peri-operative pharmacotherapy, selective AH, and pancreatic stenting for high-risk patients.
... Two studies were reviewed that directly compared procedural methods in ERCP and bleeding risk. 65,66 One study randomized patients with CTP A/B cirrhosis and common bile duct stones to undergo sphincterotomy with either mechanical lithotripsy or large balloon dilation. 65 Patients with platelet count <50,000/mL and "severe coagulopathy" were excluded and use of prophylaxis was not reported. ...
... Another study retrospectively examined patients with cirrhosis undergoing ERCP with sphincterotomy with 2 separate types of electrocautery (alternating current vs blended current). 66 Prophylaxis was provided for patients with platelet count <50,000/mL and INR >1.5. A total of 29 patients were examined and 3 bleeding events (1 major) were identified in the group using blended current compared with 0 events in the group using alternating current. ...
... Kanama ES ile direkt ilişkili olup, literatür kanama komplikasyonunu azaltmak için pre-cut'ta dikkatli olunmasını, koterin Cut modunun hızlı kesmeye neden olmamasını önermektedir. Pre-cut veya normal papillotom ile sfinkterotomi sırasında Cut modu ile yavaş başlama ve Coagulation moduyla devam edilmesi ya da miks akım koterizasyon kullanımı daha güvenlidir (16,17). Bu çalışmada elde edilen ikinci sonuç iğne uçlu papillotom ile koterin Cut modunda pre-cut yapılmasının kanamayı artırdığıdır (altı hasta %31,6). ...
... A retrospective analysis revealed a significantly lower frequency of endoscopically observed mild bleeding after EST with mixed current in alternating mode (endocut) compared to blended mode [13] . A small retrospective observational study in cirrhotic patients also reported a lower frequency of EST bleeding in patients who underwent sphincterotomy with mixed current in the alternating mode (pulsecut), compa red to blended mode [14] . Mixed current in alternating mode may also be associated with fewer episodes of uncontrolled cutting (zipper), since software applies a constant voltage. ...
Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc . It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.
... Therefore, these two forms of mixed current can be grouped together to compare with pure cutting current. Out of five RCTs [94-98], two found a significantly lower rate of pancreatitis with pure cutting compared with mixed current [94,95]. Pure cutting current was associated with more episodes of bleeding, primarily mild bleeding which did not translate into increased morbidity or mortality [94-98]. ...
This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. 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 suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).
© Georg Thieme Verlag KG Stuttgart · New York.
High-frequency electrosurgery has been widely used in the field of digestive endoscopy with constantly expanding indications. However, during operation electrocautery may cause possible risks such as bleeding or perforation, which endoscopic staffs should be attentive to. It is essential to strengthen the understanding of digestive endoscopists regarding principles of high-frequency electrical technology as well as operational safety issues, and thereby improve the safety of the clinical application. Thus, experts in digestive endoscopy, surgery, nursing, and other related fields were invited to participate in the consensus development on the clinical application of high-frequency electrosurgery in digestive endoscopy, based on relevant domestic and international literature and their experience.
The biliary tract is often affected in patients with chronic liver disease. Often, biliary diseases such as primary and secondary sclerosing cholangitis lead to chronic liver disease. Furthermore, patients with cirrhosis are also prone to develop common conditions such as choledocolithiasis, bile duct injuries, and primary or secondary hepatobiliary tumors. Whereas in patients with intact liver function the decision to perform an invasive and potentially curative procedure such as endoscopic retrograde cholangiopancreatography (ERCP) is straightforward, this is a difficult decision in patients with liver dysfunction and coagulopathy. This chapter presents a practical approach to ERCP and cholangioscopy in patients with chronic liver disease including key aspects of patient preparation, intra-procedural steps, and post-procedure care that are specifically related to ERCP and cholangioscopy.
Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) or endoscopic papillary balloon dilation (EPBD) is the most commonly used approach for choledocholithiasis in patients with cirrhosis. If this approach fails or the patient has altered anatomy, other options include transgastric ERCP with ES or EPBD, expandable stents, and/or lithotripsy. Although cirrhotic patients have some increased risk of bleeding, there appears to be no increased risk of post-ERCP pancreatitis in these patients, and they generally do well with ERCP with ES or EPBD. Because there is some risk associated with these procedures, if suspicion is not high, it is important to confirm the presence of choledocholithiasis with imaging studies, including magnetic resonance cholangiography. Surgery is an option if endoscopic management is unsuccessful. Surgical options include laparoscopic cholecystectomy with choledochotomy, laparoscopic common bile duct exploration, and T-tube placement.
Treatment of choledocholithiasis and cholelithiasis in patients with cirrhosis often requires diagnostic and therapeutic endoscopy such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Patients with underlying cirrhosis may have coagulopathy, hepatic encephalopathy, ascites and other comorbidities associated with cirrhosis that can make endoscopic therapy challenging and can be associated with a higher risk of adverse events. Given the unique derangements of physiologic parameters associated with cirrhosis this population requires a truly multifaceted and multidisciplinary understanding between therapeutic endoscopists, hepatologists and anesthesiologists. For therapeutic endoscopists, it is critical to be aware of the specific issues unique to this population of patients to optimize outcomes and avoid adverse events. The epidemiology of gallstone disease, the diagnostic and therapeutic approach to patients with varying degree of hepatic dysfunction, and a review of the available literature in this area are presented.
