Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

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FIELD OF VISION
COVID-19: Off-label therapies based on mechanism of action while waiting for evidence-based medicine
recommendations
173
Scotto Di Vetta M, Morrone M, Fazio S
Learning and competence development via clinical cases – what elements should be investigated to best
train good medical doctors?
178
Löffler-Stastka H, Wong G
REVIEW
Immunotherapy in hepatocellular carcinoma: Combination strategies
190
Jordan AC, Wu J
Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in
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210
Feng YL, Li J, Ye LS, Zeng XH, Hu B
MINIREVIEWS
Thrombopoietin-receptor agonists in perioperative treatment of patients with chronic liver disease
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Qureshi K, Bonder A
Role of non-coding RNAs in pathogenesis of gastrointestinal stromal tumors
233
Stefanou IK, Gazouli M, Zografos GC, Toutouzas KG
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Exclusive cigar smoking in the United States and smoking-related diseases: A systematic review
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Lee PN, Hamling JS, Thornton AJ
Hydatidosis and the duodenum: A systematic review of the literature
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de la Fuente-Aguilar V, Beneitez-Mascaraque P, Bergua-Arroyo S, Fernández-Riesgo M, Camón-García I, Cruza-Aguilera
I, Ugarte-Yáñez K, Ramia JM
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Prevalence of anxiety among gestational diabetes mellitus patients: A systematic review and meta-analysis
275
Lee KW, Loh HC, Chong SC, Ching SM, Devaraj NK, Tusimin M, Abdul Hamid H, Hoo FK

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Dr. Rakhshan is an editorial board member of World Journal of Meta-Analysis, and a former lecturer in the Dental
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in which he designed and implemented an AI computer vision program that could extract radiographic landmarks
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and has published about 140 peer-reviewed articles on different dentistry topics. He has also peer reviewed more
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Management, Computational Intelligence and Neuroscience, and International Journal of Dentistry, and an associate editor
of Frontiers in Oral Health. He is currently a PhD candidate of cognitive neuroscience at the Institute for Cognitive
Science Studies, Tehran, Iran
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DOI: 10.13105/wjma.v8.i3.210 ISSN 2308-3840 (online)
REVIEW
Combined endoscopy/laparoscopy/percutaneous transhepatic
biliary drainage, hybrid techniques in gastrointestinal and biliary
diseases
Yi-Long Feng, Jing Li, Lian-Song Ye, Xian-Hui Zeng, Bing Hu
ORCID number: Yi-Long Feng 0000-
0003-1645-2063; Jing Li 0000-0002-
6929-409X; Lian-Song Ye 0000-0001-
5542-2508; Xian-Hui Zeng 0000-
0002-2865-7560; Bing Hu 0000-0002-
9898-8656.
Author contributions: Feng YL and
Li J wrote the paper; Hu B revised
the paper; Ye LS and Zeng XH
collected the data.
Supported by Key Research and
Development Program of Science
and Technology Department of
Sichuan Province, No.
2018GZ0088.
Conflict-of-interest statement: No
conflict of interests.
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See: htt
p://creativecommons.org/licenses
/by-nc/4.0/
Yi-Long Feng, Jing Li, Lian-Song Ye, Xian-Hui Zeng, Bing Hu, Department of Gastroenterology,
West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
Corresponding author: Bing Hu, MD, Chief Doctor, Professor, Department of Gastroenterology,
West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wu Hou District, Chengdu
610041, Sichuan Province, China. hubingnj@163.com
Abstract
In recent years, a wide range of gastrointestinal endoscopy techniques have been
developed, such as endoscopic submucosal dissection (ESD) and endoscopic
retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an
important role in gastrointestinal and biliary diseases, each technique has its
limitations. Hybrid techniques that combine endoscopic and surgical procedures
have emerged that have the advantages of different procedures and negate their
limitations at the same time. Laparoscopic endoscopic cooperative surgery and
modified laparoscopic endoscopic cooperative surgery combine ESD and
laparoscopic techniques to resect submucosal tumors with minimum resection
area. Air leak test by intraoperative endoscopy can effectively identify a
mechanically insufficient anastomosis and decrease the complication rate. The
rendezvous technique that combines percutaneous transhepatic biliary drainage
and endoscopy can be performed as a rescue approach for the treatment of biliary
obstruction, stenosis and bile duct injuries. For patients with simultaneous
presence of stones in the gallbladder and the common bile duct, the laparo-
endoscopic rendezvous technique can perform ERCP and laparoscopic
cholecystectomy at the same time and reduces the risk of pancreatic injury caused
by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression
anastomosis is another choice for biliary obstruction. The most common used
approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-
assisted ERCP is a safe and highly effective therapy for patients who develop
biliary diseases after Roux-en-Y gastric bypass surgery.
Key words: Hybrid technique; Laparoscopic and endoscopic cooperative surgery;
Endoscopic retrograde cholangiopancreatography; Laparoscopic-assisted endoscopic
retrograde cholangiopancreatography; Rendezvous technique; Magnetic compression
anastomosis

Feng YL et al. Hybrid techniques in GI and biliary disease
WJMA https://www.wjgnet.com 211 June 28, 2020 Volume 8 Issue 3
Manuscript source: Invited
manuscript
Received: February 28, 2020
Peer-review started: February 28,
2020
First decision: May 29, 2020
Revised: June 10, 2020
Accepted: June 17, 2020
Article in press: June 17, 2020
Published online: June 28, 2020
P-Reviewer: Skok P
S-Editor: Wang JL
L-Editor: Filipodia
E-Editor: Qi LL
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Core tip: A wide range of hybrid techniques that combine two or more of endoscopy,
laparoscopy and percutaneous transhepatic biliary drainage have been developed. The
hybrid techniques include laparoscopic and endoscopic cooperative surgery, air leak test
by intraoperative endoscopy, magnetic compression anastomosis, the rendezvous
technique and laparoscopic assisted endoscopic retrograde cholangiopancreatography.
This review aims to introduce these hybrid techniques and their applications for the
treatment of gastrointestinal and biliary diseases.
Citation: Feng YL, Li J, Ye LS, Zeng XH, Hu B. Combined
endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in
gastrointestinal and biliary diseases. World J Meta-Anal 2020; 8(3): 210-219
URL: https://www.wjgnet.com/2308-3840/full/v8/i3/210.htm
DOI: https://dx.doi.org/10.13105/wjma.v8.i3.210
INTRODUCTION
In recent years, a wide range of gastrointestinal endoscopy techniques have been
developed, such as endoscopic submucosal dissection (ESD) and endoscopic
retrograde cholangiopancreatography (ERCP). ESD is now widely carried out for early
neoplastic lesions of the gastrointestinal tract and has advantages of minimal invasion,
low cost, patient tolerance and better quality of life of patients[1]. However, ESD is
confined to incision of mucosal and submucosal layers. Laparoscopy is able to perform
the full thickness resection, but sometimes laparoscopy cannot determine the precise
incision line from the peritoneal cavity. ERCP has matured into an essential technique
for managing biliary and pancreatic disorders, but it can be technically difficult in
some situations (e.g., completely biliary obstruction and altered anatomy) where
percutaneous transhepatic biliary drainage (PTBD) may get access to the biliary tree.
In brief, none of these techniques can overcome all the difficulties encountered in
the clinical practice. Therefore, many hybrid techniques that combine two or more of
endoscopy, laparoscopy and PTBD have been developed that have the advantages of
different procedures and negate their limitations at the same time. This review aims to
introduce these hybrid techniques and their applications for the treatment of
gastrointestinal and biliary diseases.
COMBINATION OF ENDOSCOPY AND LAPAROSCOPY
Resecting the gastrointestinal tumors
Gastrointestinal submucosal tumors (SMTs) are frequently seen in patients
undergoing upper gastrointestinal endoscopy[2], and gastrointestinal stromal tumor is
the most common type of SMT[3]. Usually, SMTs are treated by surgical approaches.
Laparoscopic wedge resection has been confirmed a feasible option for SMT < 5 cm[4].
However, localization of small and intraluminal growing SMTs is difficult from the
peritoneal cavity. As a result, excessive resection is needed to ensure the negative
surgical margins, which can cause the deformity of the remaining stomach and gastric
malfunction.
In order to decrease the resection area as much as possible, Hiki et al[5] firstly
reported the conventional laparoscopic and endoscopic cooperative surgery (LECS)
where the resection is performed jointly by the endoscopy and laparoscopy.
Endoscopic submucosal dissection is used in this surgery. Firstly, the periphery of the
tumor is marked by coagulation. Then three-fourths of the marked areas are cut down
to the submucosal layer after submucosal injection. Next, a perforation of the gastric
wall is created artificially, and the tip of the ultrasonically activated device is inserted
into the perforation hole. Then three-fourths of the seromusclar layer is dissected
along the incision line. After the tumor is inverted into the abdominal cavity, the
serosa of the unresected tumor is grasped and retracted, and finally the incision line is
closed by a laparoscopic stapler (Figure 1).
After the emergence of LECS, several modified LECS were developed excessively,

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Figure 1 Conceptual diagram of the classical laparoscopic endoscopic cooperative surgery procedure[14]. ESD: Endoscopic submucosal
dissection. Used with permission from John Wiley and Sons.
including inverted LECS[6], laparoscopic assisted endoscopic full thickness
resection[7,8], combination of laparoscopic and endoscopic approaches for neoplasia
with non-exposure technique[9], non-exposed wall invasion surgery (NEWS)[10] and
closed-NEWS[11]. Based on whether the gastric wall is open during the surgery, these
techniques can be divided into exposed technique and non-exposed technique. Table 1
compares characteristics of these two techniques. Though there are differences among
these techniques, in general they all consist of two main parts that are the ESD
technique and the laparoscopic surgery. The endoscopist determines the precise
margin of the tumor, and then the resection is performed jointly by the endoscopy and
laparoscopy.
As a less invasive approach, LECS has advantages of minimum resecting area and
reserving function of organs at the greatest extent. In addition, LECS can be applied to
tumors located in the esophagogastric junction or pyloric ring that cannot be removed
by laparoscopic wedge resection[12,13]. The exposed LECS has a risk of tumor seeding
and contamination of gastric juice in the peritoneal cavity due to the artificial
perforation of the gastric wall[14]. The non-exposed LECS avoids the gastric open
during the surgery and thus expands the indication of LECS for gastric epithelial
neoplasms[15]. A series of studies on LECS and modified LECS have been conducted,
showing that these techniques are feasible and safe for gastric SMTs[2,16-19].
Besides gastric tumors, LECS has been used to resect tumors in other parts of the
gastrointestinal tract. There are a few reports of LECS for early superficial duodenal
tumors (SDT), showing that this technique may be safe and feasible and could be an
option for surgical SDT resection[37-25]. Standard treatment for SDT has not been
established. Though ESD has been considered safe and effective for early gastric
tumors, ESD for early duodenal cancer is associated with a high risk of perforation
during and after surgery as a result of the narrow lumen and thin walls of the
duodenum[26,27]. In LECS, the laparoscopic suture and monitoring may help to prevent
the occurrence of perforation. Therefore, compared to ESD, LECS might be a safer
approach for the treatment of SDT. For colon polyps and colorectal tumors that cannot
be removed by conventional endoscopic techniques, LECS may also be an alternative
choice[28].
Localization of gastrointestinal tumors
Endoscopic localization is essential in both endoscopic procedures and surgeries. In
laparoscopy, endoscopic tattooing that uses suspensions of carbon particles is a
commonly used approach to localize the tumor during laparoscopy. However,
intraoperative endoscopic localization may be difficult to arrange between endoscopic
and surgical teams. Hu et al[29] reported performing tumor resection using an ultrasonic
scalpel through a gastric fistula formed by percutaneous endoscopic gastrostomy.
Some novel methods may provide other choices for preoperative localization of
tumors. Ohdaira et al[30] applied a magnet-string-clip system to gastric mucosa in 15

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Table 1 Comparison between the characteristic of exposed laparoscopic endoscopic cooperative surgery and non-exposed
laparoscopic endoscopic cooperative surgery
Exposed LECS Non-exposed LECS
Techniques Conventional LECS, Inverted LECS, LAEFR CLEAN-NET NEWS, Closed-NEWS
Opening of gastric
wall
Yes No No
Advantages Minimum resection area; more evidence of efficacy
and feasibility
Non-exposed Precise resection of both serosal and
mucosal layers
Limitations Possibility of tumor seeding and gastric juice
contamination into the abdominal cavity
Potential risk of margin positive or
excessive resection
Not applicable to tumor > 3 cm due
to peroral retrieval
LECS: Laparoscopic endoscopic cooperative surgery; LAEFR: Laparoscopic assisted endoscopic full thickness resection; NEWS: Non-exposed wall invasion
surgery; CLEAN-NET: Combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique.
patients with early gastric cancer, and the tumor site was detected in all cases during
laparoscopic gastrectomy. Hyun et al[31] introduced an endoscopic fluorescent band
ligation method. The fluorescent rubber bands were endoscopically placed on the
mucosa of porcine stomachs and colons, and the bands were clearly identified using
the near-infrared fluorescence laparoscopy system during subsequent surgery.
Air leak test by intraoperative endoscopy
Anastomotic leak (AL) is one of the most frequent and devastating complications after
many gastrointestinal surgeries[32,33]. Among measures that have been used to prevent
AL, intraoperative air leak test (ALT) is the most widely used to identify a
mechanically insufficient anastomosis[32]. The bowel proximal to the anastomosis is
clamped, and then air is insufflated into the bowel lumen using a syringe or endoscope
with the anastomosis under irrigation of saline. Leakage is detected by the bubbles
arising from the anastomosis.
Compared to syringe, the intraoperative endoscopy can simultaneously provide air
insufflation with adequate and steady pressure for ALT[33]. More importantly, it
enables real-time assessment of anastomotic integrity, bleeding, vascular insufficiency
and allows for repeatability if a leak is repaired[34]. The intraoperative ALT is easy,
quick and associated with little or no risk[35]. One prospective randomized controlled
trial showed that intraoperative endoscopy had significant lower rate of AL and lower
need for reoperation than simple visual inspection in laparoscopic Roux-en-Y gastric
bypass (RYGB)[36]. For colorectal surgeries, intraoperative endoscope has also been
confirmed safe and effective[37-39].
COMBINATION OF ERCP AND PTBD
Rendezvous technique
ERCP has become the first choice of treatment for many biliary diseases, including bile
duct injuries, obstruction and stenosis. Endoscopic treatment of the biliary stricture
relies on initial passage of a guidewire across the stricture, followed by subsequent
stricture dilation and stent placement[40]. However, this maneuver is not possible when
the biliary duct is completely obstructed or transected. The rendezvous technique
could be a choice for the recanalization of bile duct in this situation.
The rendezvous technique that combines endoscopic and percutaneous transhepatic
approach was initially described for duodenoscopic sphincterotomy in the 1980s[41,42]. A
guide wire is placed via the PTBD route, advanced into the duodenum, then grasped
by grasping forceps or snares of the duodenoscope and pulled out of the
duodenoscope. Then a catheter is advanced into the bile duct over the guidewire for
drainage. Stents or balloons can also be placed to dilate the stricture of the bile duct.
The procedure can also be completed in a reverse way where a guide wire placed
endoscopically is grasped and pulled out through the PTBD route[43,44].
Because the guide wire may be damaged during withdraw and the procedure is
cumbersome, a few modified techniques have been developed to avoid these
problems, such as parallel cannulation technique[45-47]. With the advance in endoscopic
ultrasonography (EUS) technology, the EUS guided rendezvous technique has been

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developed, where the bile duct is punctured under the EUS guidance, and a guide
wire is advanced antegrade through the papilla to perform a transpapillary
procedure[48].
The rendezvous technique increases the success rate of biliary duct cannulation and
facilitates the treatment of biliary tract diseases. It is reported with a high technical
success rate of 80%-100%[49-53] and a significantly lower complication rate when
compared to percutaneous transhepatic cholangiography[53]. The rendezvous technique
can also be used to establish the continuity of the bile duct when surgical bile duct
injury occurs, with a high primary success rate and a long term success rate of 55%[44].
Besides recanalization of bile ducts, the rendezvous technique is also reported to
remove stones in the bile ducts[43,54,55]. Lithotomy by percutaneous transhepatic
approach was performed firstly, but there were stones remaining in the intrahepatic
duct or common bile duct (CBD). After the guide wire was grasped, the endoscopy
was inserted further with the guide wire into the hepaticojejunostomy anastomotic
region or CBD and lithotomy was performed for the remaining stones.
Magnetic compression anastomosis
Besides the rendezvous technique, biliobiliary and bilioenteric anastomosis using
magnetic compression anastomosis (MCA) is another choice for the treatment of
severe biliary strictures or complete obstructions. The working principle of MCA is
that the magnetic compression force leads to gradual tissue necrosis within magnets
while with tissue healing at the edge of the magnet simultaneously[56].
Two magnets are needed for the procedure, parent and daughter magnet. These two
magnets can be delivered by a variety of methods, but the most common route is by
the percutaneous-peroral approach[57]. One magnet is delivered through the PTBD
route into the anastomosis site, and the other magnet is delivered endoscopically.
When inserting a magnet into the CBD, full sphincterotomy or balloon dilation is
usually required, and a metal stent may be inserted to facilitate further magnet
delivery[58,59]. After recanalization and magnets removal, biliary stents can also be
placed to prevent restenosis[59].
Bilioenteric anastomosis is a common operation to bypass extrahepatic biliary
obstructions[60]. The conventional hand-sewn is time-consuming and associated with a
high risk of complications[60]. In contrast, the MCA is considered to be associated with
little complication because fistula formation after MCA requires a relatively long time.
Also, there is no dilation of fibrotic tissue in the progress of fistula formation, so the
risk of restenosis upon recoiling of fibrotic tissue is low[57].
COMBINATION OF ERCP AND LAPAROSCOPY
Laparoscopic-assisted ERCP
RYGB surgery is one of the most common bariatric procedures to treat obesity[61].
However, the patients have a high risk of biliary disease with up to 40% developing
symptomatic cholelithiasis[61,62]. In addition, ERCP is challenging due to the surgically
altered anatomy. Laparoscopic-assisted ERCP (LA-ERCP) is an option for these
patients.
A gastrostomy is performed by the laparoscopy, and a port is placed into the
remnant stomach. Then ERCP is performed by a conventional side-view
duodenoscope via this port (Figure 2). After completion of the procedure, the port is
removed, and the defect is closed by a suture or stapler. The transgastric route is
commonly used to perform the LA-ERCP, and transjejunal route has also been
reported[63]. Because the jejunal loop can easily reach the abdominal wall, the
transjejunal LA-ERCP can be performed in all Roux-en-Y cases, even when the gastric
remnant is not attainable. However, the transjejunal route needs a colonoscope to
reduce the risk of intestinal injuries as a result of limited visual field of side-viewing of
the duodenoscope.
LA-ERCP is a safe and highly effective therapy for patients who develop biliary
diseases after RYGB surgery[64]. One advantage of LA-ERCP is the high successful rate,
which was reported to be approximately 90%-100%[65]. Another one is that the
successful rate remains high in long-limb reconstruction cases because a limb length of
> 150 cm is associated with a high failure rate in other ERCP techniques[66]. In addition,
LA-ERCPs would be favored if the patient also requires cholecystectomy. Therefore,
LA-ERCP is preferred in patients with long limbs who require concomitant
cholecystectomy[65].

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Figure 2 Laparoscopic-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy[73].
Laparo-endoscopic rendezvous technique
The simultaneous presence of stones in the gallbladder and the CBD is a common
clinical circumstance[67]. ERCP and laparoscopic cholecystectomy (LC) are considered
as standard approaches to treat CBD stones and gallstones, respectively[68,69]. To
perform ERCP and LC at the same time, the rendezvous intraoperative ERCP with
transcystic guide-wire-assisted cannulation technique was developed as a one-stage
intervention[70,71]. An antegrade guidewire is inserted and advanced through Vater’s
papilla into the duodenum by a surgeon. Subsequently, the guidewire is grasped by a
snare and pulled out through the working channel of the duodenoscope and then
cannulation of the CBD is performed.
The major advantage of the rendezvous procedure is a lower risk of pancreatic
injury caused by the ERCP. The transcystic guide wire facilitates the endoscopic
procedure and thus ensures elective CBD cannulation and avoids the inadvertent
cannulation of the pancreatic duct. In addition, the antegrade approach avoids the
problem of discordant patient positioning encountered when ERCP and LC are
performed at the same time but separately. A recent meta-analysis compared different
combinations of laparoscopic and intraoperative techniques (LC plus preoperative,
intraoperative and postoperative ERCP and LC plus laparoscopic CBD exploration)
and showed that the rendezvous approach was associated with the highest rates of
safety and success[67]. The major limitation is that an experienced endoscopist may not
be available for the procedure, and it may be difficult to arrange and carry out the
rendezvous procedures in the operating room[68,72]. Moreover, using intraoperative
cholangiography to detect CBD stones is essential before performing the rendezvous
procedure[68]. Therefore, in centers where preoperative ERCP is routinely used to
detect CBD stones, this technique is not applicable.
CONCLUSION
A wide range of hybrid techniques have been developed for the treatment of
gastrointestinal and biliary diseases. These techniques expand the indications of
therapeutic endoscopy, make it easier and safer to perform difficult procedures and
decrease the agony of patients. Some of the techniques are only reported in few cases
and further detailed evaluation of feasibility and efficacy is needed. For those that
have been confirmed safe and effective, how to choose between hybrid techniques and
conventional methods could be difficult. Further prospective investigations should be
conducted to determine the best treatment options.
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