Introduction

In recent years, the indications for endoscopic papillectomy (EP) have expanded, and additional ablation such as radiofrequency ablation (RFA) have been reported for residual tumors that have extended into the pancreatic duct or common bile duct after EP. However, RFA may cause adverse events due to excessive heat, highlighting the need for safe and reliable methods to manage intraductal lesions.

Aims & Methods

This study aimed to assess the efficacy and safety of additional ablation using a papillotome and bipolar hemostatic forceps for residual neoplasms in the pancreaticobiliary tract following EP of ampullary tumors. We retrospectively reviewed patients who underwent ablation for residual pancreaticobiliary lesions following endoscopic papillectomy (EP) between January 2017 and March 2023. Intraductal ablation was performed using a papillotome for endoscopic sphincterotomy in Spray Coagulation mode (VIO 3; Elbe) and bipolar hemostatic forceps (Hemostat-Y: PENTAX). Clinical data, including adverse events, were collected retrospectively. After EP, endoscopic papillotomy and endoscopic pancreatic ductotomy were performed either on the same day or within seven days as needed to expose intraductal lesions. The bipolar forceps were energized with the forceps open without grasping the tissue. The tube stent was removed during treatment, and a guidewire was inserted to stabilize the procedure and facilitate sequent stent replacement. This approach prevents excessive thermal damage to deeper tissue layers by applying heat to the targeted tumor tissue with the Bipolar forceps cup open. While the sparks from the papillotome reach the upper left half of the duct, they do not extend to the lower right half; therefore, bipolar hemostatic forceps were applied to address this problem in the lower right half of the pancreatic or common bile duct.

Results

The median lesion size was 18 mm (interquartile range: 13-21 mm). Residual pancreaticobiliary extension lesions had a median size of 13 mm (interquartile range: 8-15 mm) in the common bile duct and 7 mm (interquartile range: 6-10 mm) in the pancreatic duct. Adverse events were observed in 3 patients (11.5%), with one experiencing delayed bleeding and three developing symptomatic biliary stricture. The median follow-up period was 311 days. During the follow-up, one patient with T1 carcinoma that invaded the sphincter of Oddi experienced recurrence in the pancreatic duct. No local recurrence was detected in the other patients via endoscopy or computed tomography.

Conclusion

Ablation using a papillotome and bipolar hemostatic is a safe and effective method to treat residual intraductal pancreaticobiliary extension lesions after EP. However, more studies are needed to confirm these findings.

References

Yang MJ, Kim JH, Yoo BM, et al. Long-term outcomes of endoscopic papillectomy with or without radiofrequency ablation for ampullary adenomas: a retrospective multicenter study. Gut Liver. 2020;14(2):257-263.
Ma S, Wang W, Wang X, et al. Endoscopic radiofrequency ablation for residual or recurrent ampullary adenomas after endoscopic papillectomy. J Gastroenterol Hepatol. 2019;34(10):1790-1795.

Introduction

Endoscopic papillectomy (EP) is indicated for papillary adenoma that do not extend into the pancreatic bile duct. There are cases in which en bloc resection or curative resection is expected to be difficult with conventional EP. For such cases, we introduced hybrid EP, in which snaring is performed after peri-lesion incision using a dedicated ESD knife.

Aims & Methods

A total of 13 cases who underwent hybrid EP between 2022 and 2024 were identified from our prospectively maintained database. Hybrid EP involved a circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated.

Results

En bloc resection was achieved by hybrid EP in all 13cases, with the median procedure time of 118 (range: 65-170) minutes. The median diameters of the resected specimens and tumors were 25 and 15 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in one (7.6%), resulting in the complete resection rate of 92.4%. Postoperative bleeding developed in two (15.3%). No tumor recurrence was observed even in that case with uncertain vertical margin, after a median follow-up of 244 (range, 97-678) days.

Conclusion

Hybrid EP is an useful technique for duodenal papillary tumors that are difficult to resect en bloc or curatively by conventional EP.
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Introduction

Common bile duct (CBD) stones are one of the most frequent indications for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic complete sphincterotomy (EST) followed by balloon or basket extraction is widely considered the gold standard technique for the treatment of CBD stones; being successful in more than 90% of cases with approximately 5% overall rate of adverse events [1]. Endoscopic papillary large balloon dilatation (EPLBD) is an effective technique in treating large common bile duct (CBD) stones. However, the efficacy and safety of EPLBD in the setting of periampullary diverticula (PAD) are prospectively lacking.

Aims & Methods

This study aimed to compare the effectiveness and short-term safety of EPLBD after limited sphincterotomy with those of EST for extracting large CBD stones in the setting of PAD prospectively. Forty-eight patients with large CBD stone(s) > 1 cm were recruited. All patients had a PAD. Before the procedure patients were evaluated by history taking, clinical examination full investigations including proper imaging studies. During the procedure, patients were randomized to either group I; patients treated with EPLBD after limited sphincterotomy, and group II; patients treated with EST. CBD clearance was defined as a single procedure (EPLBD vs EST), single session (no repeat ERCP), and non-assisted (no lithotripsy used) stone extraction. After the procedure patients were hospitalized with clinical, laboratory, and imaging assessment.

Results

Table 1: Univariate regression of the parameters affecting stone extraction

PAD: periampullary diverticulum			* significant as P value≤ 0.05
	Odds ratio	95% CI	P value​
The used technique	5.92	1.32 to 25.3	0.009∗
Stone (s) number	0.62	0.17 to 2.25	0.468
Stone (s) diameter (mm)	2.59	0.63 to 10.56	0.187
Type of PAD​	1.32	0.65 to 2.67	0.437

The overall stone extraction rate in the current study was only 77.3% (n=34). The efficacy of stone extraction was significantly higher in the EPLBD (n= 21,87.5%) group compared to EST (n= 13, 54.17%) group (p = 0.011). The procedure-related adverse events were lower in the EPLBD group compared to the EST group. Pancreatitis was significantly higher in the EST (n=14, 58.33%) group than in the EPLBD (n=3, 12.5%) group (p= 0.001). There were no perforations or case fatalities in either group. The predictors of stone extraction were analyzed using univariate regression (Table 1), and it is noticeable that the used technique was the independent predictor of success in stone extraction (Odds Ratio: 5.92, 95% Confidence Interval: 1.38 to 25.30, p-value = 0.009).

Conclusion

The current practice guidelines of the ESGE and ASGE suggest that for large CBD stones, an EST followed by a large balloon dilatation is preferable to EST alone because combining dilatation with EST improves duct clearance and reduces the need for lithotripsy without adding risk. Our results among PAD patients seem to echo this: the EPLBD approach in comparison to EST yielded higher stone clearance on first attempt even without using lithotripsy by the study design. Hence, based on the current study these existing recommendations can be extrapolated to the PAD population based on our study which is one of the first randomized trials in the specific PAD subgroup.

References

1. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD). Clin Ter. 2014;165(4):e291-4.

Introduction

Endoscopic removal of common bile duct stones (CBDS) via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. In developed countries, the number of ERCP procedures for CBDS in elderly patients is increasing with the aging population. Elderly patients often present with poor performance status (PS), are frequently on antithrombotic therapy, and have multiple comorbidities. These factors raise concerns about an increased risk of ERCP-related complications; however, the safety and efficacy of ERCP in this population have not been fully evaluated.

Aims & Methods

The aim of this study was to assess the outcomes of ERCP for CBDS in elderly patients. Among 548 patients with symptomatic CBDS treated at our institution between April 2017 and February 2024, we excluded 81 cases involving altered anatomy, use of endosonography-assisted rendezvous technique, spontaneous stone passage, and biliary pancreatitis. The remaining 467 patients undergoing ERCP at our institution were retrospectively analyzed. The patients were divided into an elderly group (E group: ≥75 years, n=241) and a younger group (Y group: <75 years, n=226), and short- and long-term outcomes were compared between the two groups.

Results

Patient Characteristics: The median age was 81 years (range: 75–99) in the E group and 68 years (range: 21–74) in the Y group. Male sex was less frequent in the E group (55% vs. 68%, p=0.006). The E group had significantly higher rates of antithrombotic use (39% vs. 24%, p=0.001), American Society of Anesthesiologists physical status ≥ III (57% vs. 35%, p=0.001), and concomitant cholangitis (52% vs. 41%, p=0.012). Median stone size was slightly larger in the E group (8 mm vs. 6 mm, p=0.14), and the median bile duct diameter was significantly wider (10 mm vs. 9 mm, p=0.001). Comorbidities were more prevalent in the E group: cardiovascular disease (34% vs. 22%, p=0.004), hypertension (52% vs. 39%, p=0.004), malignancy (33% vs. 18%, p=0.001), and dementia (11% vs. 2%, p=0.001). Although endoscopic sphincterotomy (EST) was the most common papillary intervention in both groups, endoscopic papillary large balloon dilation (EPLBD) was more frequently performed in the E group (31% vs. 10%).Lithotripsy rates were similar between groups (22% vs. 16%, p=0.2).
Outcomes: Complete stone removal was achieved in 96% of the E group and 98% of the Y group (p=0.2). The median number of treatment sessions was 1 in both groups (range: 1–3, p=0.13). Overall complication rates were comparable (8% vs. 7%, p=0.63). In the E group, complications included pancreatitis (n=15), bleeding (n=5), perforation (n=1), and aspiration pneumonia (n=1); in the Y group, pancreatitis (n=10) and bleeding (n=5) were observed. No procedure-related mortality occurred in either group. There was no significant difference in the cumulative recurrence rate of stones after complete removal (p=0.29). Multivariate analysis using variables such as age, sex, presence of cholangitis, bile duct diameter, lithotripsy, and gallbladder stones revealed no definite predictors of recurrence.

Conclusion

Although recent studies have reported the potential utility of long-term biliary stenting in elderly patients, stent occlusion leading to cholangitis remains a concern. Repeated hospitalizations in elderly patients can decrease activities of daily living. Therefore, we prioritize complete stone removal in patients with a favorable long-term prognosis. This study demonstrates that even in patients aged 75 years and older, active treatment of CBDS via ERCP might be effective and safe.

Introduction

Endoscopic papillary large balloon dilatation (EPLBD) is an established technique for managing difficult common bile duct (CBD) stones. This study evaluates the efficacy and safety of EPLBD in a large cohort from a tertiary care centre.

Aims & Methods

Patients with difficult CBD stones (N = 559) who underwent EPLBD between January 2015 and December 2024 were retrospectively analysed from a prospectively maintained database. The primary outcome was complete CBD clearance. Secondary outcomes included complication rates, number of sessions required, and need for mechanical lithotripsy or surgical intervention. We also identified predictive factors for failed clearance and complications.

Results

The cohort had a mean age of 47.8 ± 14.6 years; 75% were female. The mean diameter of the largest CBD stone was 15.1 ± 4.2 mm, with an average of 2.16 ± 1.7 stones per patient. Mean CBD diameter was 15.1 ± 3.1 mm, and the average balloon size used was 14.8 ± 1.7 mm. Complete clearance was achieved in 84.9% (475/559) of the patients in a single session and in 89.9% (503/559) of the patients overall. Mechanical lithotripsy achieved additional clearance in only 11(2.5%) patients. Complications occurred in 34(6.1%) patients: perforation (n=18,3.2%), bleeding (n=15,2.7%), and pancreatitis (n=1,0.2%). Procedure-related mortality was observed in three (0.5%) patients (perforation, n=2; bleeding, n=1). Regression analysis identified larger stone size as a predictor of clearance failure (OR: 1.10; 95% CI: 1.03–1.17; p = 0.004) and need for repeat intervention as a predictor of complications (OR: 4.49; 95% CI: 1.68–11.99; p = 0.003).

Conclusion

EPLBD is a safe and effective approach for the management of difficult CBD stones. It offers high success rates with acceptable complication rates, making it a valuable one-stop management for difficult CBD stones, particularly in resource-constrained settings.

Introduction

Management of poscholecystectomy complications has been variably discussed. Various options exist but the recent trend has been towards the endoscopic retrograde approach favoring a simultaneous diagnostic and therapeutic potential.

Aims & Methods

The outcome of endoscopic biliary dilatation and stent insertion for postoperative bile duct injuries was retrospectively evaluated.
Seventy-nine patients with biliary stenosis postcholecystectomy laparoscopic were included from January 2015 to December 2024. One to five stents were inserted for average of 12 months, with stent exchange every three months to avoid chlolangites caused by obstruction.

Results

Endoscopic stricture stent insertion successful was achieved in 76/76 (100%) patients. No procedure-related mortality was observed. The endoscopic therapy was feasible only in 76/76 the success rate was 100%. Endoscopic treatment was interrupted in three patients. Stricture relapse occurred in nine patients. Early complications occurred in three patients (1 perfuration, 1cholangites 1 stent migration) and stent occlusion that required early exchanges occurred in 6 patients.

Conclusion

Endoscopic retrograde cholangiopancreatography is a safe and feasible mode of therapy for patients presenting with suspected bile duct injuries. This form of intervention should be considered as the initial step in the diagnosis and treatment of postchlocystectom laparoscopic complications.

Disclosure

No conflict of interest

Introduction

Endoscopic papillectomy (EP) for duodenal ampullary tumors is primarily performed for lesions confined to the papilla, particularly adenomatous changes. However, early complications such as bleeding (0-21.6%), pancreatitis (0-23.1%), and perforation (0-8.3%) occur at relatively high rates. Post-EP bleeding, due to anatomical characteristics of the ampulla of Vater, can be challenging to manage and may worsen, making it critical to identify factors associated with this complication to reduce its frequency.

Aims & Methods

The study aimed to investigate the factors associated with post-endoscopic papillectomy bleeding in patients with ampullary tumors. This study included 39 patients (39 lesions), excluding residual and accessory ampullary lesions, who underwent EP at our institution between March 2011 and October 2024. We evaluated univariate analysis and SHAP values based on tree-based models for several factors related to post-EP bleeding. Hyperparameters of each model were optimized by optuna, and those models were trained with the Python package scikit-learn (version 1.3.0).

Results

The cohort included 1 adenocarcinoma, 32 adenomas, 1 neuroendocrine neoplasm, and 5 cases of ampullary inflammation, with a mean age of 66.7 years (23 males, 16 females). Patient factors included: The American Society of Anesthesiologists (ASA) Physical Status Classification I/II/III in 5/21/13 participants, median Charlson Comorbidity Index (CCI) of 1 (range 0-7), 15 cases with a history of alcohol consumption, median Brinkman Index of 100 (range 0-1680), median total bilirubin of 0.7 mg/dL (range 0.2-2.1), median serum amylase of 80 IU/L (range 36-296), median platelet count of 198,000/μL (range 113,000-494,000), median PT-INR of 0.98 (range 0.86-1.14), median APTT of 28.7 seconds (range 23.0-39.4), median CEA of 1.9 ng/mL (range 0.3-12.8), and median CA19-9 of 7.7 U/mL (range 0.8-76.4). Antithrombotic agents were used in 4 participants (1 on low-dose aspirin, 1 on clopidogrel, and 2 on direct oral anticoagulants), and periampullary diverticula were observed in 3 cases. Median tumor size was 10.3 mm (range 2.0-45.0). Procedural factors included a median total procedure time of 56 minutes (range 23-230), with 36 cases receiving endoscopic biliary stenting and 38 cases receiving endoscopic pancreatic duct stenting. The electrosurgical units ICC200/VIO300D/VIO3 were used in 9/19/11 cases, respectively. Protease inhibitors were used in 9 participants, NSAID suppositories (25mg/50mg) in 5/24 cases, and local hemostatic measures included epinephrine spray in 8 cases, thrombin spray in 8 cases, and hemostatic peptide solutions in 5 cases. Clipping for ulcer after resection was performed in 33 cases. Post-EP bleeding within 30 days occurred in 12 cases (30.8%), including 9 moderate and 3 severe cases. Univariate analysis revealed that a history of alcohol consumption was significantly associated with post-EP bleeding (Odds ratio [OR] 2.33, 1.14-4.79, P = 0.02). Feature importance was evaluated using the mean absolute SHAP values across all participants. In the Random Forest model, the top contributing features were CA19-9 (mean |SHAP| = 0.026), CCI (mean |SHAP| = 0.024), and a history of alcohol consumption (mean |SHAP| = 0.023). In contrast, the XGBoost model identified tumor size (mean |SHAP| = 0.315), a history of alcohol consumption (mean |SHAP| = 0.244), and platelet count (mean |SHAP| = 0.198) as the most important features.

Conclusion

In our cohort, a history of alcohol consumption is a robust factor associated with post-endoscopic papillectomy bleeding.