Introduction

Insufficient disinfection of duodenoscopes, particularly the elevator site, can cause ERCP-related infections and serve as a significant source of multidrug-resistant (MDR) infection. To address this issue, a disposable elevator cap (DEC) was developed, and a recent randomized clinical trial demonstrated its effectiveness in reducing contamination following high-level disinfection. However, there is limited evidence in actual clinical practice to reduce cholangitis caused by MDR pathogens. This study aimed to compare the efficacy of the novel DEC duodenoscope with the standard duodenoscope in preventing infection transmission.

Aims & Methods

We conducted a prospective non-randomized cohort study in a single institution comparing baseline characteristics, technical performance, and incidence of acute cholangitis, including MDR pathogen, in 95 patients using a standard duodenoscope and 101 patients using a DEC duodenoscope.

Results

Age, sex, comorbidities, and indication for ERCP were similar between the two groups. However, the standard duodenoscope group had a higher proportion of naïve papilla (51% vs. 34%, p = 0.04), while the technical success rate was slightly higher in the DEC duodenoscope group (95% vs. 85%, p = 0.15). The rates of procedure-related adverse events were similar between the two groups (16% for DEC vs. 15% for standard). The incidence of post-ERCP cholangitis was also similar (10% for DEC vs. 11% for standard, p = 0.90). The proportion of post-ERCP cholangitis caused by MDR pathogens was similar in the two groups (1% for DEC vs. 2% for standard, p = 0.39).

Conclusion

​This study suggests that the technical performance of the DEC duodenoscope is similar to that of the standard duodenoscope. However, more clinical data are needed to confirm the efficacy of the DEC duodenoscope in preventing ERCP-related infection transmission.

Disclosure

Research grant from PENTAX MEDICAL

Introduction

Treatment and follow-up strategies for silent gallbladder (GB) stones in patients prior to kidney transplantation (KT) have not been established.

Aims & Methods

We performed a retrospective cohort analysis comparing the risk of gallstone-related biliary complications and complications after cholecystectomy in KT recipients. By obtaining this information, we expected to evaluate the role of prophylactic cholecystectomy in KT recipients. A total of 2,295 KT recipients at Seoul National University Hospital from January 2005 to July 2022 were evaluated. Silent gallstones were identified from abdominal images(US, CT or MRI) 3 years before and 1 year after KT. The main outcome was the incidence of biliary complication and post-cholecystectomy complications and their severity in KT recipients. Secondary outcomes included death-censored graft failure (DCGF), graft failure (GF), and all-cause mortality. The Fisher exact test was used to assess the significance of the incidence of postoperative complications. The Kaplan-Meier (KM) curve was plotted for biliary complication-free survival in the observation group. The Cox proportional hazards model was used to identify risk factors associated with biliary complications in the observation group. A P<0.05 was considered indicative of statistical significance. All analyses were performed using the IBM SPSS Statistics 27.

Results

A total of 230 patients with gallstones were enrolled in this study. Among them, 16 underwent cholecystectomy prior to KT and 214 were followed without any intervention or surgery. Of the 214 patients observed, the median follow-up was 73.8 months and biliary complications occurred in 20 patients, with an incidence rate of biliary complications of 9.3%. 20 had acute cholecystitis, 2 had acute cholangitis, and 3 had gallstone pancreatitis. When cholecystectomy was performed, the incidence rates of postoperative complications were 6.3% in the pre-KT cholecystectomy group and 38.8% in the post-KT cholecystectomy group, respectively (p = 0.04). The severity of postoperative complications was based on the Clavien-Dindo classification, and the post-KT cholecystectomy group had a higher incidence of fatal complications greater than grade 4 compared to the pre-KT cholecystectomy group. Patients with multiple GB stones (adjusted hazard ratio [aHR] 2.46, 95% CI 1.56-8.30, p = 0.04), GB wall thickening ([aHR] 5.41, 95% CI 1.63-17.91, p = 0.006) and large GB stones greater than 1 cm ([aHR] 5.55, 95% CI 2.02-15.23, p = 0.001) were more likely to have biliary complications.

Table 4. List of postoperative complications in pre-KT and post-KT cholecystectomy group

Conclusion

Gallstone-related biliary complications and subsequent cholecystectomy after kidney transplantation results in more serious complications and worse treatment outcomes. Therefore, it may be helpful to recommend prophylactic cholecystectomy for KT candidate with significant risk factors for biliary complications, such as multiple gallstones, large gallbladder stone greater than 1cm or Gallbladder wall thickening.

References

1. Weaver L, et al. Kidney and pancreas transplant recipients undergoing cholecystectomy experience superior outcomes in transplant centers. HPB (Oxford). 2021;23(4):609-617.
2. Rinaldis A, et al. Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population. Transplant Proc. 2021;53(7):2291-2297.
3. Sarkio S, et al. Complications of gallstone disease in kidney transplantation patients. Nephrol Dial Transplant. 2007;22(3):886-890.
4. Sianesi M, et al. The role of cholecystectomy in renal transplantation. Transplant Proc. 2005;37(5):2129-2130. doi:10.1016/j.transproceed.2005.03.028
5. Kao LS, et al. Should cholecystectomy be performed for asymptomatic cholelithiasis in transplant patients?. J Am Coll Surg. 2003;197(2):302-312.
6. Kao LS, et al. Prophylactic cholecystectomy in transplant patients: a decision analysis. J Gastrointest Surg. 2005;9(7):965-972.
7. Jackson T, et al. Management of asymptomatic cholelithiasis for patients awaiting renal transplantation. Surg Endosc. 2005;19(4):510-513.
8. Sarkio S, et al. Complications of gallstone disease in kidney transplantation patients. Nephrol Dial Transplant. 2007;22(3):886-890.
9. Greenstein SM, et al. Prevalence of asymptomatic cholelithiasis and risk of acute cholecystitis after kidney transplantation. Transplantation. 1997;63(7):1030-1032. doi:10.1097/00007890-199704150-00023
10. Melvin WS, et al. Prophylactic cholecystectomy is not indicated following renal transplantation. Am J Surg. 1998;175(4):317-319.

Disclosure

1

Introduction

Infection related morbidity and mortality is still a major hazard associated with the standard re-usable duodenoscopes used for endoscopic retrograde cholangiopancreatography (ERCP). The single use duodenoscope (SUD) has been developed as a potential disposable instrument for preventing cross-transmission of infections via contaminated devices in high-risk patients. However, data for the use of SUD in real-world practice is very scarce.

Aims & Methods

In this study we aimed to assess our single centre experience with SUDs in patients underwent ERCPs, in terms of performance and safety. We included all the patients who underwent ERCP with the use SUD (Boston Scientific designed EXALT Model D) between October 2020 and February 2023 at Cambridge University Hospitals. Based on the retrospective review of procedure notes, outcomes were analysed with regards to procedure indication, success rate for the intended clinical indication, interventions performed, and adverse events. The SUD was used when prespecified institutional criteria (immunocompromised patient, multi drug resistant infection or failed procedure with standard re-usable duodenoscopes) were met or when there was no reusable duodenoscopes available at the time of procedure.

Results

The SUD was used in total of 34 patients during the study period. Baseline patient characteristics and procedure details are shown in Table 1. 59% of the patients were females. The median age was 64.5 years. Nineteen patients (56%) had a native papilla. The most common indication for the ERCP was choledocholithiasis (12, 35%) followed by benign biliary stricture (11,32%), head of pancreas tumor (6, 18%) and cholangiocarcinoma (4,12%).
28 out of 34 (82%) procedures achieved technical success. 20 procedures (59%) had the SUD used as the primary endoscope and 19 were successful (95%). In the other 14 cases (41%) SUD was used after the standard re-usable duodenoscopes due to anatomical problems encountered preventing progression of the procedure and of these 9 (64%) were completed successfully. In 5 of these (83%), failure occurred due to distorted duodenal anatomy which did not allow the scope to reach a favorable position.
Regarding the post procedure adverse events, 5 patients (15%) developed post procedure pancreatitis, two (5%) developed cholangitis and one patient (2%) had post sphincterotomy bleeding .

Conclusion

The SUD may be an effective tool in patients with distorted gastro-duodenal anatomy with failure when using a re-usable duodenoscopes. The reason for this may be due to the diameter and stiffness of the SUD. It was observed that SUDs are associated with comparably higher rates of adverse events in this study group due to the technical difficulty of the procedures. In addition to the fact that SUD eliminates the risk of device-related infection transmission, it appears to represent a reliable and effective alternative to standard re-usable duodenoscopes for a variety of indications and levels of difficulty.

Disclosure

Dr Corbett received honorarium from Boston Scientific previously.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is performed with reusable duodenoscopes and, infections due to colonization of the endoscope are an increasing problem. The single-use EXALT Model D duodenoscope (Boston Scientific Corporation, USA) has been recently developed to avoid the risk of cross-transmission and the need for endoscope reprocessing.
The aim of this study is to report the experience of a high-volume endoscopy center in the use of this new device.

Aims & Methods

This is a retrospective observational study performed at a single high-volume endoscopy center. All consecutive patients undergoing ERCP performed with EXALT single-use duodenoscope by expert endoscopists from April 2010 to November 2022 were reviewed from a prospectively maintained ERCP database. Demographic and technical data, indications, AEs, and ERCP success rate were recorded. Statistical analysis was performed with SPSS 20 software. Descriptive data are reported as mean/median ± standard deviation/range, or percentage.

Results

Nineteen patients were included (4 children with an age of 7, 7, 11, 17). Patients’ characteristics are summarized in Table 1. Post-Liver transplantation immunodeficiency was the most common indication for the use of disposable duodenoscope (9, 47.3%), followed by SARS-CoV2 infection (6, 31.5%) (cases performed during the weekend with difficult access to reprocessing) and immunodeficiency (4, 21%). Twelve native papillae were recorded (63.1%) undergoing biliary sphincterotomy in 10 cases (52.6%) and pancreatic sphincterotomy in 1 case (5.2%). In 1 case (5.2%) precut was needed after cross-over to reusable duodenoscope. Seven cases of non-native papilla were recorded (36.8%). ERCP was completed with the single use duodenoscope in 17 cases (87.4%). In two cases a cross-over to standard duodenoscope was needed for technical failure of the insufflation valve and for the impossibility to achieve a long-route position in the second case, to approach a papilla at the inferior duodenal genu. One case of delayed bleeding (5.2%) managed endoscopically, and 1 case of post-ERCP pancreatitis (5.2%) managed conservatively, were recorded.

Table 1: Patients characteristics (n: number, LT: liver transplantation, AEs: adverse events).

Conclusion

EXALT single use duodenoscope resulted efficient and safe in the management of bilio-pancreatic diseases, also in children. However, the scope leads to some difficulties when used in non-standard anatomical scenarios. The real advantages of disposable duodenoscope and the environmental/cost impact are still controversial issues, and more studies are need for conclusive data.

Introduction

ERCP is effective for common bile duct stone treatment but carries post-op risks like pancreatitis and cholangitis. Biliary drainage post-surgery is vital, with methods like ENBD and ERBD being common. ENBD allows monitoring but has drawbacks like infection and inconvenience. ERBD mitigates these but can cause complications. A new solution, Detachable biliary plastic stents without flanges, uses soft materials for self-expulsion, reducing the need for further procedures and patient burden.

Aims & Methods

This study aimed to investigate the efficacy and safety of using detachable biliary plastic stents without flanges for the prevention of cholangitis following endoscopic retrograde cholangiopancreatography (ERCP) in patients with common bile duct stones.
The study cohort comprised patients diagnosed with common bile duct stones and treated at the First People's Hospital affiliated with West Lake University School of Medicine between January 2019 and January 2024. Participants were randomly assigned to either the group receiving detachable biliary plastic stents without flanges or the nasobiliary drainage group. In the former group, the stents were deployed for biliary drainage following the clearance of stones during ERCP. The latter group received nasobiliary drains for similar purposes. Comprehensive clinical data were gathered, encompassing preoperative and postoperative details, including laboratory investigations, endoscopic procedures, complications, hospital stay, and comfort levels assessed using the Visual Analogue Scale (VAS). Additionally, the incidence of cholangitis, the rate of spontaneous drain removal, and stent detachment were compared between the two groups.

Results

1. The study included 820 patients who underwent ERCP for common bile duct stones. After accounting for 10 patients lost to follow-up, a total of 810 patients were analyzed, with equal distribution across both study groups. The incidence of postoperative cholangitis was 2.0% in the stent group and 3.0% in the nasobiliary drainage group, showing no significant difference (P=0.365). Pancreatitis occurred in 2.7% of patients in the stent group and 4.2% in the drainage group, also not statistically significant (P=0.248). No instances of perforation or bleeding were reported in either group.
2. The median postoperative hospital stay was significantly shorter in the stent group at 2.0 days (range: 1.0 to 4.0d) compared to 3.0 days (range: 2.0 to 5.0d) in the nasobiliary drainage group (P＜0.001).
3. The VAS scores for postoperative comfort were significantly lower in the stent group with a mean of 2.86±1.08 versus 5.13±2.19 in the nasobiliary drainage group (P＜0.001).
4. All 405 patients in the stent group returned for follow-up one month postoperatively. Stent detachment was confirmed in 373 patients (92.1%). Among the 32 patients with retained stents, two developed cholangitis, and two reported recurrent abdominal pain, resulting in a complication rate of 1.0%. In the nasobiliary drainage group, 10 patients (2.5%) spontaneously removed their drains, with an average age of 72.2±8.3 years.

Conclusion

The deployment of detachable biliary plastic stents without flanges following ERCP for common bile duct stones is as effective as traditional nasobiliary drainage in preventing postoperative cholangitis. This approach offers enhanced patient comfort, reduced hospital stay, and a high rate of spontaneous stent detachment, demonstrating its safety and efficacy in clinical practice.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

Antibiotic prophylaxis has been recommended to reduce the risk of infection and mortality in patients with cirrhosis and acute variceal bleeding (AVB). Recent data from Europe indicated that, despite antibiotic prophylaxis, bacterial infections, particularly of the respiratory tract, still occur in a subset of AVB patients, even with the administration of prophylactic antibiotics. Nonetheless, evidence concerning infections in AVB patients in Asia is limited and may differ from that in Western countries.

Aims & Methods

This retrospective study aimed to determine the incidence of bacterial infections among patients with AVB and to identify characteristics correlated with the occurrence of infection. Data from consecutive cirrhotic patients with AVB admitted to a tertiary care center, Rajavithi Hospital, Bangkok, between January 1, 2018, and October 31, 2024 were reviewed and analyzed. Patients with clinical signs of infections on admission were excluded.

Results

A total of 77 patients were included, with 67 (87%) being male. The average age was 52.88 ± 12.16 years. The predominant causes of cirrhosis were alcohol (66.2%), hepatitis C virus (27.3%), and hepatitis B virus (16.9%). The severity of cirrhosis was categorized as Child-Pugh A, B, and C in 31.2%, 24.2%, and 24.6% of patients, respectively. All patients were administered intravenous ceftriaxone as prophylactic antibiotic upon admission and underwent esophagogastroduodenoscopy within 48 hours, with 82% receiving endoscopic variceal ligation. Bacterial infections were identified in 12 patients (15.6%). The observed infection types included pneumonia (41.6%), primary bacteremia (25%), spontaneous bacterial peritonitis (16.7%), and urinary tract infection (16.7%). The median time to infection commencement was 2 (1-15) days, and the median duration of hospitalization was 5 (2-6) days, with a mortality rate of 6%. In univariate analysis, significant predictors of infections included Child-Pugh class B/C (p=0.004), BMI (p=0.037), histoacryl glue injection (p=0.044), and serum albumin (p=0.003). A multivariate analysis revealed a statistically significant link between low serum albumin levels and the occurrence of bacterial infection, with an adjusted odds ratio of 0.13 (95% CI: 0.02 - 0.94); p=0.043.

Conclusion

Bacterial infections, especially pneumonia, remain a significant concern in cirrhotic patients with AVB despite the use of prophylactic antibiotic, particularly in individuals with hypoalbuminemia.