Naryzhny, Igor; Silas, Dean; Chi, Kenneth
Carbapenem-resistant Enterobacteriaceae (CRE) outbreaks have been implicated at several medical institutions involving gastroenterology laboratories and, specifically, duodenoscopes. Currently, there are no specific guidelines to eradicate or prevent the outbreak of this bacteria. We describe ethylene oxide (ETO) gas sterilizations of duodenoscopes to address this issue. A complete investigation of the gastroenterology laboratory and an evaluation by the Centers for Disease Control and Prevention concluded that no lapses were found in the reprocessing of the equipment. With no deficiencies to address, we began a novel cleaning process using surgical ETO gas sterilizers in addition to standard endoscope reprocessing recommendations and guidelines, all while trying to eradicate the CRE contamination and prevent future recurrences. We also instituted a surveillance system for recurrence of CRE contamination via monthly cultures of the duodenoscopes. Between October 2013 and April 2014, 589 ERCPs were performed with 645 ETO gas sterilizations of 6 duodenoscopes. Given the extra 16 hours needed to sterilize the duodenoscopes, our institution incurred costs resulting from purchasing additional equipment and surveillance cultures. Four duodenoscopes sustained damage during this period; however, this could not be directly attributed to the sterilization process. Furthermore, after an 18-month success period we encountered a positive CRE culture after sterilization, albeit of a different strain than originally detected during the outbreak. The duodenoscope underwent additional ETO gas sterilization, with a negative repeated culture; all potentially exposed individuals screened negative for CRE. Proper use of high-level disinfection alone may not eliminate multidrug-resistant organisms from duodenoscopes. In this single-center study, the addition of ETO sterilization and frequent monitoring with cultures reduced duodenoscope contamination and eliminated clinical infections
Paula, Helga; Tribl, Barbara; Presterl, Elisabeth; Diab-El Schahawi, Magda
Endoscopes are well-known sources of bacterial transmission in health care facilities offering endoscopy services. The association between multidrug-resistant bacterial infections in patients who had undergone an endoscopic retrograde cholangiopancreatography procedure with reprocessed duodenoscopes has been much discussed. Bacterial contamination of duodenoscopes has been attributed to difficulties with reprocessing these devices, specifically the distal end of the scope, which features a movable forceps elevator. In light of a recent Food and Drug Administration warning letter to Olympus regarding their closed-channel duodenoscope model TJF-Q180V, the aim of our study was to prospectively evaluate the efficacy and safety of our current reprocessing procedures with regard to the TJF-Q180V duodenoscope models used in our hospital. From August 2015-March 2016, we prospectively collected microbiologic surveillance samples from 6 TJF-Q180V model duodenoscopes in routine use at the Division of Gastroenterology and Hepatology using the ESwab collection system (COPAN Diagnostics Inc, Murrieta, CA). A total of 237 microbiologic samples from the forceps elevator were obtained during the survey period. None of the samples yielded microorganism growth. These findings suggest that when following a diligent and validated reprocessing standard in accordance with manufacturer's recommendations, closed-channel endoscope models can still be used. Nevertheless, validated adaptions of current closed-channel duodenoscope models are needed to allow for simple and safe reprocessing. Furthermore, comprehensive postmarket surveillance needs to be established. Copyright © 2017. Published by Elsevier Inc.
Humphries, Romney M; Yang, Shuan; Kim, Stephen; Muthusamy, Venkatara Raman; Russell, Dana; Trout, Alisa M; Zaroda, Teresa; Cheng, Quen J; Aldrovandi, Grace; Uslan, Daniel Zachary; Hemarajata, Peera; Rubin, Zachary Aaron
Carbapenem-resistant Klebsiella pneumoniae infections are increasingly prevalent in North American hospitals. We describe an outbreak of carbapenem-resistant K. pneumoniae containing the blaOXA-232 gene transmitted by contaminated duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedures. An outbreak investigation was performed when 9 patients with blaOXA-232 carbapenem-resistant K. pneumoniae infections were identified at a tertiary care hospital. The investigation included 2 case-control studies, review of duodenoscope reprocessing procedures, and culture of devices. Carbapenem-resistant Enterobacteriacieae (CRE) isolates were evaluated with polymerase chain reaction analysis for carbapenemase genes, and isolates with the blaOXA-232 gene were subjected to whole-genome sequencing and chromosome single-nucleotide polymorphism analysis. On recognition of ERCP as a key risk factor for infection, targeted patient notification and CRE screening cultures were performed. Molecular testing ultimately identified 17 patients with blaOxa-232 carbapenem-resistant K. pneumoniae isolates, including 9 with infections, 7 asymptomatic carriers who had undergone ERCP, and 1 additional patient who had been hospitalized in India and was probably the initial carrier. Two case-control studies established a point-source outbreak associated with 2 specific duodenoscopes. A field investigation of the use, reprocessing, and storage of deuodenoscopes did not identify deviations from US Food and Drug Administration or manufacturer recommendations for reprocessing. This outbreak demonstrated the previously underappreciated potential for duodenoscopes to transmit disease, even after undergoing high-level disinfection according to manufacturers' guidelines.
Laurence, B H; Cotton, P B
Interest is increasing in non-operative methods of relieving malignant obstruction of the bile duct, and drainage tubes and prostheses may be placed in the bile duct via the percutaneous transhepatic route. Two cases are described, however, in which a duodenoscope was used and the approach was via the papilla of Vater. This method allows temporary or permanent drainage tubes to be placed through malignant strictures. This endoscopic approach is less invasive and should be safer than that by t...
Rex, Douglas K; Sieber, Marnie; Lehman, Glen A; Webb, Douglas; Schmitt, Bryan; Kressel, Amy Beth; Bang, Ji Young; Easler, Jeffery; McHenry, Lee; El-Hajj, Ihab; Fogel, Evan; Watkins, James; Sherman, Stuart
Background and study aim Duodenoscopes have been the source of serious infection, despite correct performance of high-level disinfection (HLD). This study aimed to observe the impact of performing HLD twice on the rate of positive cultures from duodenoscope elevators. Methods We performed double HLD (DHLD; i. e. complete manual cleaning followed by automated reprocessing, with the entire process repeated) and then randomly cultured the elevators of our duodenoscopes on about 30 % of occasions. Results DHLD was associated with positive elevator cultures for any microorganism in 9.4 % of cases, with a 0.8 % rate of known pathogens (627 cultures) between May 2015 and February 2016. After February 2016, and in association with changing the precleaning fluid, as well as use of a new FDA-recommended cleaning brush, the rate of positive cultures for any microorganism after DHLD was 4.8 % and 0.2 % for known pathogens (420 cultures). In a third phase, characterized by a change in personnel performing DHLD and retirement of a duodenoscope with a high rate of positive cultures, the rate of positive cultures for any microorganism was 4.9 % (783 cultures) and the rate of positive culture for known pathogens was 0.3 %. To our knowledge, no duodenoscope transmission of infection occurred during the study interval. Conclusions DHLD resulted in a low rate of positive cultures for known pathogens and for organisms of low pathogenic potential, but did not eliminate these, from duodenoscope elevators. Additional improvements in HLD protocols and/or duodenoscope design are needed. © Georg Thieme Verlag KG Stuttgart · New York.
Michelle J. Alfa
Full Text Available IntroductionSimulated-use buildup biofilm (BBF model was used to assess various extraction fluids and friction methods to determine the optimal sample collection method for polytetrafluorethylene channels. In addition, simulated-use testing was performed for the channel and lever cavity of duodenoscopes.Materials and methodsBBF was formed in polytetrafluorethylene channels using Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa. Sterile reverse osmosis (RO water, and phosphate-buffered saline with and without Tween80 as well as two neutralizing broths (Letheen and Dey–Engley were each assessed with and without friction. Neutralizer was added immediately after sample collection and samples concentrated using centrifugation. Simulated-use testing was done using TJF-Q180V and JF-140F Olympus duodenoscopes.ResultsDespite variability in the bacterial CFU in the BBF model, none of the extraction fluids tested were significantly better than RO. Borescope examination showed far less residual material when friction was part of the extraction protocol. The RO for flush-brush-flush (FBF extraction provided significantly better recovery of E. coli (p = 0.02 from duodenoscope lever cavities compared to the CDC flush method.Discussion and conclusionWe recommend RO with friction for FBF extraction of the channel and lever cavity of duodenoscopes. Neutralizer and sample concentration optimize recovery of viable bacteria on culture.
Alfa, Michelle J; Singh, Harminder; Duerksen, Donald R; Schultz, Gale; Reidy, Carol; DeGagne, Pat; Olson, Nancy
Some outbreaks associated with contaminated duodenoscopes have been attributed to biofilm formation. The objective of this study was to determine whether bacteria within an organic matrix could survive if the elevator lever was improperly positioned in the automated endoscope reprocessor (AER) after 1 round of reprocessing. Duodenoscope lever cavities with an open or sealed elevator wire channel were inoculated with 6-7 Log 10 of both Escherichia coli and Enterococcus faecalis in ATS2015 (Healthmark Industries, Fraser, MI) and dried for 2 hours. The duodenoscopes with the lever in the horizontal position were processed through 2 makes of AERs. The cavity was sampled using a flush-brush-flush method to determine the quantity of surviving bacteria. E faecalis (range, 21-6 Log 10 CFU) and E coli (range, 0-3 Log 10 CFU) survived disinfection of sealed or unsealed elevator wire channel duodenoscopes in 2 different AERs with and without cleaning cycles. If bacteria in organic residue are under the improperly positioned lever, then just 1 round of use is sufficient for bacteria to survive both liquid chemical sterilization and liquid chemical HLD regardless of whether or not the AER had a cleaning cycle. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Prevention of multidrug-resistant infections from contaminated duodenoscopes: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA).
Beilenhoff, Ulrike; Biering, Holger; Blum, Reinhard; Brljak, Jadranka; Cimbro, Monica; Dumonceau, Jean-Marc; Hassan, Cesare; Jung, Michael; Neumann, Christiane; Pietsch, Michael; Pineau, Lionel; Ponchon, Thierry; Rejchrt, Stanislav; Rey, Jean-François; Schmidt, Verona; Tillett, Jayne; van Hooft, Jeanin
Patients should be informed about the benefits and risks of endoscopic retrograde cholangiopancreatography (ERCP)Only specially trained and competent personnel should carry out endoscope reprocessing.Manufacturers of duodenoscopes should provide detailed instructions on how to use and reprocess their equipment.In the case of modifications to their equipment, manufacturers should provide updated instructions for use.Detailed reprocessing protocols based on the manufacturer's instructions for use should clearly lay out the different reprocessing steps necessary for each endoscope model.Appropriate cleaning equipment should be used for duodenoscopes in compliance with the manufacturer's instructions for use. Only purpose-designed, endoscope type-specific, single-use cleaning brushes should be used, to ensure optimal cleaning. As soon as the endoscope is withdrawn from the patient, bedside cleaning should be performed, followed by leak testing, thorough manual cleaning steps, and automated reprocessing, in order to: · Remove debris from external and internal surfaces;. · Prevent any drying of body fluids, blood, or debris;. · Prevent any formation of biofilms.. In addition to the leak test, visual inspection of the distal end as well as regular maintenance of duodenoscopes should be performed according to the manufacturer's instructions for use, in order to detect any damage at an early stage.The entire reprocessing procedure in endoscope washer-disinfectors (EWDs) should be validated according to the European and International Standard, EN ISO 15883. Routine technical tests of EWDs should be performed according to the validation reports.Microbiological surveillance of a proportion of the department's endoscopes should be performed every 3 months, with the requirement that all endoscopes used in the unit are tested at least once a year.In the case of suspected endoscopy-related infection, the relevant device (e. g., endoscope, EWD) should be taken out of service
Humphries, Romney M; McDonnell, Gerald
Inadequate flexible endoscope reprocessing has been associated with infection outbreaks, most recently caused by carbapenem-resistant Enterobacteriaceae. Lapses in essential device reprocessing steps such as cleaning, disinfection/sterilization, and storage have been reported, but some outbreaks have occurred despite claimed adherence to established guidelines. Recommended changes in these guidelines include the use of sterilization instead of high-level disinfection or the use of routine microbial culturing to monitor efficacy of reprocessing. This review describes the current standards for endoscope reprocessing, associated outbreaks, and the complexities associated with both microbiological culture and sterilization approaches to mitigating the risk of infection associated with endoscopy. Copyright © 2015, American Society for Microbiology. All Rights Reserved.
... Duodenoscope Sampling Method Interim Duodenoscope Culture Method Multiplex Real-Time PCR Detection of KPC & NDM-1 genes Quinolones ... bacterium are usually of the skin and the soft tissues under the skin. It is also a ...
... Duodenoscope Sampling Method Interim Duodenoscope Culture Method Multiplex Real-Time PCR Detection of KPC & NDM-1 genes Quinolones ... The most commonly used external catheter is a soft flexible sheath that fits over the penis (“condom” ...
... Duodenoscope Sampling Method Interim Duodenoscope Culture Method Multiplex Real-Time PCR Detection of KPC & NDM-1 genes Quinolones ... bacterium are usually of the skin and the soft tissues under the skin. It can also cause ...
Burcharth, F.; Holst Pedersen, J.
In five patients with pancreatitis, obstructive jaundice was relieved by internal drainage of the biliary tract with an endoprosthesis inserted by percutaneous transhepatic technique. The average duration of treatment was 3.5 months. The endoprosthesis was removed by means of a duodenoscope, and jaundice did not recur. (orig.) [de
Kim, M H; Myung, S J; Lee, S K; Yoo, B M; Seo, D W; Lee, M H; Jung, S A; Kim, Y S; Min, Y I
Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. ERCP is essential to demonstrate a choledochocele. The aim of this study was to investigate the duodenoscopic and cholangiographic findings during ERCP. Over a 4-year period, 17 symptomatic patients (8 men, 9 women; age range 45 to 83 years) were identified as having choledochoceles. The diagnosis of choledochocele was made by both duodenoscopic and cholangiographic findings. As a characteristic duodenoscopic finding, the enlarged bulging papilla was noted in 8 patients (47%), whereas a normal-appearing papilla was noted in 9 patients (53%) before the injection of contrast media. However, in all 17 patients progressive enlargement or ballooning of the papilla was noted during contrast injection. The maximum diameter of the choledochocele, determined by cholangiography, was significantly larger (19 +/-4 mm) in patients with initially bulging papilla than in those with normal-appearing papilla (9+/-3 mm) (p < 0.05). Ballooning of the papilla during contrast injection may be a specific duodenoscopic finding for choledochocele. To avoid missing the diagnosis of a choledochocele, especially when it is small, it is important to watch the papilla carefully during contrast injection.
Kalff, V.; Kelly, M.J.; Dudley, F.; Metz, G.
Gastrointestinal blood pool scintigraphy, using a modified in-vivo blood cell labelling technique with technetium-99, is a new, easily performed, non-invasive procedure. It is valuable in screening patients with acute or intermittent gastrointestinal blood loss in whom duodenoscopic and sigmoidoscopic findings are unhelpful. This paper reviews the value of this scintigraphic technique over the first eight months of its use in a major teaching hospital, and compares the results with other published data. If used and interpreted appropriately, scintigraphy is sensitive in detecting and localizing the bleeding site, and is very helpful in indicating the optimal timing of emergency contrast angiography
Kim, Do-Hyun; Kim, Moon S.; Hwang, Jeeseong
Contamination of the inner surface of indwelling (implanted) medical devices by microbial biofilm is a serious problem. Some microbial bacteria such as Escherichia coli form biofilms that lead to potentially lifethreatening infections. Other types of medical devices such as bronchoscopes and duodenoscopes account for the highest number of reported endoscopic infections where microbial biofilm is one of the major causes for these infections. We applied a hyperspectral imaging method to detect biofilm contamination on the surface of several common materials used for medical devices. Such materials include stainless steel, titanium, and stainless-steeltitanium alloy. Potential uses of hyperspectral imaging technique to monitor biofilm attachment to different material surfaces are discussed.
Full Text Available A 69-year-old woman with jaundice was referred to our hospital. After a final diagnosis of pancreatic cancer with liver metastasis, we performed transpapillary biliary drainage with a covered self-expandable metal stent (SEMS. Three months later, we also placed an uncovered duodenal stent for duodenal stricture in a side-to-end fashion. Another month later, for biliary SEMS obstruction, we attempted a transpapillary approach. A duodenoscope was advanced and a guidewire was passed through the mesh of the duodenal stent into the bile duct with a flexible tip catheter, but the catheter was not. Thus, we exchanged the duodenoscope for a forward-viewing two-channel endoscope and used the left working channel with a flexible tip catheter. By adjusting the axis, we finally succeeded biliary cannulation and accomplished balloon cleaning for recanalization of the SEMS. This is the first case with successful biliary cannulation by combined use of a two-channel endoscope and a flexible tip catheter.
Full Text Available We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.
Odabasi, Mehmet; Yildiz, Mehmet Kamil; Abuoglu, Haci Hasan; Eris, Cengiz; Ozkan, Erkan; Gunay, Emre; Aktekin, Ali; Muftuoglu, Ma Tolga
To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs. Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast. An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%. The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.
Manes, Gianpiero; Baratti, Cinzia; Ardizzone, Sandro; Ferla, Fabio; Spiropoulos, Jean; Corsi, Fabio; Foschi, Diego; Trabucchi, Emilio; Bianchi Porro, Gabriele
Endoscopic retrograde cholangiopancreatography (ERCP) rendezvous during laparoscopic cholecystectomy is an efficient and safe method to treat cholecystocholedocholithiasis. Advancing a guidewire through the cystic duct into the duodenum and withdrawing it in the accessory channel of duodenoscope may be, however, laborious. Moreover, rendezvous performed in the typical manner needs the use of several costly accessories. We herein describe a simpler and cheaper method to gain access to the biliary duct at rendezvous. Twenty-four consecutive patients undergoing ERCP rendezvous during laparoscopic cholecystectomy were considered. A catheter was introduced in the cystic duct and advanced into the duodenum. Access to the bile duct was than achieved by means of a precut sphincterotomy performed over the catheter emerging from the papilla. Cannulation was successful in all but two patients, in whom ERCP was performed in the conventional manner. The only complication was a case of mild post-sphincterotomy bleeding. In comparison with the typical rendezvous technique our procedure allowed savings of about 250, since its performance only requires a catheter and a knife sphincterotome. Over-the-catheter precut during ERCP rendezvous is a feasible and safe method which avoids the need for the manipulation of several accessories and guidewires, and thus results in money and time savings.
Gebhardt, C; Gall, F P; Lux, G; Riemann, J; Link, W
In patients with haemorrhagic necrotizing pancreatitis who are scheduled for surgery we have been carrying out a preoperative retrograde investigation of the pancreatic duct system for the past months. The results in, to date, ten patients revealed four different morphological findings of importance for the surgical tactic: 1. A normal pancreatic duct system with no signs of fistulae: only peripancreatic necrosectomy is required. - 2. Contrast medium leaks via a ductal fistula: left resection including the removal of the fistulous area must be done. - 3. Normal duct system with complete segmental parenchymal staining, representing total necrosis in this region: left resection of the pancreas. - 4. Duodenoscopically demonstrable perforation into the duodenum of a necrotic cavity in the head of the pancreas: conservative management only, no surgery, since this lesion resulting in drainage of the necrotic cavity into the bowel permits self-healing, while the site of the perforation within the necrotic wall cannot be dealt with by surgery. - The experience gained so far indicates that the surgical tactic can be determined with greater selectivity by the use of ERP.
Gebhardt, C; Riemann, J F; Lux, G
In patients with haemorrhagic necrotizing pancreatitis who are scheduled for surgery, we have been carrying out a preoperative retrograde investigation of the pancreatic duct system for the past 3 months. The results in, to date, ten patients, all of whom survived their severe illness, revealed four different morphological findings of importance for the surgical tactic. 1. A normal pancreatic duct system with no signs of fistulae: only peripancreatic necrosectomy is required. 2. Contrast medium leaks via a ductal fistula: left resection, including the removal of the fistulous area, must be done. 3. Normal duct system with complete segmental parenchymal staining, representing total necrosis in this region: left resection of the pancreas. 4. Duodenoscopically demonstrable perforation into the duodenum of a necrotic cavity in the head of the pancreas: conservative management only, no surgery, since this lesions, resulting in drainage of the necrotic cavity into the bowel, permits self-healing, while the site of the perforation within the necrotic wall cannot be dealt with by surgery. The experience gained so far indicates that the surgical tactic can be determined with greater selectivity by the use of ERCP.
Kawakubo, Kazumichi; Kawakami, Hiroshi; Kuwatani, Masaki; Kudo, Taiki; Abe, Yoko; Kawahata, Shuhei; Kubo, Kimitoshi; Kubota, Yoshimasa; Sakamoto, Naoya
Bilateral self-expandable metallic stent (SEMS) placement for the management of unresectable malignant hilar biliary obstruction (UMHBO) is technically challenging to perform using the existing metallic stents with thick delivery systems. The recently developed 6-Fr delivery systems could facilitate a single-step simultaneous side-by-side placement through the accessory channel of the duodenoscope. The aim of this study was to evaluate the feasibility of this procedure. Between May and September 2013, 13 consecutive patients with UMHBO underwent a single-step simultaneous side-by-side placement of SEMS with the 6-Fr delivery system. The technical success rate, stent patency, and rate of complications were evaluated from the prospectively collected database. Technical success was achieved in 11 (84.6%, 95% confidence interval [CI]: 57.8-95.8) patients. The median procedure time was 25 min. Early and late complications were observed in 23% (one segmental cholangitis and two liver abscesses) and 15% (one segmental cholangitis and one cholecystitis) patients, respectively. Median dysfunction free patency was 263 days (95% CI: 37-263). Five patients (38%) experienced stent occlusion that was successfully managed by endoscopic stent placement. A single-step simultaneous side-by-side placement of SEMS with a 6-Fr delivery system was feasible for the management of UMHBO. © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
Full Text Available Introduction: Endoscopic retrograde cholangiopancreatography (ERCP has been proven to be a safe and effective method for diagnosis and treatment of biliary and pancreatic disorders. Major complications of ERCP include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. We report a third case in literature of pneumoperitoneum after ERCP due to rupture of intrahepatic bile ducts and Glisson’s capsule in a peripheral hepatic lesion. Case Report: A 50-year-old male with a history of metastatic pancreatic neuroendocrine tumor and who had a partially covered metallic stent placed in the biliary tree 1 year ago presented to the oncology clinic with fatigue, abdominal pain, and hypotension. He was planned for ERCP for possible cholangitis secondary to obstructed previously placed biliary stent. However, the duodenoscope could not be advanced to the level of the major papilla because of narrowed pylorus and severely strictured duodenal sweep. Forward-view gastroscope was then passed with careful manipulation to the severely narrowed second part of the duodenum where the previously placed metallic stent was visualized. Balloon sweeping of stenting was done. Cholangiography did not show any leak. Following the procedure, the patient underwent CT scan of the abdomen that showed pneumoperitoneum which was communicating with pneumobilia through a loculated air collection in necrotic hepatic metastasis perforating Glisson’s capsule. The patient was managed conservatively. Conclusion: In our case, pneumoperitoneum resulted from rupture of intrahepatic bile ducts and Glisson’s capsule in hepatic metastasis. This case emphasizes the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic subjected to ERCP.
Iwashita, Takuji; Yasuda, Ichiro; Mukai, Tsuyoshi; Iwata, Keisuke; Ando, Nobuhiro; Doi, Shinpei; Nakashima, Masanori; Uemura, Shinya; Mabuchi, Masatoshi; Shimizu, Masahito
Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study. EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation. The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20). EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates. Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
Tsuchiya, Takayoshi; Itoi, Takao; Sofuni, Atsushi; Tonozuka, Ryosuke; Mukai, Shuntaro
Endoscopic retrograde cholangiopancreatography (ERCP) requires deep biliary cannulation. When deep biliary cannulation is failed, the endoscopic ultrasonography rendezvous technique (EUS-RV) is a useful salvage method. From the previous 15 articles that included 382 EUS-RV cases, the overall success rate of EUS-RV is 81 % with a complication rate of 10 %. In EUS-RV, the bile duct is punctured under EUS guidance and a guidewire is advanced into the duodenum via the papilla. The EUS scope is then switched to a duodenoscope and inserted into the bile duct over the guidewire exiting the papilla, or the guidewire is grasped with forceps and passed through the working channel; the catheter can then be inserted through the papilla over the wire. There are three puncture routes for EUS-RV: transgastric puncture of the intrahepatic bile duct (IHBD), transduodenal puncture of the extrahepatic bile duct (EHBD) via the proximal duodenum (D1), and transduodenal puncture of the EHBD via the second portion of the duodenum (D2). The puncture route for each patient should be selected based on the patient condition. GW selection for EUS-RV is critical, a hydrophilic GW is useful for this procedure. Although EUS-RV is now performed relatively routinely in a few high-volume centers, procedure standardization and the development of exclusive devices for EUS-RV are still underway. The development of exclusive devices for EUS-RV and prospective comparative studies with other salvage methods are needed to truly evaluate the procedure's usefulness and safety.
Decristoforo, P; Kaltseis, J; Fritz, A; Edlinger, M; Posch, W; Wilflingseder, D; Lass-Flörl, C; Orth-Höller, D
Several outbreaks of severe infections due to contamination of gastrointestinal (GI) endoscopes, mainly duodenoscopes, have been described. The rate of microbial endoscope contamination varies dramatically in literature. The aim of this multicentre prospective study was to evaluate the hygiene quality of endoscopes and automated endoscope reprocessors (AERs) in Tyrol/Austria. In 2015 and 2016, a total of 463 GI endoscopes and 105 AERs from 29 endoscopy centres were analysed by a routine (R) and a combined routine and advanced (CRA) sampling procedure and investigated for microbial contamination by culture-based and molecular-based analyses. The contamination rate of GI endoscopes was 1.3%-4.6% according to the national guideline, suggesting that 1.3-4.6 patients out of 100 could have had contacts with hygiene-relevant microorganisms through an endoscopic intervention. Comparison of R and CRA sampling showed 1.8% of R versus 4.6% of CRA failing the acceptance criteria in phase I and 1.3% of R versus 3.0% of CRA samples failing in phase II. The most commonly identified indicator organism was Pseudomonas spp., mainly Pseudomonas oleovorans. None of the tested viruses were detected in 40 samples. While AERs in phase I failed (n = 9, 17.6%) mainly due to technical faults, phase II revealed lapses (n = 6, 11.5%) only on account of microbial contamination of the last rinsing water, mainly with Pseudomonas spp. In the present study the contamination rate of endoscopes was low compared with results from other European countries, possibly due to the high quality of endoscope reprocessing, drying and storage. Copyright © 2018 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Nathalia Saber de ANDRADE
Full Text Available ABSTRACT BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A, partially visualized (position B or not visualized (position C. If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8% with mean age of 49 years. Of the 671 patients, 324 (48.3% major duodenal papilla was identified in position A, 112 (16.7% in position B and 235 (35% in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%, position B in 51 (14.7% and position C in 110 (31.7%. Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%, position B in 14 (8.7% and position C in 53 (32.9%. The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90% of the patients (P<0.01 and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.
Quan, Erik; Mahmood, Rizwan; Naik, Amar; Sargon, Peter; Shastri, Nikhil; Venu, Mukund; Parada, Jorge P; Gupta, Neil
There have been reported outbreaks of carbapenem-resistant Enterobacteriaceae infections linked to endoscopes with elevator mechanisms. Adenosine triphosphate (ATP) testing has been used as a marker for bioburden and monitoring manual cleaning for flexible endoscopes with and without an elevator mechanism. The objective of this study was to determine whether routine ATP testing could identify areas of improvement in cleaning of endoscopes with an elevator mechanism. ATP testing after manual cleaning of TJF-Q180V duodenoscopes and GF-UCT180 linear echoendoscopes (Olympus America Inc, Center Valley, PA) was implemented. Samples were tested from the distal end, the elevator mechanism, and water flushed through the lumen of the biopsy channel. Data were recorded and compared by time point, test point, and reprocessing technician. Overall failure rate was 6.99% (295 out of 4,219). The highest percentage of failed ATP tests (17.05%) was reported in the first quarter of routine testing, with an overall decrease in rates over time. The elevator mechanism and working channel lumen had higher failure rates than the distal end. Quality of manual cleaning between reprocessing technicians showed variation. ATP testing is effective in identifying residual organic material and improving quality of manual cleaning of endoscopes with an elevator mechanism. Cleaning efficacy is influenced by reprocessing technicians and location tested on the endoscope. Close attention to the working channel and elevator mechanism during manual cleaning is warranted. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Dhir, Vinay; Bhandari, Suryaprakash; Bapat, Mukta; Maydeo, Amit
Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy. To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. Retrospective study. Tertiary care referral center. Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3
duodenoscope, performing on pig model because it is easier to pass through the pyloric sphincter, although this is not very suitable for cannulation of the duodenal papilla. After passing the first stage, we used the canine model to acquire the skills and abilities specific to this technique. The performance evaluation is done through an anonymous survey. Results. 76% of students confirmed that they have made good progress with this training, 18% regular and 6% that shortly. 75% believed that after making this training would be found competent to carry out the technique in their hospitals. About 94% of students would recommend this activity. Conclusions. The use of animal model in training in endoscopic retrograde cholangiopancreatography (ERCP permits the acquisition of basic skills needed for practice, as it enables the repetition of the maneuvers and continuing care. We believe that this mixed methodology could shorten the learning curve for ERCP and reduce iatrogenic in the early stages.