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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Safety and Utility of Single-Session Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography for the Evaluation of Pancreatobiliary Diseases

Kazumichi Kawakubo, Hiroshi Kawakami*, Masaki Kuwatani, Shin Haba, Taiki Kudo, Yoko Abe, Shuhei Kawahata, Manabu Onodera, Nobuyuki Ehira, Hiroaki Yamato, Kazunori Eto, and Naoya Sakamoto

Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.

Correspondence to: Hiroshi Kawakami. Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sappro 060-8638, Japan. Tel: +81-11-716-1161, Fax: +81-11-706-7867, hiropon@med.hokudai.ac.jp

Received: October 18, 2013; Revised: December 5, 2013; Accepted: January 23, 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2014;8(3):329-332. https://doi.org/10.5009/gnl.2014.8.3.329

Published online May 12, 2014, Published date May 29, 2014

Copyright © Gut and Liver.

Both endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are required to evaluate and treat patients with pancreatobiliary diseases. ERCP is a well-established technique to evaluate and manage biliary obstructions, but it carries a risk of complications, such as post-ERCP pancreatitis, bleeding, and perforation.1 Therefore, ERCP is reserved mainly for therapeutic indications. EUS is a less-invasive modality and has high accuracy for diagnosing pancreatobiliary diseases such as biliary stones and pancreatic tumors.2,3 These two procedures can be performed during a single session under same anesthesia, but concern regarding their safety has been raised due to complications.4,5 However, a single session results in a reduction in hospital stay and avoidance of repeated sedation as compared to multiple sessions.6,7,8,9,10,11 Previous studies only evaluate the utility of single-session EUS and ERCP in a single setting. Therefore, we performed a retrospective analysis of patients with pancreatobiliary diseases who underwent single-session EUS and ERCP to evaluate their safety and efficacy in a variable setting.

We retrospectively reviewed data from a prospectively maintained database of patients who underwent single-session EUS with/without fine-needle aspiration (FNA) and ERCP at Hokkaido University Hospital between July 2008 and December 2012. The collected data included age, sex, indications for the procedure, primary diseases, endoscopic and clinical outcomes, procedural complications, and pathological findings if observed. This study was approved by the Institutional Review Board of Hokkaido University Hospital and was registered with the University Hospital Medical Information Network-Clinical Trial Registry (UMIN-CTR; number, UMIN000008409).

Written informed consent was obtained from all patients before the procedures. Combined EUS and ERCP were performed under conscious sedation using intravenous midazolam with fentanyl. Before 2009, EUS was performed with a radial echoendoscope (GF-UM2000 or GF-UE260; Olympus Medical Systems Co., Tokyo, Japan). After introduction of the linear echoendoscope (GF-UCT240-AL5; Olympus Medical Systems Co.) to our institution, we used either type of echoendoscope at the discretion of the endoscopist. Patients also underwent EUS-guided FNA (EchoTip Ultra, Cook-Japan, Tokyo, Japan; or Expect, Boston Scientific Japan, Tokyo, Japan) with rapid on-site cytology evaluation if necessary. Subsequent ERCP-related procedures were performed following EUS during the same session using a duodenoscope (JF-240, TJF-240, or TJF-260V; Olympus Medical Systems Co.). In patients who were using antithrombotic or antiplatelet agents, each procedure was performed according to the Japanese guidelines.12 After the procedure, patients were monitored at an inpatient unit in the same way as those who underwent ERCP alone. Procedural-related complications were classified and graded according to consensus criteria.13

A total of 1,519 ERCP and 1,559 EUS procedures were performed respectively at our institution. Among them, 68 patients (mean age, 69 years; 38 males and 30 females) underwent EUS and ERCP in a single session and were included in this study (Table 1). Diagnostic EUS was performed in 38 patients (linear EUS in 14 and radial EUS in 24) with a median procedure time of 32 minutes. EUS-FNA was performed in 30 patients (44%) (Table 2). The sensitivity and specificity of EUS-FNA for malignancy were 100% and 100%. Choledocholithiasis was confirmed in all patients with acute cholangitis. Bile duct cannulation following EUS was successful in all but one patient. Sixty patients underwent therapeutic ERCP, whereas the remaining eight were diagnostic procedures. Thirteen patients underwent endoscopic sphincterotomy followed by stone extraction, whereas six patients underwent plastic stent placement due to severe cholangitis or were taking antithrombotic agents. Biliary drainage was performed using self-expandable metallic stents in 12 patients, plastic stents in 11, and nasobiliary drainage in 25.

Seven complications (10.3%; 95% confidence interval, 3.1 to 17.5) were observed. Six were post-ERCP pancreatitis. One patient with bile duct carcinoma who underwent EUS-FNA for lymph node and endoscopic nasobiliary drainage placement for obstructive jaundice developed severe pancreatitis. Three patients were mild, and two patients were moderate, according to the consensus criteria.13 All patients resolved with conservative management. One patient developed Mallory-Weiss syndrome 1 day after the single-session procedure, which required endoscopic hemostasis. No severe cardiopulmonary complications or deaths related to the combined procedure were observed.14

We revealed that single-session EUS and ERCP were both safe and effective for managing pancreatobiliary disorder in a variable setting. The combined procedure facilitated appropriate patient management without severe complications and could be considered a standard treatment that reduces hospital stay and avoids unnecessary sedation.

It was necessary but sometimes difficult to distinguish between malignant and benign originating lesions in patients with biliary obstructions. EUS has greater sensitivity for detecting small pancreatic tumors or preoperative staging than computed tomography,2 and improves the diagnosis of indeterminate bile duct strictures without EUS-FNA.15 Therefore, identifying unresectable malignant tumors by EUS in patients with a biliary obstruction may require a metallic stent rather than a plastic stent due to the longer patency.16 Furthermore, if the presence of a biliary stent interferes with preoperative staging of a pancreatic head tumor by EUS, EUS should be performed before ERCP to avoid unnecessary laparotomies.17 In this study, three patients who did not have tumors following the EUS examination were diagnosed with a benign biliary stricture, and were managed successfully. Ascunece et al.9 also reported that benign biliary strictures can be diagnosed and managed successfully by single-session EUS-ERCP without FNA.

EUS-FNA has great sensitivity for detecting malignancy in not only pancreatic tumors,18 but also biliary strictures.19 Identifying a malignancy by EUS-FNA eliminates the need for biliary brushing, the sensitivity of which is inferior to that of EUS-FNA.20 Furthermore, because preoperative biliary drainage is not necessary in patients with obstructive jaundice who undergo a Whipple resection, positive cytology could avoid unnecessary biliary stenting.21 Ross et al.7 reported that the combination of EUS-FNA with ERCP for evaluation of patients with obstructive jaundice from presumed pancreatic malignancy provides accurate tissue diagnosis and biliary drainage. In this study, EUS-FNA was performed in 30 patients; malignancy was detected in all malignant diseases. Three patients without malignancy were diagnosed with autoimmune pancreatitis and successfully managed with steroid therapy. Furthermore, EUS-FNA immediately after biliary stent placement was associated with a high rate of inconclusive cytology; thus, EUS-FNA should be performed before ERCP for a correct diagnosis.22 In patients with indeterminate biliary stricture, single-session EUS and ERCP would be the most reasonable.

EUS is superior to other modalities for detecting biliary stones and can avoid unnecessary ERCP in patients with suspected biliary stone or biliary pancreatitis.3,23,24 Fabbri et al.8 reported that single-session EUS and ERCP in patients at low risk of biliary stones is safe and effective with reduced procedural time and costs compared to performance in separate sessions. In our study, 13 patients underwent EUS and ERCP with sphincterotomy and stone extraction without complications, whereas the remaining patients with severe cholangitis and/or those who were taking antithrombotic agents underwent placement of a biliary stent without sphincterotomy. One of the concerns regarding a single-session procedure is total procedural time. However, Benjaminov et al.6 reported that separate EUS and ERCP sessions for symptomatic choledocholithiasis expose the patient to a higher risk of cholangitis as compared to a single-session procedure. Stone extraction in a single session is reasonable considering its safety and decreased hospital stay. Therefore, single-session EUS and ERCP would be the most useful for patients with cholangitis in whom choledocholithiasis could not be confirmed by other imaging modalities.

The advantage of single-session EUS and ERCP as compared to a separate session is expedited patient management, shortening of the hospital stay, reduced cost and avoidance of repeated sedation.8,10 The major disadvantages of these procedures are the long procedural time and the increase in intestinal gas volume.4,5 However, previous studies of single-session EUS and ERCP reported no severe complications.7,8,9,10 We observed six cases of post-ERCP pancreatitis, all of which resolved with conservative management. However, post-ERCP pancreatitis is an inherent complication of ERCP and was not attributed to the single-session procedure. We had experienced one Mallory-Weiss syndrome, which was also one of the complications of upper endoscopy. Iles-Shih et al.11 reported the safety of single-session EUS and ERCP in elderly patients, with no more adverse events than in nonelderly patients. Therefore, this disadvantage does not preclude performance of both procedures in a single session, considering their efficacy.

Our study had some limitations. First, it was of a retrospective design conducted at a single center. Second, a single-session procedure can be performed only by endoscopists experienced in both EUS and ERCP. A single-session procedure is not the standard. Third, we did not compare hospital stay duration and the cost of a single-session procedure with those of separate sessions. Fourth, we could not evaluate the patients who could avoid unnecessary ERCP.

Our results show that single-session EUS and ERCP were safe and useful for management of pancreatobiliary diseases. However, development of a new therapeutic endoscope, using which both EUS and ERCP can be performed in a single-session without scope exchange, is necessary for the widespread acceptance of this combined procedure.



Patient Characteristics


Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.

Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.



Characteristics of the Procedures


Data are presented as number (%) or median (interquartile range).

EUS, endoscopic ultrasonography; EUS-FNA, EUS-guided fine-needle aspiration; ERCP, endoscopic retrograde cholangiopancreatography; ENBD, endoscopic nasobiliary drainage; SEMS, self-expandable metallic stent.

Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.

  1. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70;80-88.
    Pubmed
  2. DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med. 2004;141;753-763.
    Pubmed
  3. Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study. Clin Gastroenterol Hepatol. 2005;3;1238-1244.
    Pubmed
  4. Mergener K, Jowell PS, Branch MS, Baillie J. Pneumoperitoneum complicating ERCP performed immediately after EUS-guided fine needle aspiration. Gastrointest Endosc. 1998;47;541-542.
    Pubmed
  5. Di Matteo F, Shimpi L, Gabbrielli A, et al. Same-day endoscopic retrograde cholangiopancreatography after transduodenal endoscopic ultrasound-guided needle aspiration: do we need to be cautious?. Endoscopy. 2006;38;1149-1151.
    Pubmed
  6. Benjaminov F, Stein A, Lichtman G, Pomeranz I, Konikoff FM. Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis. Surg Endosc. 2013;27;2117-2121.
    Pubmed
  7. Ross WA, Wasan SM, Evans DB, et al. Combined EUS with FNA and ERCP for the evaluation of patients with obstructive jaundice from presumed pancreatic malignancy. Gastrointest Endosc. 2008;68;461-466.
    Pubmed
  8. Fabbri C, Polifemo AM, Luigiano C, et al. Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis. J Gastroenterol Hepatol. 2009;24;1107-1112.
    Pubmed
  9. Ascunce G, Ribeiro A, Rocha-Lima C, et al. Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders. Surg Endosc. 2010;24;1447-1450.
    Pubmed
  10. Aslanian HR, Estrada JD, Rossi F, Dziura J, Jamidar PA, Siddiqui UD. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography for obstructing pancreas head masses: combined or separate procedures?. J Clin Gastroenterol. 2011;45;711-713.
    Pubmed
  11. Iles-Shih L, Hilden K, Adler DG. Combined ERCP and EUS in one session is safe in elderly patients when compared to non-elderly patients: outcomes in 206 combined procedures. Dig Dis Sci. 2012;57;1949-1953.
    Pubmed
  12. Ogoshi K, Kaneko E, Tada M, et al. The management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastroenterol Endosc. 2005;47;2691-2695.
  13. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37;383-393.
    Pubmed
  14. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71;446-454.
    Pubmed
  15. Lee JH, Salem R, Aslanian H, Chacho M, Topazian M. Endoscopic ultrasound and fine-needle aspiration of unexplained bile duct strictures. Am J Gastroenterol. 2004;99;1069-1073.
    Pubmed
  16. Isayama H, Yasuda I, Ryozawa S, et al. Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): Covered Wallstent versus DoubleLayer stent. Dig Endosc. 2011;23;310-315.
    Pubmed
  17. Fusaroli P, Manta R, Fedeli P, et al. The influence of endoscopic biliary stents on the accuracy of endoscopic ultrasound for pancreatic head cancer staging. Endoscopy. 2007;39;813-817.
    Pubmed
  18. Haba S, Yamao K, Bhatia V, et al. Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience. J Gastroenterol. 2013;48;973-981.
    Pubmed
  19. Ohshima Y, Yasuda I, Kawakami H, et al. EUS-FNA for suspected malignant biliary strictures after negative endoscopic transpapillary brush cytology and forceps biopsy. J Gastroenterol. 2011;46;921-928.
    Pubmed
  20. Oppong K, Raine D, Nayar M, Wadehra V, Ramakrishnan S, Charnley RM. EUS-FNA versus biliary brushings and assessment of simultaneous performance in jaundiced patients with suspected malignant obstruction. JOP. 2010;11;560-567.
    Pubmed
  21. van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362;129-137.
    Pubmed
  22. Fisher JM, Gordon SR, Gardner TB. The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma. Pancreas. 2011;40;21-24.
    Pubmed
  23. Lee YT, Chan FK, Leung WK, et al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc. 2008;67;660-668.
    Pubmed
  24. Kondo S, Isayama H, Akahane M, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol. 2005;54;271-275.
    Pubmed

Article

Brief Communication

Gut Liver 2014; 8(3): 329-332

Published online May 29, 2014 https://doi.org/10.5009/gnl.2014.8.3.329

Copyright © Gut and Liver.

Safety and Utility of Single-Session Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography for the Evaluation of Pancreatobiliary Diseases

Kazumichi Kawakubo, Hiroshi Kawakami*, Masaki Kuwatani, Shin Haba, Taiki Kudo, Yoko Abe, Shuhei Kawahata, Manabu Onodera, Nobuyuki Ehira, Hiroaki Yamato, Kazunori Eto, and Naoya Sakamoto

Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.

Correspondence to: Hiroshi Kawakami. Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sappro 060-8638, Japan. Tel: +81-11-716-1161, Fax: +81-11-706-7867, hiropon@med.hokudai.ac.jp

Received: October 18, 2013; Revised: December 5, 2013; Accepted: January 23, 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION

Both endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are required to evaluate and treat patients with pancreatobiliary diseases. ERCP is a well-established technique to evaluate and manage biliary obstructions, but it carries a risk of complications, such as post-ERCP pancreatitis, bleeding, and perforation.1 Therefore, ERCP is reserved mainly for therapeutic indications. EUS is a less-invasive modality and has high accuracy for diagnosing pancreatobiliary diseases such as biliary stones and pancreatic tumors.2,3 These two procedures can be performed during a single session under same anesthesia, but concern regarding their safety has been raised due to complications.4,5 However, a single session results in a reduction in hospital stay and avoidance of repeated sedation as compared to multiple sessions.6,7,8,9,10,11 Previous studies only evaluate the utility of single-session EUS and ERCP in a single setting. Therefore, we performed a retrospective analysis of patients with pancreatobiliary diseases who underwent single-session EUS and ERCP to evaluate their safety and efficacy in a variable setting.

CASE REPORT

We retrospectively reviewed data from a prospectively maintained database of patients who underwent single-session EUS with/without fine-needle aspiration (FNA) and ERCP at Hokkaido University Hospital between July 2008 and December 2012. The collected data included age, sex, indications for the procedure, primary diseases, endoscopic and clinical outcomes, procedural complications, and pathological findings if observed. This study was approved by the Institutional Review Board of Hokkaido University Hospital and was registered with the University Hospital Medical Information Network-Clinical Trial Registry (UMIN-CTR; number, UMIN000008409).

Written informed consent was obtained from all patients before the procedures. Combined EUS and ERCP were performed under conscious sedation using intravenous midazolam with fentanyl. Before 2009, EUS was performed with a radial echoendoscope (GF-UM2000 or GF-UE260; Olympus Medical Systems Co., Tokyo, Japan). After introduction of the linear echoendoscope (GF-UCT240-AL5; Olympus Medical Systems Co.) to our institution, we used either type of echoendoscope at the discretion of the endoscopist. Patients also underwent EUS-guided FNA (EchoTip Ultra, Cook-Japan, Tokyo, Japan; or Expect, Boston Scientific Japan, Tokyo, Japan) with rapid on-site cytology evaluation if necessary. Subsequent ERCP-related procedures were performed following EUS during the same session using a duodenoscope (JF-240, TJF-240, or TJF-260V; Olympus Medical Systems Co.). In patients who were using antithrombotic or antiplatelet agents, each procedure was performed according to the Japanese guidelines.12 After the procedure, patients were monitored at an inpatient unit in the same way as those who underwent ERCP alone. Procedural-related complications were classified and graded according to consensus criteria.13

A total of 1,519 ERCP and 1,559 EUS procedures were performed respectively at our institution. Among them, 68 patients (mean age, 69 years; 38 males and 30 females) underwent EUS and ERCP in a single session and were included in this study (Table 1). Diagnostic EUS was performed in 38 patients (linear EUS in 14 and radial EUS in 24) with a median procedure time of 32 minutes. EUS-FNA was performed in 30 patients (44%) (Table 2). The sensitivity and specificity of EUS-FNA for malignancy were 100% and 100%. Choledocholithiasis was confirmed in all patients with acute cholangitis. Bile duct cannulation following EUS was successful in all but one patient. Sixty patients underwent therapeutic ERCP, whereas the remaining eight were diagnostic procedures. Thirteen patients underwent endoscopic sphincterotomy followed by stone extraction, whereas six patients underwent plastic stent placement due to severe cholangitis or were taking antithrombotic agents. Biliary drainage was performed using self-expandable metallic stents in 12 patients, plastic stents in 11, and nasobiliary drainage in 25.

Seven complications (10.3%; 95% confidence interval, 3.1 to 17.5) were observed. Six were post-ERCP pancreatitis. One patient with bile duct carcinoma who underwent EUS-FNA for lymph node and endoscopic nasobiliary drainage placement for obstructive jaundice developed severe pancreatitis. Three patients were mild, and two patients were moderate, according to the consensus criteria.13 All patients resolved with conservative management. One patient developed Mallory-Weiss syndrome 1 day after the single-session procedure, which required endoscopic hemostasis. No severe cardiopulmonary complications or deaths related to the combined procedure were observed.14

DISCUSSION

We revealed that single-session EUS and ERCP were both safe and effective for managing pancreatobiliary disorder in a variable setting. The combined procedure facilitated appropriate patient management without severe complications and could be considered a standard treatment that reduces hospital stay and avoids unnecessary sedation.

It was necessary but sometimes difficult to distinguish between malignant and benign originating lesions in patients with biliary obstructions. EUS has greater sensitivity for detecting small pancreatic tumors or preoperative staging than computed tomography,2 and improves the diagnosis of indeterminate bile duct strictures without EUS-FNA.15 Therefore, identifying unresectable malignant tumors by EUS in patients with a biliary obstruction may require a metallic stent rather than a plastic stent due to the longer patency.16 Furthermore, if the presence of a biliary stent interferes with preoperative staging of a pancreatic head tumor by EUS, EUS should be performed before ERCP to avoid unnecessary laparotomies.17 In this study, three patients who did not have tumors following the EUS examination were diagnosed with a benign biliary stricture, and were managed successfully. Ascunece et al.9 also reported that benign biliary strictures can be diagnosed and managed successfully by single-session EUS-ERCP without FNA.

EUS-FNA has great sensitivity for detecting malignancy in not only pancreatic tumors,18 but also biliary strictures.19 Identifying a malignancy by EUS-FNA eliminates the need for biliary brushing, the sensitivity of which is inferior to that of EUS-FNA.20 Furthermore, because preoperative biliary drainage is not necessary in patients with obstructive jaundice who undergo a Whipple resection, positive cytology could avoid unnecessary biliary stenting.21 Ross et al.7 reported that the combination of EUS-FNA with ERCP for evaluation of patients with obstructive jaundice from presumed pancreatic malignancy provides accurate tissue diagnosis and biliary drainage. In this study, EUS-FNA was performed in 30 patients; malignancy was detected in all malignant diseases. Three patients without malignancy were diagnosed with autoimmune pancreatitis and successfully managed with steroid therapy. Furthermore, EUS-FNA immediately after biliary stent placement was associated with a high rate of inconclusive cytology; thus, EUS-FNA should be performed before ERCP for a correct diagnosis.22 In patients with indeterminate biliary stricture, single-session EUS and ERCP would be the most reasonable.

EUS is superior to other modalities for detecting biliary stones and can avoid unnecessary ERCP in patients with suspected biliary stone or biliary pancreatitis.3,23,24 Fabbri et al.8 reported that single-session EUS and ERCP in patients at low risk of biliary stones is safe and effective with reduced procedural time and costs compared to performance in separate sessions. In our study, 13 patients underwent EUS and ERCP with sphincterotomy and stone extraction without complications, whereas the remaining patients with severe cholangitis and/or those who were taking antithrombotic agents underwent placement of a biliary stent without sphincterotomy. One of the concerns regarding a single-session procedure is total procedural time. However, Benjaminov et al.6 reported that separate EUS and ERCP sessions for symptomatic choledocholithiasis expose the patient to a higher risk of cholangitis as compared to a single-session procedure. Stone extraction in a single session is reasonable considering its safety and decreased hospital stay. Therefore, single-session EUS and ERCP would be the most useful for patients with cholangitis in whom choledocholithiasis could not be confirmed by other imaging modalities.

The advantage of single-session EUS and ERCP as compared to a separate session is expedited patient management, shortening of the hospital stay, reduced cost and avoidance of repeated sedation.8,10 The major disadvantages of these procedures are the long procedural time and the increase in intestinal gas volume.4,5 However, previous studies of single-session EUS and ERCP reported no severe complications.7,8,9,10 We observed six cases of post-ERCP pancreatitis, all of which resolved with conservative management. However, post-ERCP pancreatitis is an inherent complication of ERCP and was not attributed to the single-session procedure. We had experienced one Mallory-Weiss syndrome, which was also one of the complications of upper endoscopy. Iles-Shih et al.11 reported the safety of single-session EUS and ERCP in elderly patients, with no more adverse events than in nonelderly patients. Therefore, this disadvantage does not preclude performance of both procedures in a single session, considering their efficacy.

Our study had some limitations. First, it was of a retrospective design conducted at a single center. Second, a single-session procedure can be performed only by endoscopists experienced in both EUS and ERCP. A single-session procedure is not the standard. Third, we did not compare hospital stay duration and the cost of a single-session procedure with those of separate sessions. Fourth, we could not evaluate the patients who could avoid unnecessary ERCP.

Our results show that single-session EUS and ERCP were safe and useful for management of pancreatobiliary diseases. However, development of a new therapeutic endoscope, using which both EUS and ERCP can be performed in a single-session without scope exchange, is necessary for the widespread acceptance of this combined procedure.

Table 1 Patient Characteristics

Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.

|@|Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.

Table 2 Characteristics of the Procedures

Data are presented as number (%) or median (interquartile range).

EUS, endoscopic ultrasonography; EUS-FNA, EUS-guided fine-needle aspiration; ERCP, endoscopic retrograde cholangiopancreatography; ENBD, endoscopic nasobiliary drainage; SEMS, self-expandable metallic stent.

|@|Data are presented as number or median (interquartile range).

EUS, endoscopic ultrasonography; WBC, white blood cells; CRP, C-reactive protein.

References

  1. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70;80-88.
    Pubmed
  2. DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med. 2004;141;753-763.
    Pubmed
  3. Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study. Clin Gastroenterol Hepatol. 2005;3;1238-1244.
    Pubmed
  4. Mergener K, Jowell PS, Branch MS, Baillie J. Pneumoperitoneum complicating ERCP performed immediately after EUS-guided fine needle aspiration. Gastrointest Endosc. 1998;47;541-542.
    Pubmed
  5. Di Matteo F, Shimpi L, Gabbrielli A, et al. Same-day endoscopic retrograde cholangiopancreatography after transduodenal endoscopic ultrasound-guided needle aspiration: do we need to be cautious?. Endoscopy. 2006;38;1149-1151.
    Pubmed
  6. Benjaminov F, Stein A, Lichtman G, Pomeranz I, Konikoff FM. Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis. Surg Endosc. 2013;27;2117-2121.
    Pubmed
  7. Ross WA, Wasan SM, Evans DB, et al. Combined EUS with FNA and ERCP for the evaluation of patients with obstructive jaundice from presumed pancreatic malignancy. Gastrointest Endosc. 2008;68;461-466.
    Pubmed
  8. Fabbri C, Polifemo AM, Luigiano C, et al. Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis. J Gastroenterol Hepatol. 2009;24;1107-1112.
    Pubmed
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Gut and Liver

Vol.19 No.1
January, 2025

pISSN 1976-2283
eISSN 2005-1212

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