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• W2089616730 abstract "Radial or linear EUS and MRCP are less-invasive procedures than ERCP, with a diagnostic accuracy for CBD stones that is nearly as good as that of ERCP.ERCP has evolved considerably since its conception in the seventies.1McCune W.S. Shorb P.E. Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report.Ann Surg. 1968; 167: 752-756Crossref PubMed Scopus (497) Google Scholar The introduction of therapeutic options with sphincterotomy, followed by techniques of stone extraction2Kawai K. Akasaka Y. Murakami K. Tada M. Koli Y. Endoscopic sphincterotomy of the ampulla of Vater.Gastrointest Endosc. 1974; 20: 148-151Abstract Full Text PDF PubMed Scopus (634) Google Scholar, 3Classen M. Demling L. Endoskopische sphinkterotomie der papilla vateri und steinextraktion aus dem ductus choledochus.Dtsch Med Wochenschr. 1974; 99: 496-497Crossref PubMed Scopus (591) Google Scholar and stenting, were logical steps towards complex endotherapy, which now is performed routinely throughout the world. ERCP complications were recognized early in its evolution, and the development of alternative diagnostic tools (eg, EUS and MRCP) has now limited ERCP to a predominantly therapeutic procedure. Indications and patient selection for ERCP have been outlined in an National Institutes of Health state-of-the-science statement4NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.NIH Consens State Sci Statements. 2002; 19: 1-26Google Scholar and a recent American Society for Gastrointestinal Endoscopy (ASGE) guideline.5Adler D.G. Baron T.H. Davila R.G. et al.ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.Gastrointest Endosc. 2005; 62: 1-8Abstract Full Text Full Text PDF PubMed Scopus (307) Google ScholarRadial or linear EUS and MRCP are less-invasive alternatives to ERCP for investigating the biliary and pancreatic tree, both of which have a reported accuracy nearly equal to good-quality endoscopic retrograde cholangiography (ERC) in the diagnosis of common bile duct (CBD) stones.6Ainsworth A.P. Rafaelsen S.R. Wamberg P.A. Durup J. Pless T.K. Mortensen M.B. Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?.Endoscopy. 2003; 35: 1029-1032Crossref PubMed Scopus (85) Google Scholar, 7Prat F. Amouyal G. Amouyal P. et al.Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.Lancet. 1996; 346: 75-79Crossref Scopus (302) Google Scholar, 8Kohut M. Nowakowska-Dulawa E. Marek T. Kaczor R. Nowak A. Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.Endoscopy. 2002; 34: 299-303Crossref PubMed Scopus (80) Google Scholar EUS has the distinct advantage of allowing patients to undergo a therapeutic ERCP in the same setting, should this be necessary. This approach has been advocated, especially for patients with biliary pancreatitis.9Prat F. Edery J. Meduri B. et al.Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.Gastrointest Endosc. 2001; 54: 724-729Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar However, this procedure can pose logistic difficulties, and there are no clear data on how to proceed in patients with moderate to low risk of CBD stones and no biliary pancreatitis.In this issue of Gastrointestinal Endoscopy, Rocca et al10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar present their findings from a feasibility study by using a combined oblique-viewing endoscope and radial echoendoscope (JF-UM20; Olympus Optical Co, Tokyo, Japan) in patients identified to be at low to intermediate risk for CBD stones.They included 19 patients with acute abdominal pain associated with elevated liver enzyme levels (aminotransferases and γ-glutamyl transpeptidase or alkaline phosphatase greater than 3 times the normal values) and abdominal US results negative for CBD stones in this observational pilot study. Mild acute biliary pancreatitis (Glasgow score <3) was present in 7 cases (37%) on admission. Other patients with clear evidence of CBD stones underwent ERCP directly.At first sight, the results of this study are impressive. After a mean time of 27 minutes, all but 1 patient had undergone the radial EUS and, whenever necessary, therapeutic ERC in one session. ERC failed in 1 patient, who had to undergo conventional therapeutic ERC the following day. Therapeutic biliary interventions were undertaken via the dedicated echoendoscope in 16 of 19 patients (84%). Sludge was suspected on EUS results and confirmed by sphincterotomy and instrumental bile duct exploration in 12 patients and stones in 4 patients, respectively. There were no short-term or 30-day, long-term complications.The study does demonstrate the technical feasibility of the combined approach, and the authors discuss its technical limitations openly. However, commonly seen problems with observational studies also hamper interpretation of the study by Rocca et al.10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The main drawbacks lie in poor patient selection criteria, incomplete data on important investigations, and the unblinded nature of the study. Rocca et al10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar selected patients for the combined approach on the basis of right upper quadrant pain, elevated liver enzyme levels 3 times the normal value, and negative abdominal US results. Little is said about the quality of the abdominal US or whether repeat scans were made after fasting in patients with difficult scans. Only 6 of 19 patients had negative MRCP results, and we are not told which of these patients had sludge or stones on EUS. Furthermore, elevated transaminase and alkaline phosphatase/γ-glutamyl transpeptidase levels have a predictive value for stones on their own; combined with typical biliary pain, these can be considered strong predictors of stones or sludge.11Trondsen E. Edwin B. Reiertsen O. Faerden A.E. Fagertun H. Rosseland A.R. Prediction of common bile duct stones prior to cholecystectomy: a prospective validation of a discriminant analysis function.Arch Surg. 1998; 133: 162-166Crossref PubMed Scopus (98) Google Scholar, 12Onken J.E. Brazer S.R. Eisen G.M. et al.Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis.Am J Gastroenterol. 1996; 91: 762-767PubMed Google Scholar This is confirmed indirectly by the high intervention rate of 84% for stones or sludge. Therefore, first-line ERCP in the patients also would have been a reasonable approach. Alternatively, either extraductal endoscopic miniprobe US or intraductal miniprobe US could be considered a true alternative in this group of patients.13Seifert H. Wehrmann T. Hilgers R. Gouder S. Braden B. Dietrich C.F. Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.Gastrointest Endosc. 2004; 60: 61-67Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 14Domagk D. Wessling J. Reimer P. et al.Endoscopic retrograde cholangiopancreatography, intraductal ultrasonography, and magnetic resonance cholangiopancreatography in bile duct strictures: a prospective comparison of imaging diagnostics with histopathological correlation.Am J Gastroenterol. 2004; 99: 1684-1689Crossref PubMed Scopus (112) Google ScholarThe current technical drawbacks of the combined radial EUS and side-viewing endoscope with fiberoptics, a small working channel, and only single-frequency EUS can certainly be overcome, but it is questionable whether this technology will find much clinical use. In this context, it is worth noting that the sensitivity of EUS to diagnose entities other than bile duct stones (eg, to exclude a stenosis of the biliary or pancreatic duct system) has not been systematically investigated yet.We consider the combination of linear array EUS with a large working channel, side-viewing endoscope and an elevator to be a more useful development. These instruments already allow both diagnostic and therapeutic EUS (eg, pancreatic pseudocyst puncture) and, with a modified design, possibly bile duct cannulation via the ampulla of Vater in the future. Interventional EUS with linear array echoendoscopes clearly will be used in the future, particularly when transpapillary access to the CBD is difficult or impossible. Recent reports include EUS-guided puncture of the CBD in a transduodenal fashion and transgastric access to the biliary system in patients with malignant biliary obstruction where conventional ERCP fails.15Burmester E. Niehaus J. Leineweber T. Huetteroth T. EUS-cholangio-drainage of the bile duct: report of 4 cases.Gastrointest Endosc. 2003; 57: 246-251Abstract Full Text PDF PubMed Scopus (275) Google Scholar, 16Giovannini M. Moutardier V. Pesenti C. Bories E. Lelong B. Delpero J.R. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.Endoscopy. 2001; 33: 898-900Crossref PubMed Scopus (494) Google Scholar, 17Mallery S. Matlock J. Freeman M.L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.Gastrointest Endosc. 2004; 59: 100-107Abstract Full Text Full Text PDF PubMed Scopus (313) Google ScholarAt present, consecutive use of EUS and then ERCP, if necessary, can be considered the reference standard, especially in the setting of presumed biliary pancreatitis. However, further technical refinements may lead to the development of a perfect EUS-duodenoscope, which could make the simultaneous EUS-ERCP approach a strong combination. Radial or linear EUS and MRCP are less-invasive procedures than ERCP, with a diagnostic accuracy for CBD stones that is nearly as good as that of ERCP.ERCP has evolved considerably since its conception in the seventies.1McCune W.S. Shorb P.E. Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report.Ann Surg. 1968; 167: 752-756Crossref PubMed Scopus (497) Google Scholar The introduction of therapeutic options with sphincterotomy, followed by techniques of stone extraction2Kawai K. Akasaka Y. Murakami K. Tada M. Koli Y. Endoscopic sphincterotomy of the ampulla of Vater.Gastrointest Endosc. 1974; 20: 148-151Abstract Full Text PDF PubMed Scopus (634) Google Scholar, 3Classen M. Demling L. Endoskopische sphinkterotomie der papilla vateri und steinextraktion aus dem ductus choledochus.Dtsch Med Wochenschr. 1974; 99: 496-497Crossref PubMed Scopus (591) Google Scholar and stenting, were logical steps towards complex endotherapy, which now is performed routinely throughout the world. ERCP complications were recognized early in its evolution, and the development of alternative diagnostic tools (eg, EUS and MRCP) has now limited ERCP to a predominantly therapeutic procedure. Indications and patient selection for ERCP have been outlined in an National Institutes of Health state-of-the-science statement4NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.NIH Consens State Sci Statements. 2002; 19: 1-26Google Scholar and a recent American Society for Gastrointestinal Endoscopy (ASGE) guideline.5Adler D.G. Baron T.H. Davila R.G. et al.ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.Gastrointest Endosc. 2005; 62: 1-8Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar Radial or linear EUS and MRCP are less-invasive procedures than ERCP, with a diagnostic accuracy for CBD stones that is nearly as good as that of ERCP. Radial or linear EUS and MRCP are less-invasive procedures than ERCP, with a diagnostic accuracy for CBD stones that is nearly as good as that of ERCP. Radial or linear EUS and MRCP are less-invasive alternatives to ERCP for investigating the biliary and pancreatic tree, both of which have a reported accuracy nearly equal to good-quality endoscopic retrograde cholangiography (ERC) in the diagnosis of common bile duct (CBD) stones.6Ainsworth A.P. Rafaelsen S.R. Wamberg P.A. Durup J. Pless T.K. Mortensen M.B. Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?.Endoscopy. 2003; 35: 1029-1032Crossref PubMed Scopus (85) Google Scholar, 7Prat F. Amouyal G. Amouyal P. et al.Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.Lancet. 1996; 346: 75-79Crossref Scopus (302) Google Scholar, 8Kohut M. Nowakowska-Dulawa E. Marek T. Kaczor R. Nowak A. Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.Endoscopy. 2002; 34: 299-303Crossref PubMed Scopus (80) Google Scholar EUS has the distinct advantage of allowing patients to undergo a therapeutic ERCP in the same setting, should this be necessary. This approach has been advocated, especially for patients with biliary pancreatitis.9Prat F. Edery J. Meduri B. et al.Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.Gastrointest Endosc. 2001; 54: 724-729Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar However, this procedure can pose logistic difficulties, and there are no clear data on how to proceed in patients with moderate to low risk of CBD stones and no biliary pancreatitis. In this issue of Gastrointestinal Endoscopy, Rocca et al10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar present their findings from a feasibility study by using a combined oblique-viewing endoscope and radial echoendoscope (JF-UM20; Olympus Optical Co, Tokyo, Japan) in patients identified to be at low to intermediate risk for CBD stones. They included 19 patients with acute abdominal pain associated with elevated liver enzyme levels (aminotransferases and γ-glutamyl transpeptidase or alkaline phosphatase greater than 3 times the normal values) and abdominal US results negative for CBD stones in this observational pilot study. Mild acute biliary pancreatitis (Glasgow score <3) was present in 7 cases (37%) on admission. Other patients with clear evidence of CBD stones underwent ERCP directly. At first sight, the results of this study are impressive. After a mean time of 27 minutes, all but 1 patient had undergone the radial EUS and, whenever necessary, therapeutic ERC in one session. ERC failed in 1 patient, who had to undergo conventional therapeutic ERC the following day. Therapeutic biliary interventions were undertaken via the dedicated echoendoscope in 16 of 19 patients (84%). Sludge was suspected on EUS results and confirmed by sphincterotomy and instrumental bile duct exploration in 12 patients and stones in 4 patients, respectively. There were no short-term or 30-day, long-term complications. The study does demonstrate the technical feasibility of the combined approach, and the authors discuss its technical limitations openly. However, commonly seen problems with observational studies also hamper interpretation of the study by Rocca et al.10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The main drawbacks lie in poor patient selection criteria, incomplete data on important investigations, and the unblinded nature of the study. Rocca et al10Rocca R. De Angelis C. Castellino F. et al.EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.Gastrointest Endosc. 2006; 63: 479-484Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar selected patients for the combined approach on the basis of right upper quadrant pain, elevated liver enzyme levels 3 times the normal value, and negative abdominal US results. Little is said about the quality of the abdominal US or whether repeat scans were made after fasting in patients with difficult scans. Only 6 of 19 patients had negative MRCP results, and we are not told which of these patients had sludge or stones on EUS. Furthermore, elevated transaminase and alkaline phosphatase/γ-glutamyl transpeptidase levels have a predictive value for stones on their own; combined with typical biliary pain, these can be considered strong predictors of stones or sludge.11Trondsen E. Edwin B. Reiertsen O. Faerden A.E. Fagertun H. Rosseland A.R. Prediction of common bile duct stones prior to cholecystectomy: a prospective validation of a discriminant analysis function.Arch Surg. 1998; 133: 162-166Crossref PubMed Scopus (98) Google Scholar, 12Onken J.E. Brazer S.R. Eisen G.M. et al.Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis.Am J Gastroenterol. 1996; 91: 762-767PubMed Google Scholar This is confirmed indirectly by the high intervention rate of 84% for stones or sludge. Therefore, first-line ERCP in the patients also would have been a reasonable approach. Alternatively, either extraductal endoscopic miniprobe US or intraductal miniprobe US could be considered a true alternative in this group of patients.13Seifert H. Wehrmann T. Hilgers R. Gouder S. Braden B. Dietrich C.F. Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.Gastrointest Endosc. 2004; 60: 61-67Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 14Domagk D. Wessling J. Reimer P. et al.Endoscopic retrograde cholangiopancreatography, intraductal ultrasonography, and magnetic resonance cholangiopancreatography in bile duct strictures: a prospective comparison of imaging diagnostics with histopathological correlation.Am J Gastroenterol. 2004; 99: 1684-1689Crossref PubMed Scopus (112) Google Scholar The current technical drawbacks of the combined radial EUS and side-viewing endoscope with fiberoptics, a small working channel, and only single-frequency EUS can certainly be overcome, but it is questionable whether this technology will find much clinical use. In this context, it is worth noting that the sensitivity of EUS to diagnose entities other than bile duct stones (eg, to exclude a stenosis of the biliary or pancreatic duct system) has not been systematically investigated yet. We consider the combination of linear array EUS with a large working channel, side-viewing endoscope and an elevator to be a more useful development. These instruments already allow both diagnostic and therapeutic EUS (eg, pancreatic pseudocyst puncture) and, with a modified design, possibly bile duct cannulation via the ampulla of Vater in the future. Interventional EUS with linear array echoendoscopes clearly will be used in the future, particularly when transpapillary access to the CBD is difficult or impossible. Recent reports include EUS-guided puncture of the CBD in a transduodenal fashion and transgastric access to the biliary system in patients with malignant biliary obstruction where conventional ERCP fails.15Burmester E. Niehaus J. Leineweber T. Huetteroth T. EUS-cholangio-drainage of the bile duct: report of 4 cases.Gastrointest Endosc. 2003; 57: 246-251Abstract Full Text PDF PubMed Scopus (275) Google Scholar, 16Giovannini M. Moutardier V. Pesenti C. Bories E. Lelong B. Delpero J.R. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.Endoscopy. 2001; 33: 898-900Crossref PubMed Scopus (494) Google Scholar, 17Mallery S. Matlock J. Freeman M.L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.Gastrointest Endosc. 2004; 59: 100-107Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar At present, consecutive use of EUS and then ERCP, if necessary, can be considered the reference standard, especially in the setting of presumed biliary pancreatitis. However, further technical refinements may lead to the development of a perfect EUS-duodenoscope, which could make the simultaneous EUS-ERCP approach a strong combination." @default.
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• W2089616730 title "EUS and ERCP combined: together we are strong?" @default.
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