https://www.commed.vcu.edu/Chronic_Disease/2012/cochranrvwrschbias.pdf

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

Cholangiocarcinoma (CCA) is a heterogeneous group of malignancies with features of biliary tract differentiation. CCA is the second most common primary liver tumour and the incidence is increasing worldwide. CCA has high mortality owing to its aggressiveness, late diagnosis and refractory nature. In May 2015, the "European Network for the Study of Cholangiocarcinoma" (ENS-CCA: www.enscca.org or www.cholangiocarcinoma.eu) was created to promote and boost international research collaboration on the study of CCA at basic, translational and clinical level. In this Consensus Statement, we aim to provide valuable information on classifications, pathological features, risk factors, cells of origin, genetic and epigenetic modifications and current therapies available for this cancer. Moreover, future directions on basic and clinical investigations and plans for the ENS-CCA are highlighted.

/pdf/expert-consensus-document-cholangiocarcinoma-current-1ot5rctd8a.pdf

Expert consensus document: Cholangiocarcinoma: current knowledge and future perspectives consensus statement from the European Network for the Study of Cholangiocarcinoma (ENS-CCA)

LETTERS to the EDITORPublication bias

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations
 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 – 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

/pdf/prophylaxis-of-post-ercp-pancreatitis-european-society-of-1hcftrp19s.pdf

Prophylaxis of post-ERCP pancreatitis: European society of gastrointestinal endoscopy (ESGE) guideline - Updated June 2014

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations
 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation). In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation). ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation). When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation). In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).

/pdf/papillary-cannulation-and-sphincterotomy-techniques-at-ercp-4fffk67pzp.pdf

Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

There is no clear answer regarding use of precut technique versus conventional method in achieving successful biliary cannulation. To compare the effectiveness of precut technique with that of conventional biliary cannulation by meta-analysis of available randomized controlled trials (RCTs). Databases including MEDLINE, EMBASE, Cochrane Library, and Science Citation Index updated to July 2009 were searched. Main outcome measures were success rates of biliary cannulation, incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications, and post-ERCP pancreatitis rate. Meta-analysis of these clinical trials was performed. Six RCTs were included. The primary biliary cannulation rate reported with precut and conventional techniques was 89.3 and 78.1%, respectively. Pooled analysis of all selected studies comparing precut cannulation technique with conventional techniques yielded an odds ratio (OR) of 2.05 [95% confidence interval (CI): 0.64–6.63]. Pooled analysis comparing post-ERCP pancreatitis rates for the precut-cannulation groups with those for the conventional-method groups yielded an rate ratio (RR) of 0.46 (95% CI: 0.23–0.92). This meta-analysis shows that the precut technique does not increase the primary cannulation rate. However, the technique reduces the risk of post-ERCP pancreatitis compared with conventional technique. Further large, well-performed, randomized controlled studies are needed to confirm these findings.

Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials

Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis.

Previous studies comparing sodium picosulfate/magnesium citrate (SPMC) with polyethylene glycol (PEG) drew inconsistent conclusions. We conducted a meta-analysis to compare the performance of the two agents for colonoscopy preparation. A search of randomized controlled trials (RCTs) up to July 2015 was acquired, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. We calculated the pooled estimates of bowel cleanliness, polyp/adenoma detection rate (PDR/ADR), completion of preparation, willingness to repeat identical bowel preparation, and adverse events by using relative risk (RR) with random-effects models. A non-inferiority analysis was performed, comparing SPMC to PEG for bowel cleaning efficacy. A total of 25 RCTs were qualified for analysis. There was no statistically significant difference between the two agents in bowel cleanliness, but the effect direction showed a trend in favor of PEG (RR 0.93; 95 % CI 0.86–1.01, P = 0.07). The non-inferiority analysis demonstrated the non-inferiority of SPMC by retaining at least 90 % of the effect of PEG. Similarly, there was no significant difference between the two agents in PDR (RR 0.94; 95 % CI 0.82–1.08, P = 0.37) and ADR (RR 0.88; 95 % CI 0.74–1.05, P = 0.16). However, a higher proportion of patients were likely to complete SPMC preparation (RR 1.08; 95 % CI 1.04–1.13, P < 0.001) and were willing to repeat SPMC preparation (RR 1.44; 95 % CI 1.25–1.67, P < 0.001). The total number of adverse events was significantly lower in the SPMC group (RR 0.78; 95 % CI 0.66–0.93, P = 0.004). SPMC, with better tolerability and less frequent adverse events, demonstrated non-inferior bowel cleaning efficacy than that of the PEG. Large-scale, well-organized, head-to-head studies are warranted.

Systematic review and meta-analysis: sodium picosulfate/magnesium citrate vs. polyethylene glycol for colonoscopy preparation.

Objective The aim of this study was to compare the short-term and long-term outcomes of endoscopic sphincterotomy (EST) with endoscopic papillary balloon dilation (EPBD), and to find out risk factors for long-term complications. Patients and methods From January 2008 to June 2011, patients who underwent endoscopic retrograde cholangiopancreatography for common bile duct stone removal were included, and they were divided into EST and EPBD groups. Clinical information was retrospectively viewed, and the patients were contacted through telephone or by searching for the medical records to get long-term outcomes. Results A total of 863 patients were included, with 636 patients in the EST group and 227 patients in the EPBD group. There was no difference in the rate of complete stone removal and early complications, except for pancreatitis. In all, 493 patients in the EST group and 170 patients in the EST group were followed up for 36.7-77.6 months. More patients in the EST group developed cholangitis, stone recurrence, and cholecystitis in the long term. Multivariate analysis showed that EPBD was a protective factor for cholangitis, stone recurrence, and cholecystitis. Gall stones were risk factors for cholangitis and cholecystitis. Mechanical lithotripsy may also be a risk factor for stone recurrence. Conclusion EST shows better results in early outcomes, but during long-term follow-up patients following EST experienced more number of late complications. Gall stones and mechanical lithotripsy may be risk factors for long-term complications.

Short-term and long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.

Background and aimPeriampullary diverticulum (PAD) is frequently encountered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate the association of PAD with pancreaticobiliary diseases as well as the impact of PAD on the technical su

Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography.

Biao Gong

Papers

Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials

Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis.

Systematic review and meta-analysis: sodium picosulfate/magnesium citrate vs. polyethylene glycol for colonoscopy preparation.

Short-term and long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones.

Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography.