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

[Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea]

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Society of Pancreatobiliary Endoscopy has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five pre-procedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs.

Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures-a propensity score match analysis of the Hungarian ERCP Registry

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for the minimally invasive management of biliary and pancreatic disorders. Under certain indications, performing ERCP without delay during the weekend can be important for improving outcomes.

Objectives

To compare the outcomes of ERCP performed on weekends and holidays with those of regular weekday ERCPs.

Design

Propensity score match analysis of the data from the Hungarian ERCP Registry.

Methods

A total of 116 ERCPs were performed during weekends or holidays, and 3144 during weekday working hours. The analyses were performed on 1:2 propensity-matched groups (116 weekend and 232 weekday cases).

Results

Weekend ERCPs were mostly performed for acute cholangitis and acute biliary pancreatitis (70% of cases), whereas in the weekday group, only 32% of cases were performed for these indications. No significant difference was found between weekday and weekend ERCPs in terms of the rates of successful (91.38% vs 93.1%, p = 0.565) and difficult (33.62% vs 36.64%, p = 0.511) biliary cannulations. We found no significant differences in the number of adverse events (bleeding, post-ERCP pancreatitis, and 30-day mortality) in ERCPs performed during weekends or weekdays. Moreover, no significant differences in the aforementioned outcomes were detected between the propensity-matched groups.

Conclusion

In this propensity-matched study, no significant differences were found in the outcomes of weekend and weekday ERCPs.

Multistep validation of a post-ERCP pancreatitis prediction system integrating multimodal data: a multicenter study

BACKGROUND AND AIMS

The impact of various categories of information on the prediction of post-ERCP pancreatitis (PEP) remains uncertain. We comprehensively investigated the risk factors associated with PEP by constructing and validating a model incorporating multimodal data through multiple steps.

METHODS

Cases (n = 1916) of ERCP were retrospectively collected from multiple centers for model construction. Through literature research, 49 electronic health record (EHR) features and 1 image feature related to PEP were identified. The EHR features were categorized into baseline, diagnosis, technique, and prevention strategies, covering pre-ERCP, intra-ERCP, and peri-ERCP phases. We first incrementally constructed models 1 to 4 incorporating these 4 feature categories and then added the image feature into models 1 to 4 and developed models 5 to 8. All models underwent testing and comparison using both internal and external test sets. Once the optimal model was selected, we conducted comparisons among multiple machine learning algorithms.

RESULTS

Compared with model 2 that incorporated baseline and diagnosis features, adding technique and prevention strategies (model 4) greatly improved the sensitivity (63.89% vs 83.33%, P < .05) and specificity (75.00% vs 85.92%, P < .001). A similar tendency was observed in the internal and external tests. In model 4, the top 3 features ranked by weight were previous pancreatitis, nonsteroidal anti-inflammatory drug use, and difficult cannulation. The image-based feature has the highest weight in models 5 to 8. Finally, model 8 used a random forest algorithm and showed the best performance.

CONCLUSIONS

We first developed a multimodal prediction model for identifying PEP with a clinical-acceptable performance. The image and technique features are crucial for PEP prediction.

Effective use of the two-devices-in-one-channel technique for stent exchange following endoscopic ultrasound-guided hepaticogastrostomy

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Same versus separate sessions of endoscopic ultrasound-guided fine-needle biopsy and endoscopic retrograde cholangiopancreatography for distal malignant biliary obstruction: a propensity score-matched study

BACKGROUND

Same-session endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) is an attractive policy for patients with distal malignant biliary obstruction (DMBO) requiring fine-needle biopsy (FNB) and biliary drainage. However, scanty and conflicting data exists regarding safety and efficacy when comparing these two procedures performed in same versus separate sessions.

METHODS

Single-center, retrospective, propensity score-matched study including patients with DMBO who underwent EUS-FNB followed by ERCP during the same or separate sessions. The primary outcome was the safety of the procedure [number of patients experiencing adverse events (AEs), overall AEs, its severity, post-ERCP pancreatitis (PEP)]. Secondary outcomes were successful ERCP, use of advanced cannulation techniques, EUS-FNB adequacy, length of hospital stay, overall procedure time, and time to recurrent biliary obstruction.

RESULTS

After propensity matching, 87 patients were allocated to each group. AEs developed in 23 (26.4%) vs. 17 (19.5%) patients in the same and separate sessions group, respectively (p = 0.280). The overall number, the severity of AEs, and the rate of PEP were similar in the two groups. Secondary outcome parameters were also comparable in the 2 groups.

CONCLUSIONS

Same-session EUS-FNB followed by ERCP with biliary drainage is safe and does not impair technical outcomes of tissue adequacy and biliary cannulation.

Impact of periampullary diverticula on the rates of successful cannulation and ERCP complications: An up-to-date systematic review and meta-analysis

OBJECTIVES

Periampullary diverticulum (PAD) is usually incidentally discovered during abdominal imaging, gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The influence of PAD on ERCP outcomes is unclear. The aim of this systematic review and meta-analysis was to provide an up-to-date evaluation of the impact of PAD on cannulation and ERCP-related complications.

METHODS

PubMed, Web of Science, Cochrane Library and EMBASE databases were searched for relevant articles published up to October 31, 2023. The rates of successful cannulation and post-ERCP complications were compared between the PAD and non-PAD groups. The quality of the studies was evaluated with the Newcastle-Ottawa Scale (NOS). The meta-analysis was conducted using Review Manager 5.3.

RESULTS

Twenty-eight articles were included. Non-PAD was associated with a relatively high cannulation success rate (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54-0.97, p = 0.03). However, after 2015, PAD was not correlated with cannulation failure (OR 0.81, 95% CI 0.59-1.11, p = 0.20). Compared with intradiverticular papilla (IDP), non-IDP had a higher successful cannulation rate (OR 0.42, 95% CI 0.25-0.72, p = 0.002), while IDP increased the difficult cannulation rate (OR 1.60, 95% CI 1.05-2.44, p = 0.03). Additionally, PAD increased the incidence of ERCP-related pancreatitis (OR 1.24, 95% CI 1.10-1.40, p = 0.0006) and bleeding (OR 1.34, 95% CI 1.03-1.73, p = 0.03).

CONCLUSIONS

Although PAD, especially IDP, decreased the cannulation success rate, PAD was no longer considered a significant obstacle to cannulation after 2015. PAD increased the incidence of post-ERCP pancreatitis and bleeding.

Current Gallstone Treatment Methods, State of the Art

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Efficacy of Diclofenac and Indomethacin for Prevention of Post-Endoscopic Cholangiopancreatography (ERCP) Pancreatitis: A Systematic Review

Endoscopic cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic tool for pancreaticobiliary conditions. One of its major complications is pancreatitis. This study aims to understand the incidence of post-ERCP pancreatitis after using rectal diclofenac and Indomethacin as prophylactic measures. We retrieved 2870 articles from the PubMed, ScienceDirect, and Google Scholar databases. Using the Medical Subject Headings (MeSH) strategy in PubMed, we chose research articles published in the last five years. Exclusion criteria included paid full-text articles, abstracts, letters to editors, patients not undergoing ERCP, ages more than 45 years, animal studies, and non-English studies. The 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria were used in the design of our systematic reviews. It was found that the medical world is still debating whether rectal diclofenac and Indomethacin are beneficial in avoiding post-ERCP pancreatitis (PEP). Rectal diclofenac is used. Although its effectiveness is debated due to mixed findings and concerns about certain outcomes, it is also considered beneficial in specific circumstances, such as before ERCP. Studies on rectal Indomethacin also yield contradictory results; while some emphasize the drug's large reduction in PEP incidence, especially in low-risk people, others question its efficacy. We need further studies to clarify the remaining uncertainties.

Visibility of the biliary orifice after precut papillotomy: Comparison between white light imaging and texture and color enhancement imaging

BACKGROUND

Precut papillotomy is performed in cases of difficult biliary cannulation, but identification of the biliary orifice is difficult. Texture and color enhancement imaging (TXI) can enhance the structure, color, and brightness. This study compared TXI and white light imaging (WLI) in visibility of biliary orifices.

METHODS

We retrospectively examined 20 patients who underwent bile duct cannulation using both WLI and TXI after precut papillotomy at our center between 2021 and 2022. On WLI and TXI images displayed in random order, bile duct orifice on precut-incision surface of each image was independently evaluated by eight evaluators. Single-indication accuracy rate of biliary orifices, visibility score rated on a 4-grade scale, and color difference between the biliary orifice and the surrounding tissue were examined.

RESULTS

The single-indication accuracy rate was higher in TXI compared to WLI (50.6% vs. 35.6%, odds ratio 2.26 [95% CI: 1.32-3.89], p = .003). The time to indicate the biliary orifice was comparable between TXI and WLI (median, 9.7 s [range, 2.6-43] vs. 10.9 s [1.5-64], p = .086). Furthermore, the visibility score was higher in TXI than in WLI (median, 3 [interquartile range, 2-3] vs. 2 [2, 3], p < .001), and the color difference between the biliary orifice and surrounding tissue in TXI was more pronounced than in WLI (median, 22.9 [range, 9.39-55.2] vs. 18.0 [6.48-43.0]; p < .001).

CONCLUSIONS

TXI enhanced the color difference and visibility of the biliary orifice after precut and improved single-indication accuracy rate, suggesting that it could be useful for biliary cannulation after precut papillotomy.

Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea.

Pure cut vs. Endocut in endoscopic biliary sphincterotomy: Systematic review and meta-analysis of randomized clinical trials

Background and study aims Biliary sphincterotomy is a crucial step in endoscopic retrograde cholangiopancreatography (ERCP), a procedure known to carry a 5% to 10% risk of complications. The relationship between Pure cut, Endocut, post-ERCP pancreatitis (PEP) and bleeding is unclear. This systematic review and meta-analysis compared these two current types and their relationships with adverse events. Patients and methods This systematic review involved searching articles in multiple databases until August 2023 comparing pure cut versus Endocut in biliary sphincterotomy. The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results A total of 987 patients from four randomized controlled trials were included. Overall pancreatitis: A higher risk of pancreatitis was found in the Endocut group than in the Pure cut group ( P =0.001, RD=0.04 [range, 0.01 to 0.06]; I 2 =29%). Overall immediate bleeding: Statistical significance was found to favor Endocut, ( P =0.05; RD=-0.15 [range, -0.29 to -0.00]; I 2 =93%). No statistical significance between current modes was found in immediate bleeding without endoscopic intervention ( P =0.10; RD=-0.13 [range, -0.29 to 0.02]; I 2 =88%), immediate bleeding with endoscopic intervention ( P =0.06; RD=-0.07 [range, -0.14 to 0.00]; I 2 =76%), delayed bleeding (P=0.40; RD=0.01 [range, -0.02 to 0.05]; I 2 =72%), zipper cut ( P =0.58; RD=-0.03 [range, -0.16 to 0.09]; I 2 =97%), perforation ( P =1.00; RD=0.00 [range, -0.01 to 0.01]; I 2 =0%) and cholangitis ( P =0.77; RD=0.00 [range, -0.01 to 0.02]; I 2 =29%). Conclusions The available data in the literature show that Endocut carries an increased risk for PEP and does not prevent delayed or clinically significant bleeding, although it prevents intraprocedural bleeding. Based on such findings, Pure cut should be the preferred electric current mode for biliary sphincterotomy.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD)

Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a minimally invasive procedure that allows for biliary access when conventional endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. The technique can be divided based on biliary access route: intrahepatic or extrahepatic, as well as on stenting approach: rendezvous approach (EUS-RV), antegrade placement, or transluminal (intra or extra hepatic) placement. There is no clear consensus on which approach is superior. Compared to percutaneous transhepatic biliary drainage, EUS-BD offers lower rates of adverse events without the need for an external drain. Compared to conventional ERCP, EUS-BD shows comparable, and in some cases superior, outcomes related to technical success, clinical success, and adverse events.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP), with its clinical ad-vantages of less trauma and faster recovery, has become the primary treatment for choledocholithiasis.

AIM

To investigate the effects of different ERCP procedures on the sphincter of Oddi.

METHODS

The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively. The patients were divided into endoscopic sphincterotomy (EST, n = 24) and endoscopic papillary balloon dilation (EPBD, n = 67) groups. The duration of operation, pancreatic development, pancreatic sphincterotomy, intubation difficulties, stone recurrence, and incidence of reflux cholangitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction in the EST and EPBD groups.

RESULTS

Differences in hypertension, diabetes, increased bilirubin, small diameter of the common bile duct, or ampullary diverticulum between the two groups were not significant. Statistically significant differences were observed between the two groups concerning sex and age (< 60 years). Patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group. The number of cases of pancreatic development, pancreatic duct sphincterotomy, and difficult intubation were higher in the EST group than in the EPBD group. The number of Oddi's sphincter manometries, ERCP surgical outcomes, and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group. The numbers of stone recurrences, reflux cholangitis, and cholecystitis were higher in the EST group than in the EPBD group.

CONCLUSION

In summary, common bile duct stones, pancreatitis history, and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD. Based on this evidence, this study can provide actionable insights for clinicians and researchers.

Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis

Acute biliary pancreatitis (ABP) with cholangitis requires endoscopic retrograde cholangiopancreatography (ERCP) within 24 h to resolve ductal obstruction. However, this recommendation is based on the timing of emergency room (ER) visits. We wanted to determine the optimal timing of ERCP for ABP based on the timing of symptom onset, not the timing of the ER visit. We retrospectively reviewed 162 patients with ABP with cholangitis who underwent urgent ERCP (within 24 h of ER admission). Area under the receiver operating characteristic (ROC) curve (AUC) was analyzed to determine differences in complication rates according to time from symptom onset. A difference in ERCP-related adverse events (AEs) was identified, and Youden's J statistic was used to determine a cutoff time from symptom onset (18 h). We compared mortality and complications based on this cutoff. Based on time to symptom onset, significantly higher rates of aspiration pneumonia (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.15-13.92, P = 0.021) and post-ERCP hypotension (OR 11.9, 95% CI 1.39-101.33, P = 0.005) were observed in the ≤ 18-h group than in the > 18-h group. The study found that patients who underwent ERCP within 18 h of symptom onset is associated with an increased risk of ERCP-related AEs.

Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation

BACKGROUND

When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed.

AIMS

Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS.

METHODS

We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting.

RESULTS

Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis.

CONCLUSIONS

The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.

Needle-Knife Fistulotomy Versus Needle-Knife Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP.

Methods

We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate.

Results

Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I2 = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed.

Conclusions

Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.

Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial

OBJECTIVE

Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk.

METHODS

In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay.

RESULTS

A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups.

CONCLUSION

We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number, NCT01855841).

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

BACKGROUND AND AIMS

Although quality improvement is crucial for ERCP, a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation.

METHODS

Our hospital performs approximately 200 ERCPs annually, with 1 expert endoscopist performing approximately half of them and 3 nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases 3 years before and after the introduction of TPS. The primary endpoints of the study were the differences in 2 ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP).

RESULTS

A total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before, 87.4%; after, 92.3%, P = .032), whereas the incidence of PEP decreased, but not significantly (before, 4.0%; after, 2.8%; P = .402). All endoscopists benefited from using TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before, 85.5%; after, 93.1%; P = .019).

CONCLUSIONS

TPS can effectively enhance the quality of ERCP irrespective of practice volume.

Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study

INTRODUCTION AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training.

MATERIAL AND METHODS

Patients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods.

RESULTS

Of the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%).

CONCLUSION

Papilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Long-term prognosis and risk factors associated with post-ERCP pneumobilia in patients with common bile duct stones

BACKGROUND AND AIMS

Post-ERCP pneumobilia is not uncommon; however, studies focusing on the long-term prognosis of patients with post-ERCP pneumobilia are limited. This study aimed to explore long-term prognosis and risk factors associated with post-ERCP pneumobilia in patients with common bile duct stones (CBDSs).

METHODS

We conducted a retrospective analysis of 1380 patients who underwent ERCP for CBDSs at our hospital from January 2010 to December 2017. Patients were selected based on inclusion and exclusion criteria and divided into pneumobilia and nonpneumobilia groups, followed by propensity score matching. The matched groups were then compared in terms of incidence rates of both single and multiple recurrences of CBDSs, acute cholangitis, and acute cholecystitis. Multivariate logistic regression analysis was used to explore risk factors associated with pneumobilia.

RESULTS

After propensity matching, there was no significant difference in the rate of single recurrence of CBDSs (22.5% vs 30%; P = .446) between the pneumobilia and nonpneumobilia groups. However, the incidences of multiple recurrences of CBDSs (32.5% vs 12.5%; P = .032) and acute cholangitis without stone recurrence (32.5% vs 2.5%; P = <.001) were significantly higher in the pneumobilia group. Based on multivariate logistic regression analysis, in addition to a dilated CBD (diameter of >1 cm) (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.03-3.76; P = .043), endoscopic sphincterotomy with moderate incision (OR, 5.38; 95% CI, 1.14-25.47; P = .034) and with large incision (OR, 8.7; 95% CI, 1.83-41.46; P = .007) were identified as independent risk factors for pneumobilia after initial ERCP.

CONCLUSIONS

Patients with post-ERCP pneumobilia have increased risk of multiple recurrences of CBDSs and acute cholangitis without stone recurrence. Independent risk factors for pneumobilia include peripapillary diverticulum, a dilated CBD (>1 cm), and endoscopic sphincterotomy with moderate and large incisions. A normal-sized CBD appears to serve as a secondary barrier against enterobiliary reflux, necessitating further research for confirmation.

The usefulness of texture and color enhancement imaging to identify the minor papilla orifice

In clinical cases of pancreas divisum, endoscopic retrograde cholangiopancreatography often necessitates cannulation of the pancreatic duct through the minor papilla. Nevertheless, this procedure can be challenging because of the small size of the minor papilla and the difficulty in visualizing the ductal orifice. A new image-enhanced endoscopy technique called texture and color enhancement imaging (TXI) has been developed, which enhances texture, brightness, and color compared with white-light imaging, resulting in subtle differences in the surface mucosa. Herein, we describe the case of a 73-year-old man with pancreas divisum in whom TXI was useful in identifying the orifice of the minor papilla. He was referred to our hospital with repetitive acute exacerbation of chronic pancreatitis. Since contrast-enhanced computed tomography revealed a pancreatic stone in the main pancreatic duct, endoscopic retrograde cholangoepancreatography was performed as a therapeutic intervention. Despite the initial difficulty in identifying the orifice of the minor papilla on white-light imaging, TXI enhanced its visibility successfully, enabling dorsal pancreatic duct cannulation via the minor papilla. Subsequently, endoscopic pancreatic sphincterotomy was performed and a 6Fr plastic stent was placed. Post-endoscopic therapy, the patient's abdominal pain was relieved. TXI was useful in identifying the minor papilla orifice and led to successful cannulation.

Double-guidewire technique for selective biliary cannulation does not increase the rate of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with naïve papilla

BACKGROUND/AIMS

This study aimed to compare the safety of the double-guidewire technique (DGT) with that of the conventional single-guidewire technique (SGT) in real-world situations.

METHODS

A total of 240 patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Daegu Catholic University Medical Center between January 2021 and December 2021 were included. The primary outcome was the rate of post-ERCP pancreatitis (PEP) in the SGT and DGT groups.

RESULTS

A total of 163 patients (67.9%) belonged to the SGT group, and 77 (32.1%) belonged to the DGT group. The rates of successful biliary cannulation were 95.7% and 83.1% in the SGT and DGT groups, respectively (p=0.002). In the study group, PEP occurred in 14 patients (5.8%). The PEP rates were not significantly different between the SGT and DGT groups (4.3% vs. 9.1%, p=0.150). In the multivariate analysis, the age of <50 years (odds ratio [OR], 9.305; 95% confidence interval [CI], 1.367-63.358; p=0.023) and hyperlipidemia (OR, 7.384; 95% CI, 1.103-49.424; p=0.039) were significant risk factors for PEP in the DGT group.

CONCLUSION

DGT did not increase the PEP rate in patients with naïve papilla. In addition, the age of <50 years and hyperlipidemia were significant risk factors for PEP in the DGT group.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation

BACKGROUND AND AIMS

Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear.

PATIENTS AND METHODS

This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events.

RESULTS

Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69).

CONCLUSIONS

NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Adverse Events in Endoscopic Retrograde Cholangiopancreticography for Choledocholithiasis: A Holistic Perspective

Background and aims In this study, we aimed to investigate the frequency of adverse events (AEs) in patients undergoing endoscopic retrograde cholangiopancreticography (ERCP) for choledocholithiasis and the independent risk factors that may cause these conditions. We planned to evaluate all AEs including cardiopulmonary complications and the risk factors that may affect them holistically. Methods This study was designed as a retrospective cohort study conducted at a single tertiary center's gastroenterology clinic. The study included patients with naive papillae and undergoing ERCP for choledocholithiasis between May 2019 and June 2022. Risk factors that may lead to AEs were analyzed in terms of both patient-related factors and procedure-related factors. Patients with and without AEs after ERCP were compared. Results This study included 812 patients who underwent ERCP for choledocholithiasis. AE occurred in 149 (18.3%) of patients, and the most common complication was pancreatitis (n=112, 13.8%). In regression analysis, of the patient- and procedure-related factors, only difficult cannulation was a significant independent risk factor for AEs (odds ratio=3.85, 95% CI: 1.102-13.498, p=0.035). Conclusion This study showed that, of patient- and procedure-related factors, only difficult cannulation is an independent risk factor for ERCP-related AEs.

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis

OBJECTIVES

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP.

METHODS

We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI).

RESULTS

In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2  = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2  = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686).

CONCLUSIONS

Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Analysis of the Effectiveness of Second Attempt Endoscopic Retrograde Cholangiopancreatography (ERCP) 24 Hours (Second Day) After Primary Failure

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive intervention that has established itself as the gold standard therapeutic option for various pancreaticobiliary conditions. Deep cannulation of the common bile duct (CBD) is essential in ERCP. However, cannulation is not possible in approximately 20% of the cases with the usual techniques even when performed by highly trained professionals or at major healthcare institutions. In case of failure on the first attempt, alternative choices include redoing the procedure (on the second attempt) or moving on to more proficient endoscopic methods such as endoscopic ultrasound (EUS) or radiology-aided techniques (rendezvous procedures), totally percutaneous approaches, or surgical treatments.

OBJECTIVE

To analyze the effectiveness of the second attempt ERCP 24 hours (second day) after primary failure.

METHODOLOGY

This analytical study was conducted to check the outcomes of second attempt ERCP in patients with prior failed cannulation, from June 20, 2023, to November 20, 2023, at the Department of Gastroenterology, Lady Reading Hospital, Peshawar. Patients of either sex, aged >16 years with failed biliary cannulation, and who were otherwise clinically stable were included in the study. Patients with surgically modified anatomy, an unidentified main duodenal papilla, or a history of sphincterotomy at another setup were excluded. Outcomes were assessed in terms of gaining deep biliary access (cannulation) using a therapeutic duodenoscope and endoscopy system supported by a fluoroscope while using a wire-guided sphincterotome. Factors linked to second ERCP cannulation success or failure were analyzed using SPSS version 24.

RESULTS

Ninety-four patients were enrolled including 61 (64.9%) males and 33 (35.10%) females. The mean age of the participants was 39.01±14.831 years. The most common indication for the intervention was CBD stones, which were present in 70 (74.5%) patients. Successful cannulation on the second attempt was achieved in 72 (76.6%) patients. Experienced endoscopists achieved a greater proportion of successful cannulation (86.8%) compared to 33.3% by endoscopists with lower experience (p-value: <0.001). Logistic regression analysis was conducted to predict the outcomes (cannulation), which revealed an odds ratio for endoscopist experience of 33.604 (95% confidence interval: 6.948-162.52).

CONCLUSION

A second ERCP attempt 24 hours after the primary failed attempt appears to be the best course of action for the majority of clinically stable patients.

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study

INTRODUCTION

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations.

OBJECTIVE

To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis.

METHOD

A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs.

RESULTS

The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02).

CONCLUSION

Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

Rotatable sphincterotome as a rescue device for endoscopic retrograde cholangiopancreatography cannulation: a single-center experience

BACKGROUND/AIMS

Selective bile duct or pancreatic duct cannulation remains a significant initial hurdle in endoscopic retrograde cholangiopancreatography (ERCP) despite advances in endoscopy and accessories. This study evaluated our experience with a rotatable sphincterotome in cases of difficult cannulation.

METHODS

We retrospectively reviewed ERCP cases using TRUEtome, a rotatable sphincterotome, as a rescue device for cannulation at a cancer institute in Japan from October 2014 to December 2021.

RESULTS

TRUEtome was used in 88 patients. Duodenoscopes were used for 51 patients, while single-balloon enteroscopes (SBE) were used for 37 patients. TRUEtome was used for biliary and pancreatic duct cannulation (84.1%), intrahepatic bile duct selection (12.5%), and strictures of the afferent limb (3.4%). Cannulation success rates were similar in the duodenoscope and SBE groups (86.3% vs. 75.7%, p=0.213). TRUEtome was more commonly used in cases with steep cannulation angles in the duodenoscope group and in cases requiring cannulation in different directions in the SBE group. There were no significant differences in adverse events between the two groups.

CONCLUSION

The cannulation sphincterotome was useful for difficult cannulations in both unaltered and surgically altered anatomies. It may be an option to consider before high-risk procedures such as precut and endoscopic ultrasound-guided rendezvous techniques.

Endoscopic Hemostatic Treatment with a Novel Self-Assembling Peptide Gel for Precut Fistulotomy-Related Bleeding

Introduction

Precut fistulotomy is of interest as one of the salvage techniques for selective bile duct cannulation using endoscopic retrograde cholangiopancreatography. Of the various endoscopic treatments reported to date for bleeding associated with papillotomy incision, endoscopic hemostasis treatment with a novel self-assembling peptide (SAP) matrix-forming gel (TDM-621) (3-D Matrix Ltd., Tokyo, Japan) remains only insufficiently reported in the literature.

Case Presentation

We herein report 6 cases of precut fistulotomy-related bleeding successfully treated with endoscopic hemostasis treatment with TDM-621, i.e., 5 and 1 cases during and after precut fistulotomy, respectively, in 2 males and 4 females aged 68-96 years (mean age, 85 years), 3 of whom had been on antithrombotic drugs. Types of bleeding treated included oozing bleeding (n = 5) and oozing bleeding from a visible vessel (n = 1). In all cases, complete hemostasis was achieved with TDM-621 without causing rebleeding.

Conclusion

Endoscopic hemostasis with TDM-621 may prove effective for precut fistulotomy-related bleeding and represent a potential modality of first choice in hemostasis. In addition, endoscopic hemostasis with combined modality therapy using TDM-621 and endoscopic hemoclips may prove effective for bleeding from visible vessels.

Comparison of Physician-Controlled Maneuver and Assistant-Controlled Maneuver during Endoscopic Retrograde Cholangiopancreatography

PURPOSE

Cannulation of the major papilla is the most challenging part of endoscopic retrograde cholangiopancreatography (ERCP) for which physician-controlled wire-guided cannulation (PCWGC) and assistant-controlled wire-guided cannulation (ACWGC) are used as the cannulation techniques. PCWGC can reportedly save up to about 30% of the labor cost by reducing the number of assistants. This study aims to compare the safety and efficacy of PCWGC and ACWGC.

MATERIALS AND METHODS

Of the 2151 patients aged >20 years (4193 cases) who underwent ERCP at Yonsei University Medical Center between January 2015 and December 2016, 989 were included in this study.

RESULTS

Among efficacy outcomes, cannulation success rate, rate of precut sphincterotomy (PCWGC vs. ACWGC: 21.3% vs. 25.9%), bile duct cannulation time (PCWGC vs. ACWGC: median 3.0 minutes vs. 3.6 minutes), and total procedure time (PCWGC vs. ACWGC: median 13.6 minutes vs. 13.1 minutes) were not significantly different. Among safety outcomes, lower rates of post-ERCP pancreatitis were observed with PCWGC than with ACWGC (PCWGC vs. ACWGC: 5.8% vs. 8.8%, p=0.128). Among other post-ERCP adverse events (bleeding, perforation, and cholangitis), the difference was not significant between the groups. Radiation exposure (total dose area product, PCWGC vs. ACWGC: median 1979.9 µGym² vs. 2062.0 µGym², p=0.194) and ERCP cost excluding labor cost (PCWGC vs. ACWGC: $1576 vs. $1547, p=0.606) were not significantly different.

CONCLUSION

Requiring less assistants, PCWGC showed comparable efficacy and safety to ACWGC. PCWGC can be considered as an alternative option, especially in facilities lacking manpower and resources.

Combination of Precut Techniques in Difficult Biliary Cannulation

Background

Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation.

Patients and methods

The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data.

Results

The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar.

Conclusion

In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS.

How to cite this article

Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.

Development and evaluation of artificial organ models for ERCP training in patients with surgically altered anatomies

Endoscopy training models (ETM) using artificial organs are practical, hygienic and comfortable for trainees. However, few models exist for training endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. This training is necessary as the number of bariatric surgeries performed worldwide increases. ETM with human-like anatomy were developed to represent the postoperative anatomy after Billroth II (BII) reconstruction for a standard duodenoscope and the situs of a long-limbed Roux-en-Y (RY) for device-assisted enteroscopy (DAE). In three independent workshops, the models were evaluated by international ERCP experts. In RY model, a simulation for small bowel behavior in endoscopy was created. Thirty-three experts rated the ETM in ERCP expert courses. The BII model was evaluated as suitable for training (school grades 1.36), with a haptic and visual impression rating of 1.73. The RY model was rated 1.50 for training suitability and 2.06 for overall impression. Animal tissue-free ETMs for ERCP in surgically altered anatomy were successfully created. Evaluation by experienced endoscopists indicated that the models are suitable for hands-on ERCP training, including device-assisted endoscopy. It is expected that patient care will improve with appropriate training in advanced procedures.

Global prospective case series of ERCPs using a single-use duodenoscope

BACKGROUND

 The first commercialized single-use duodenoscope was cleared by the US Food and Drug Administration in December 2019. Data regarding endoscopic retrograde cholangiopancreatography (ERCP) using a single-use duodenoscope are needed on a broader range of cases conducted by endoscopists with varying levels of experience in a wide range of geographic areas.

METHODS

 61 endoscopists at 22 academic centers in 11 countries performed ERCP procedures in adult patients aged ≥ 18. Outcomes included ERCP completion for the intended indication, rate of crossover to a reusable endoscope, device performance ratings, and serious adverse events (SAEs).

RESULTS

 Among 551 patients, 236 (42.8 %) were aged > 65, 281 (51.0 %) were men, and 256 (46.5 %) had their procedure as an inpatient. ERCPs included 196 (35.6 %) with American Society for Gastrointestinal Endoscopy complexity of grades 3-4. A total of 529 ERCPs (96.0 %) were completed: 503 (91.3 %) using only the single-use duodenoscope, and 26 (4.7 %) with crossover to a reusable endoscope. There were 22 ERCPs (4.0 %) that were not completed, of which 11 (2.0 %) included a crossover and 11 (2.0 %) were aborted cases (no crossover). Median ERCP completion time was 24.0 minutes. Median overall satisfaction with the single-use duodenoscope was 8.0 (scale of 1 to 10 [best]). SAEs were reported in 43 patients (7.8 %), including 17 (3.1 %) who developed post-ERCP pancreatitis.

CONCLUSIONS

 In academic medical centers over a wide geographic distribution, endoscopists with varying levels of experience using the first marketed single-use duodenoscope had good ERCP procedural success and reported high performance ratings for this device.

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

BACKGROUND

Demonstration of access to the bile duct through Enlarged Papillary Fistulotomy, a method different from conventional fistulotomy.

AIMS

Demonstration of the EFP technique with dissection in layers of the papilla for accessing the common bile duct, its efficiency and safety, rescue of cases of failure in cannulation and cases of access failure by EFP in the first attempt, facilitating cannulation in the second attempt.

METHODS

Cross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, analysis of success and complications.

RESULTS

528 patients underwent EFP on the first attempt, with success in 465 cases (88.06%) and 63 failures (11.94%). Of these failures, 33 patients (52.38%) returned for a second EFP attempt, with success in 30 cases (90.9%) and failure in 3 cases (9.1%). Deep bile duct cannulation was achieved in 93.75% of EFP procedures, and cannulation failure occurred in 33 cases (6.25%).

CONCLUSION

EFP showed efficiency in CBD cannulation, did not induce post-ERCP pancreatitis, no cases of perforation or false tract, but resulted in higher rates of minor bleeding, rescued cases of access failure by EFP, facilitated the posterior approach on the second attempt, it is safe, effective, low risk and associated with few comorbidities.

Natural Course of Common Bile Duct Microlithiasis

BACKGROUND

Common bile duct microlithiasis (CBDM) with a diameter of ≤ 3 mm can pass spontaneously without causing any symptoms, but in some cases, it can also cause severe cholangitis and pancreatitis. The optimal strategy for managing CBDM is yet to be determined.

METHODS

Data of 154 patients with CBDM were collected and divided into two groups: with endoscopic retrograde cholangiopancreatography (with ERCP, n = 82) and without ERCP (n = 72). Clinical outcomes, including the incidence of unfavorable outcomes (UOs), such as cholangitis and pancreatitis, were observed and compared between the two groups.

RESULTS

The incidence of UOs was significantly lower in the ERCP group than in the without ERCP group (3.7% vs. 23.6%, respectively, p < 0.001). Moreover, the total number of readmissions was also lower in the ERCP group than in the without ERCP group (p < 0.001). A multivariate analysis adjusted for age, sex, and the American Society of Anesthesiologists (ASA) class revealed that endoscopic sphincterotomy (EST) and cholecystectomy were associated with a lower risk of UOs.

CONCLUSION

The high rate of UOs in CBDM patients without ERCP suggests that its natural clinical course may not be as favorable as previously suggested. This finding implies that efforts should be made to clear the bile ducts.

Development and external validation of a nomogram for prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for management of pancreatobiliary diseases; however, post-ERCP pancreatitis (PEP) remains as an unsolved problem. Although various risk factors for PEP have been reported, the prediction of PEP remains controversial. This study aimed to develop a predictive model for PEP.

METHODS

Consecutive patients undergoing ERCP for biliary indications at two centers were retrospectively studied. Using data from a training cohort, we utilized a multivariable model to select five variables to construct a nomogram. The predictive model was internally and externally validated. Based on the nomogram, the patients were categorized into low-, moderate-, and high-risk groups.

RESULTS

Using the data of 2224 patients in the training cohort, five variables were selected to generate a nomogram: 1) sex, 2) indication for ERCP, 3) difficult cannulation, 4) guidewire insertion into the pancreatic duct, and 5) endoscopic sphincterotomy or sphincteroplasty. The most significant risk factor was endoscopic papillary balloon dilation such as endoscopic sphincterotomy or sphincteroplasty. The bias-corrected concordance index was 0.72 in the training cohort and 0.72 in the validation cohort. Calibration curves for both cohorts demonstrated good agreement between the predicted and observed frequencies of the actual outcome. In the validation cohort, PEP developed in 5.0% and 14% of patients in the moderate- and high-risk groups, respectively.

CONCLUSIONS

We successfully developed a good predictive model for PEP. The prevention of PEP in high risk patients should be investigated further.

Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video)

OBJECTIVES

Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP.

METHODS

Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed.

RESULTS

Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465).

CONCLUSIONS

The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.

Initial experience of visualized biliary cannulation during ERCP

BACKGROUND : Selective biliary cannulation is the most challenging step in endoscopic retrograde cholangiopancreatography (ERCP) because only indirect radiographic images can be obtained. Therefore, we developed a novel endoscopic retrograde direct cholangioscopy (ERDC) technology to facilitate visible biliary cannulation. METHODS : In this case series, we used ERDC to treat 21 patients with common bile duct stones who were enrolled consecutively between July 2022 and December 2022. The procedure details and complications were recorded, and all patients were followed up for 3 months after the procedure. The learning curve effect was analyzed by comparing the early and later cases. RESULTS : Biliary cannulation was successful in all patients, and the stones were removed completely. The median (interquartile range [IQR]) time for cholangioscopy-guided biliary cannulation was 240.0 (10.0-430.0) seconds, and the median (IQR) number of cannulation procedures was 2 (1-5). Despite there being one episode of post-ERCP pancreatitis, one of cholangitis, and three patients developing asymptomatic hyperamylasemia, all of the patients recovered after symptomatic treatment, being discharged and with no serious adverse events occurring during the 3-month follow-up period. Compared with the early cases, the number of intubations and the use of guidewire guidance decreased in later cases. CONCLUSION : Our research confirms that ERDC is a feasible technology for biliary cannulation under direct vision.

Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial)

BACKGROUND & AIMS

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M).

METHODS

In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles.

RESULTS

From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted.

CONCLUSIONS

Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO.

CLINICALTRIALS

gov, Number: NCT03870386.

Clinical outcomes and learning curve for ERCP during advanced endoscopy training: a comparison of supine versus prone positioning

BACKGROUND AND AIMS

No studies have evaluated trainees' outcomes when learning ERCP with patients in the supine and prone positions simultaneously. We aimed to assess whether patient position impacts procedural outcomes and learning curve.

METHODS

We prospectively evaluated patients undergoing ERCP by a supervised advanced endoscopy trainee (AET) at a tertiary care center. Adult patients with native papillae were included. The AET was universally given 5 attempts per cannulation. Outcomes were evaluated quarterly.

RESULTS

Successful cannulation was achieved in 44 supine (69%) and 17 prone (68%) patients (P = .95). Although mean time to reach the papilla was shorter in the supine patient position, time to biliary cannulation (7.8 vs 9.4 minutes, P = .53) and number of attempts were similar. A stepwise increase was seen in cannulation rates throughout the academic year (P < .01) and increased more in supine patients (P = .01). Procedure and total room times were shorter in supine patients.

CONCLUSIONS

Shorter procedure and room turnover times and a comparable cannulation rate were found for supine versus prone ERCP.