Predictors of complications after endoscopic retrograde cholangiopancreatography: a prognostic model for early discharge

Patient Safety and Care After Outpatient Endoscopic Retrograde Cholangiopancreatography (ERCP): A Single-Center Experience in Germany

The current goal of adapting care structures in the German healthcare system is to increase the provision of interventional treatments in outpatient settings. Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures were traditionally performed in an inpatient setting until 2022. However, with the introduction of a new Ambulatory Surgery Contract (according to Section 115b, Paragraph 1 of the Social Code, Book V) on January 1, 2023, these procedures are now intended to be carried out more strictly on an outpatient basis, meaning that hospitalization will no longer be reimbursed in most cases.Between June 1, 2023, and December 31, 2023 all ERCP procedures performed in an outpatient setting were included in this study. This cohort had standard ERCP indications and a low comorbidity burden according to the §115b specifications. Using propensity score matching (nearest-neighbor), these cases were matched with patients who underwent ERCP procedures in an inpatient setting between June 1, 2022, and December 31, 2022.Propensity-score matching identified a cohort of 166 patients (83 outpatients and 83 inpatients) with similar baseline characteristics. The most common indications for ERCP were choledocholithiasis and biliary strictures. Reported complications comprised pancreatitis, bleeding and cholangitis and were rare in both groups, occurring in 7% of inpatient procedures and in 6% of outpatient procedures. The latter cases required inpatient admission after self-presenting to the emergency department. No serious adverse events were reported.Outpatient ERCP is a safe procedure for selected patients with a low risk profile. Complications occurred rarely and could be adequately managed.

Acute pancreatitis and biliary obstruction from metastatic lymph node compression during [177Lu] Lu-PSMA-617 therapy: a case report

Radioligand therapies such as [177Lu] Lu-PSMA-617 have gained significant momentum in cancer treatment after clinical trials and multicenter studies demonstrated their safety and efficacy. As these innovative treatments become more widespread, rare and unique clinical manifestations are expected to be observed. In this report, we describe a case with metastatic castration-resistant prostate cancer (mCRPC) and peripancreatic lymph node metastases who developed acute pancreatitis following [177Lu] Lu-PSMA-617 therapy.

Synergistic effect of independent risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis: a multicenter retrospective study in Japan

BACKGROUND/AIMS

This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile duct stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP.

RESULTS

PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033).

CONCLUSIONS

As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.

Determining the Risk Factors of Complications Due to Endoscopic Retrograde Cholangiopancreatography

Background and objective The effective use of endoscopic retrograde cholangiopancreatography (ERCP) has been on the rise in diagnosing and treating benign and malignant pathologies of the common bile duct and pancreas. ERCP, a complex procedure requiring high knowledge, skills, and practice, differs from other endoscopic applications as it involves the use of different techniques and equipment and the occurrence of more complications. The most commonly observed complications of ERCP are pancreatitis, bleeding, perforation, and infections. In this study, we aimed to assess the incidence of post-ERCP complications to identify the associated risk factors and indications. Methodology In this study, 181 ERCP procedures performed on 122 consecutive patients in the endoscopy unit of Istanbul Training Hospital were prospectively evaluated by using an observational method to determine the frequency of and risk factors for post-ERCP complications. The patients were followed up in the course of the ERCP procedure and for 30 days after the procedure; the complications and clinical developments were recorded. Results The mean age of the cohort was 59.7 ± 17.7 (19-97) years; 40.9% were female and 59.1% were male. The cannulation success was achieved in 77.3% of the ERCP procedure performed. Among the ERCP procedures applied, 89% were performed for therapeutic purposes, and choledocholithiasis (60.2%) was the most common indication for ERCP. Major complications were detected in 25.4% of the patients after ERCP. The most common major complication was cholangitis (9.9%), followed by pancreatitis (7.2%), cholecystitis (5.5%), bleeding (3.9%), and perforation (1.1%). It was observed that sphincterotomy was associated with an increase in all complications. The incidence of cholangitis decreased in the presence of dilated bile ducts unrelated to obstruction. The increased incidence of pancreatitis was associated with the female gender, the use of sphincterotomy and basket, inexperienced endoscopists, and inpatient admissions. The incidence of cholecystitis, on the other hand, was found to be linked with sphincterotomy and inexperienced endoscopists. Conclusions ERCP is a complex endoscopic procedure that requires high technical knowledge and skill and can cause serious complications. For endoscopists to perform clinically effective and accurate ERCP, it is important that they correctly determine the indications for the procedure, know its potential complications, and refrain from practices that will create complications and are unnecessary as much as possible.

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.

Machine learning for the prediction of post-ERCP pancreatitis risk: A proof-of-concept study

BACKGROUND

Predicting Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis (PEP) risk can be determinant in reducing its incidence and managing patients appropriately, however studies conducted thus far have identified single-risk factors with standard statistical approaches and limited accuracy.

AIM

To build and evaluate performances of machine learning (ML) models to predict PEP probability and identify relevant features.

METHODS

A proof-of-concept study was performed on ML application on an international, multicenter, prospective cohort of ERCP patients. Data were split in training and test set, models used were gradient boosting (GB) and logistic regression (LR). A 10-split random cross-validation (CV) was applied on the training set to optimize parameters to obtain the best mean Area Under Curve (AUC). The model was re-trained on the whole training set with the best parameters and applied on test set. Shapley-Additive-exPlanation (SHAP) approach was applied to break down the model and clarify features impact.

RESULTS

One thousand one hundred and fifty patients were included, 6.1% developed PEP. GB model outperformed LR with AUC in CV of 0.7 vs 0.585 (p-value=0.012). GB AUC in test was 0.671. Most relevant features for PEP prediction were: bilirubin, age, body mass index, procedure time, previous sphincterotomy, alcohol units/day, cannulation attempts, gender, gallstones, use of Ringer's solution and periprocedural NSAIDs.

CONCLUSION

In PEP prediction, GB significantly outperformed LR model and identified new clinical features relevant for the risk, most being pre-procedural.

Comparison of one-stage treatment versus two-stage treatment for the management of patients with common bile duct stones: A meta-analysis

Background

Cholelithiasis is a frequently occurring disease in clinic. Due to changes in people's living environments, dietary habits and the aging population, cholelithiasis incidence is increasing. Currently, laparoscopic cholecystectomy (LC) is the preferred treatment for gallbladder stones, but the surgical method for patients with choledocholithiasis is controversial. An endoscopic retrograde cholangiopancreatography (pERCP) is performed preoperatively, followed by LC as the general treatment method. However, pERCP still has some disadvantages, such as prolonged hospital stay, increased incidence of postoperative pancreatitis, and increased duration of anesthesia. Therefore, intraoperative endoscopic retrograde cholangiopancreatography (iERCP) is proposed.

Objective

To compare the efficacy and safety of one-stage treatment and two-stage treatment for the management of patients with cholecystolithiasis and choledocholithiasis.

Search strategy

PubMed, Embase, Web of Science, and Cochrane databases were searched through October 2022. The search terms include cholangiolithiasis/bile duct stones/calculi, endoscopic retrograde cholangiopancreatography/ERCP, endoscopic sphincterotomy/EST, laparoendoscopic rendezvous (LERV), and laparoscopic cholecystectomy/LC.

Selection criteria

For the treatment of patients with cholecystolithiasis and choledocholithiasis in adults, randomized controlled trials (RCTs) comparing LC with iERCP vs. pERCP followed by LC were conducted.

Data collection and analysis

Data extraction and quality assessment were performed by two reviewers. We used Revman version 5.3 to analyze the collected data. The trials were grouped according to the evaluation results such as the overall mortality rate, overall morbidity rate, clearance rate of choledocholithiasis, incidence of pancreatitis, the length of hospitalization, and the length of operation.

Results

9 RCTs (950 participants) were included in this meta-analyses. The overall morbidity rate in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.57, 95% CI = 0.41-0.79, p = 0.0008). The clearance rate of choledocholithiasis in LC + iERCP group was almost the same as that in LC + pERCP group (RR: 1.03, 95% CI = 0.98-1.08, p = 0.28). The incidence of pancreatitis in LC + iERCP group is lower than that in LC + pERCP group (RR: 0.29, 95% CI = 0.13-0.67, p = 0.004). The length of operation of the LC + iERCP group seems to be similar to that of the LC + pERCP group (MD: 16.63 95% CI = -5.98-39.24, p = 0.15). LC + iERCP group has a shorter length of hospitalization than that in LC + pERCP group (MD: -2.68 95% CI = -3.39--1.96, p < 0.00001). LC + iERCP group has lower postoperative second ERCP rate than that in LC + pERCP group (RR: 0.13, 95% CI = 0.03-0.57, p = 0.006).

Conclusion

Our study suggest that LC + iERCP may be a better option than LC + pERCP in the management of patients with both cholecystolithiasis and choledocholithiasis. This procedure can reduce the overall incidence of postoperative complications, especially the occurrence of postoperative pancreatitis. It could shorten the length of hospital stay, reduce postoperative second ERCP rate.

Risk factors for ERCP-related complications and what is the specific role of ASGE grading system

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the main therapeutic and sometimes diagnostic methods in biliary and pancreatic diseases. A grading system for the difficulty of ERCP (grade one to four, the higher grade represents the more complexity of the procedure) has been developed by the American Society for Gastrointestinal Endoscopy (ASGE). This study aimed to assess the prevalence of ERCP-related complications, their common risk factors, and specifically the role of difficulty of the procedure based on ASGE grading.

Material and Methods

This cross-sectional study was performed on 620 ERCP-operated patients over 4 years in two tertiary referral centers affiliated with Isfahan University of Medical Sciences. Data about the difficulty of procedures based on the ASGE grading scale, complications including pancreatitis, bleeding, infection, perforation, arrhythmia, respiratory suppression, aspiration, and major common risk factors were collected.

Results

The overall prevalence of complications was 11.6% including pancreatitis 8.2%, perforation 0.8%, gastrointestinal bleeding 1.3%, cholangitis 2.4%, and cardiopulmonary problems 0.5% (arrhythmia 0.3% and respiratory depression 0.2%). Patients with pancreatic contrast injection (66.7% vs. 11.3% P = 0.04) and sphincter of Oddi dysfunction (SOD) (44.4% vs. 11.1%; P = 0.01) showed a statistically significant higher overall complication rate. The association of these risk factors remained significant in multivariable logistic regression analysis. Patients with pancreatic contrast injection also showed a statistically significant higher prevalence of post-ERCP pancreatitis (66.7% vs. 11.3% P = 0.04). Furthermore, a significantly higher prevalence of arrhythmia (3.6% vs. 0; P = 0.008) was observed among patients with difficult cannulation. Based on the ASGE difficulty grading score, most of the patients were classified as grade 2 (74.2%) and 3 and 4 (23.4%). No statistically significant difference was noted between the difficulty-based groups in terms of complications.

Conclusion

The current study showed that the most critical risk factors of ERCP-induced complications were pancreatic contrast injection and SOD. ASGE grading scale for ERCP complexity did not predict the occurrence of complications in our study population.

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

When to Discharge a Patient After Endoscopy: A Narrative Review

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Disease-Based Risk Stratification of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis for Common Bile Duct Stones

BACKGROUND

Risk stratification of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) for common bile duct (CBD) stones is needed for clinicians to adequately explain to patients regarding the risk of PEP in advance of ERCP and to proactively take preventive measures in high-risk patients.

AIMS

To stratify the risk of PEP for CBD stones based on CBD-related diseases.

METHODS

A total of 1551 patients with naïve papilla who underwent ERCP for CBD stones were divided into three groups: Group A: asymptomatic CBD stones, Group B: obstructive jaundice and elevated liver test values without cholangitis, and Group C: mild, moderate, and severe cholangitis. We stratified the risk of PEP by comparing its incidence among the three groups using the Holm's method. Furthermore, we performed one-to-one propensity score matching between Group A and the other groups to examine the risk of PEP in Group A.

RESULTS

The incidence rates in Groups A, B, and C were 13.7%, 7.3%, and 1.8%, respectively. The Holm-adjusted p values between Groups A and B, Groups A and C, and Groups B and C were 0.023, < 0.001, and < 0.001, respectively. Propensity score matching revealed that the incidence of PEP was significantly more in Group A than in the other groups (13.3% vs. 1.5%; p < 0.001).

CONCLUSIONS

The risk of PEP for CBD stones was stratified into low risk (Group C), intermediate risk (Group B), and high risk (Group A). This simple disease-based risk stratification may be useful to predict the risk of PEP in advance of ERCP.

Pre- and post-procedure risk prediction models for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event. Given recent endoscopic advances, we aimed to develop and validate a risk prediction model for PEP using the latest clinical database.

METHODS

We analyzed the data of patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP). Pre-ERCP and post-ERCP risk prediction models for PEP were developed using logistic regression analysis. Patients were classified into low- (0 points), intermediate- (1-2 points), and high-risk (≥ 3 points) groups according to point scores.

RESULTS

We included 760 and 735 patients in the derivation and validation cohorts, respectively. The incidence of PEP was 5.5% in the derivation cohort and 3.9% in the validation cohort. Age ≤ 65 (1 point), female sex (1 point), acute pancreatitis history (2 points), malignant biliary obstruction (2 points [pre-ERCP model] or 1 point [post-ERCP model]), and pancreatic sphincterotomy (2 points, post-ERCP model only) were independent risk factors. In the validation cohort, the high-risk group (≥ 3 points) had a significantly higher risk of PEP compared to the low- or intermediate-risk groups under the post-ERCP risk prediction model (low: 2.0%; intermediate: 3.4%; high: 18.4%), while there was no significant between-group difference under the pre-ERCP risk prediction model (low: 2.2%; intermediate: 3.8%; high: 6.9%).

CONCLUSIONS

We developed and validated pre-ERCP and post-ERCP risk prediction models. In the latter, the high-risk group had a higher risk of PEP development than the low- or intermediate-risk groups. Our study findings will help clinicians stratify patient risk for the development of PEP.

The milestone for preventing post-ERCP pancreatitis using novel simplified predictive scoring system: a propensity score analysis

BACKGROUND

Post-ERCP pancreatitis (PEP) with trans-papillary approach remains a major issue, and the multi-factorial etiology can lead to the development of unpredictable PEP. Therefore, the early identification of PEP is highly desirable to assist with the health cost containment, the reduction in unnecessary admissions, earlier appropriate primary care, and intensive care for preventing progression of severe pancreatitis. This study aimed to establish a simplified predictive scoring system for PEP.

METHODS

Between January 1, 2012, and December 31, 2019, 3362 consecutive trans-papillary ERCP procedures were retrospectively analyzed. Significant risk factors were extracted by univariate, multivariate, and propensity score analyses, and the probability of PEP in the combinations of each factor were quantified using propensity score analysis. The results were internally validated using bootstrapping resampling.

RESULTS

In the scoring system with four stratifications using combinations of only five extracted risk factors, the very high-risk group showed 28.79% (95% confidence interval [CI], 18.30%-41.25%; P < 0.001) in the predicted incidence rate of PEP, and 9.09% (95% CI, 3.41%-18.74%; P < 0.001) in that of severe PEP; although the adjusted prevalence revealed 3.74% in PEP and 0.90% in severe PEP, respectively. The prediction model had an area under the curve of 0.86 (95% CI, 0.82-0.89) and the optimism-corrected model as an internal validation had an area under the curve of 0.81 (95% CI, 0.77-0.86).

CONCLUSIONS

We established and validated a simplified predictive scoring system for PEP using five risk factors immediately after ERCP to assist with the early identification of PEP.

Pancreatic Duct Variations and the Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic procedure in the management of biliary and pancreatic disorders. Despite advances in ERCP facilities and techniques, pancreatitis remains the most common and feared complication of this procedure. The technical challenges of ERCP could be further compounded by variations in the configuration of the pancreatic ductal system. As a result, the knowledge of these variations and their potential role in the development of post-ERCP pancreatitis (PEP) is essential to any successful risk reduction strategy. This review provides an overview of the anatomy and embryological basis of pancreatic duct variations, as well as explore the different types and prevalence of these variations. Also, we discuss the mechanisms of PEP and provide evidence supporting a link between the variations and PEP using published data

Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.

Endoscopic papillary large balloon dilatation for the extraction of common bile duct stones

BACKGROUND AND AIM

endoscopic papillary large balloon dilatation (EPLBD) is increasingly accepted as an appropriate option for the management of difficult common bile duct stones (CBDS). This study aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) for the extraction of difficult CBDS.

PATIENTS AND METHODS

a total of 40 patients were recruited with obstructive jaundice and dilated CBD (≥ 10 mm) subsequent to a single large CBDS of ≥ 10 mm or multiple stones (≥ 3). All patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) with limited sphincterotomy and large balloon dilatation followed by stone extraction using an extraction balloon or dormia basket, without lithotripsy, stenting or further ERCP sessions.

RESULTS

successful stone extraction was achieved in 34 patients (85%) and stone extraction failure occurred in six patients (15%). Complications included minimal pancreatitis in four cases (10%), mild pancreatitis in two cases (5%), cholangitis in two cases (5%) and bleeding in two cases (5%). There were no recorded cases of perforation or mortality subsequent to the procedure.

CONCLUSION

EPLBD is a safe and efficient procedure for the extraction of difficult CBDS and may be advisable in patients with a bleeding risk or abnormal papillary anatomy.

Preliminary Report of Percutaneous Cholecystostomy as Diagnosis and Treatment of Biliary Tract Trauma

BACKGROUND

Biliary leak following severe blunt liver injuries is a complex problem becoming more frequent with improvements in non-operative management. Standard treatment requires main bile duct drainage usually performed by endoscopic sphincterotomy and stent placement. We report our experience with cholecystostomy as a first minimally invasive diagnostic and therapeutic approach.

METHODS

We performed a retrospective analysis of consecutive patients with post-traumatic biliary leak between 2006 and 2015. In the first period (2006-2010), biliary fistula was managed using perihepatic drainage and endoscopic, percutaneous or surgical main bile duct drainage. After 2010, cholecystostomy as an initial minimally invasive approach was performed.

RESULTS

Of 341 patients with blunt liver injury, 18 had a post-traumatic biliary leak. Ten patients received standard treatment and eight patients underwent cholecystostomy. The cholecystostomy (62.5%) and the standard treatment (80%) groups presented similar success rates as the first biliary drainage procedure (p = 0.41). Cholecystostomy presented no severe complications and resulted, when successful, in a bile flow rate inversion between the perihepatic drains and the gallbladder drain within a median [IQR] 4 days [1-7]. The median time for bile leak resolution was 26 days in the cholecystostomy group and 39 days in the standard treatment group (p = 0.09). No significant difference was found considering median duration of hospital stay (54 and 74 days, respectively, p = 0.37) or resuscitation stay (17.5 and 19.5 days, p = 0.59).

CONCLUSION

Cholecystostomy in non-operative management of biliary fistula after blunt liver injury could be an effective, simple and safe first-line procedure in the diagnostic and therapeutic approach of post-traumatic biliary tract injuries.

ERCP PERFORMANCE IN A TERTIARY BRAZILIAN CENTER: FOCUS ON NEW RISK FACTORS, COMPLICATIONS AND QUALITY INDICATORS

Background:

ERCP can lead to complications, which can be prevented by the recognition of risk factors.

Aim:

To identify these risk factors, with quality evaluation.

Methods:

Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy.

Results:

211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending’s procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041).

Conclusion:

Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.

Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects - A randomized study

BACKGROUND

The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement.

AIM

To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography.

MATERIALS AND METHODS

This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared.

RESULTS

Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered.

CONCLUSION

Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity

AIM

To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity.

METHODS

This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected.

RESULTS

The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP.

CONCLUSION

PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

Primary sclerosing cholangitis increases the risk for pancreatitis after endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS

Patients with primary sclerosing cholangitis (PSC) have an increased risk for adverse events following endoscopic retrograde cholangiopancreatography (ERCP), mainly caused by bacterial cholangitis. The risk of pancreatitis is less examined. Therefore, our aim was to study adverse events following ERCP and to evaluate if PSC is a risk factor for pancreatitis.

METHODS

Data were collected through a Swedish nationwide quality registry comprising fifty-one Swedish ERCP centres. The final study cohort consisted of 8932 adults who had undergone ERCP from 1 January 2007 to 31 December 2009. A total of 141 patients had PSC. Variables of importance for adverse events were entered into a multivariate logistic regression model for risk factor analysis.

RESULTS

The following adverse events were increased in PSC as compared with non-PSC patients: overall (18.4% vs. 7.3%), pancreatitis (7.8% vs. 3.2%, P = 0.002), cholangitis (7.1% vs. 2.1%, P < 0.001) and per-operative extravasation of contrast (5.7% vs. 0.7%, P < 0.001). PSC was shown to be an independent risk factor for all of these adverse events: pancreatitis, OR 2.02 (95% CI, 1.04-3.92), cholangitis, OR 2.88 (95% CI, 1.47-5.65), and extravasation of contrast, OR 5.84 (95% CI, 2.24-15.23).

CONCLUSION

The rate of adverse events overall following ERCP in PSC is 18% and PEP occurs in 8%. PSC is an independent risk factor for PEP and the risk is doubled. These findings underline the importance of a careful selection of PSC patients eligible for ERCP as well as a need for high competence of the treating team.

Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of the present study was to investigate patient- and procedure-related risk factors for post-ERCP complications in a large-scale study of procedures performed by a single experienced endoscopist.

METHODS

This is a retrospective cohort study which included a total of 2,715 therapeutic ERCPs enrolled in the final analysis. Potential important patient- and procedure-related risk factors for overall post-ERCP complications, pancreatitis and post-endoscopic sphincterotomy (ES) bleeding were investigated by univariate and multivariate analyses.

RESULTS

Following the first therapeutic ERCP, 327 patients suffered complications; pancreatitis was observed in 132 (4.9%) patients, hemorrhage in 122 (4.5%) patients, cholangitis in 63 (2.3%) patients, perforation in 3 (0.11%) patients, and basket impaction in 7 (0.26%) patients. History of acute pancreatitis was more common in patients with post-ERCP complications (P<0.001). Female gender, young age (<40 years), periampullary diverticulum, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct and suprapapillary fistulotomy were not found to be risk factors for overall post-ERCP complications and post-ERCP pancreatitis (PEP). Multivariate analysis showed a history of acute pancreatitis, difficult cannulation, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first and second class pancreatic ductules and acinarization as independent risk factors for overall complications and PEP, whereas antiplatelet and anticoagulation drug use were not found to be independent risk factors for post-ES bleeding.

CONCLUSIONS

The results of this study demonstrate that the endoscopist's experience reduces patient- and procedure-related risk factors for post-ERCP complications.

Risk factors for cholangitis after endoscopic stent placement for malignant biliary obstruction

AIM: To explore the risk factors for cholangitis after endoscopic stent placement for malignant biliary obstruction.

METHODS: Eighty malignant biliary obstructive patients who underwent endoscopic stent placement at Nanjing Medical University Affiliated Suzhou Hospital between January 2008 and December 2013 were divided into two groups: a cholangitis group (n = 40, with post-endoscopic stent placement cholangitis) and a non-cholangitis group (n = 40, without post-endoscopic stent placement cholangitis). The two groups were matched for age and gender. The relationship between post-endoscopic stent placement cholangitis and various factors was investigated by univariate and multivariate analyses.

RESULTS: Univariate analysis showed that the location of obstruction, stent type and history of diabetes were significantly different between the two groups. Multivariate analysis demonstrated that the location of obstruction was significantly related to post-endoscopic stent placement cholangitis (OR = 8.815, 95%CI: 1.575-50.009).

CONCLUSION: Upper biliary obstruction might be an independent risk factor for post-endoscopic stent placement cholangitis.

Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance

BACKGROUND

The American Society for Gastrointestinal Endoscopy Committee on Outcomes Research has recommended monitoring nine endoscopic retrograde cholangiopancreatography (ERCP)-specific quality indicators for quality assurance in ERCP. With the development of a self-assessment tool for ERCP (Rotterdam Assessment Form for ERCP-RAF-E), key indicators can easily be assessed.

OBJECTIVE

The aim of this study was to test in daily practice an easy-to-use form for assessment of procedural quality in ERCP and to determine ERCP quality outcomes in a tertiary referral hospital.

DESIGN

This was a prospective study carried out in a tertiary referral hospital. In January 2008, a quality self-assessment programme was started. Five qualified endoscopists participated in this study. All ERCPs were appraised using RAF-E. Primary parameters were common bile duct (CBD) cannulation rate and procedural success. The indication was classified and procedural difficulty was graded; success rates of therapeutic interventions were measured for all different difficulty degrees.

RESULTS

A total number of 1691 ERCPs were performed. 1515 (89.6%) of these were appraised using RAF-E. Median CBD cannulation success rate was 94.1%. Successful sphincterotomy was accomplished in almost all patients (median 100%; range 98.2-100%). Stent placement was successful in 97.8% and complete stone extraction, if indicated, was achieved in 86.8%.

CONCLUSIONS

Quality indicators for ERCP can be measured using the Rotterdam self-assessment programme for ERCP. Outcome data in ERCPs obtained with this RAF-E provide insight into the quality of individual as well as group performance and can be used to assess and set standards for quality control in ERCP.

Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of the present study was to investigate patient- and procedure-related risk factors for post-ERCP complications in a large-scale study of procedures performed by a single experienced endoscopist.

METHODS

This is a retrospective cohort study which included a total of 2,715 therapeutic ERCPs enrolled in the final analysis. Potential important patient- and procedure-related risk factors for overall post-ERCP complications, pancreatitis and post-endoscopic sphincterotomy (ES) bleeding were investigated by univariate and multivariate analyses.

RESULTS

Following the first therapeutic ERCP, 327 patients suffered complications; pancreatitis was observed in 132 (4.9%) patients, hemorrhage in 122 (4.5%) patients, cholangitis in 63 (2.3%) patients, perforation in 3 (0.11%) patients, and basket impaction in 7 (0.26%) patients. History of acute pancreatitis was more common in patients with post-ERCP complications (P<0.001). Female gender, young age (<40 years), periampullary diverticulum, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct and suprapapillary fistulotomy were not found to be risk factors for overall post-ERCP complications and post-ERCP pancreatitis (PEP). Multivariate analysis showed a history of acute pancreatitis, difficult cannulation, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first and second class pancreatic ductules and acinarization as independent risk factors for overall complications and PEP, whereas antiplatelet and anticoagulation drug use were not found to be independent risk factors for post-ES bleeding.

CONCLUSIONS

The results of this study demonstrate that the endoscopist's experience reduces patient- and procedure-related risk factors for post-ERCP complications.