Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction

A case of delayed pancreatic fistula after covered self-expandable metallic stent deployment for pancreatic head cancer

A 69-year-old man was referred to our hospital with obstructive jaundice. A tumor with poor contrast enhancement was found in the pancreatic head, but there was no evidence of pancreatic atrophy, irregular stenosis, or dilation of the main pancreatic duct. He was diagnosed with borderline resectable pancreatic cancer with distal malignant biliary obstruction. After plastic stent placement, serum bilirubin levels improved, and chemotherapy was started. However, he developed cholangitis; thus, the plastic stent was replaced with a covered self-expandable metallic stent. He subsequently developed a delayed pancreatic fistula due to main pancreatic duct disruption. An endoscopic nasopancreatic duct drainage tube was placed to bridge the main pancreatic duct disruption after removing the covered self-expandable metallic stent. In addition, endoscopic ultrasound-guided transmural drainage was performed for the infected fluid collection caused by the pancreatic fistula, and the clinical symptoms quickly improved. This case presents the possibility of a delayed pancreatic fistula due to self-expandable metallic stent deployment. The need for considering such delayed complications when placing self-expanding metallic stents is highlighted.

Endoscopic management of benign and malignant hilar stricture

Management of hilar strictures pose a significant challenge for endoscopists. Several strategies have been demonstrated in the last decade beyond decompression, however, there remains controversy and minimal consensus in the literature. This review seeks to summarize the current literature and discuss emerging therapies, such as photodynamic therapy and radiofrequency ablation.

Risk of Pancreatitis Following Biliary Stenting With/Without Endoscopic Sphincterotomy: A Randomized Controlled Trial

BACKGROUND & AIMS

The efficacy of endoscopic sphincterotomy (ES) before endoscopic transpapillary biliary drainage in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has not been established. The aim of this study was to evaluate the effect of performing ES before biliary stent/tube placement on the occurrence of PEP.

METHODS

Three hundred seventy patients with biliary stricture requiring endoscopic biliary stenting were enrolled and randomly allocated to the ES group (n = 185) or non-ES group (n = 185). All participants were followed up for 30 days after the procedure. The data and occurrence of adverse events were prospectively collected. The primary outcome measure of this study was the incidence of PEP within 2 days of initial transpapillary biliary drainage. Secondary outcome measures were the incidence of other adverse events related to biliary stent/tube placement.

RESULTS

PEP occurred in 36 patients (20.6%) in the non-ES group and in 7 patients (3.9%) in the ES group (P < .001). The difference in the incidence of PEP between the 2 groups in the per-protocol population was 16.7% (95% confidence interval, 10.1%-23.3%), which was not within the noninferiority margin of 6%. Except for bleeding, the incidences of other adverse events were not significantly different between the groups.

CONCLUSION

ES before endoscopic biliary stenting could have the preventive effect on the occurrence of PEP in patients with biliary stricture. University Hospital Medical Information Network Number, UMIN000025727.University Hospital Medical Information Network Clinical Trial Registry URL: https://www.umin.ac.jp/ctr/index.htm.

Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

INTRODUCTION

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

AREAS COVERED

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

EXPERT OPINION

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

Self-expandable metallic stent placement above the papilla without endoscopic sphincterotomy in patients with distal malignant biliary obstruction

Background and study aims  The best method for endoscopic placement of self-expandable metallic stents (SEMS) for distal malignant biliary obstruction (MBO) has not yet been determined. The aim of this study was to evaluate how SEMS placement above the papilla and without endoscopic sphincterotomy (EST) impacts the time to recurrent biliary obstruction (RBO) in patients with distal MBO. Patients and methods  We retrospectively reviewed data for 73 consecutive patients with unresectable distal MBO who underwent endoscopic SEMS placement for the first time at our institution between April 2014 and March 2016. We compared time to RBO of SEMS placement above the papilla (intraductal placement) with SEMS placement across the papilla (transpapillary placement). In the intraductal placement group, we also compared time to RBO of placement without EST with placement with EST. Results  Endoscopic SEMS placement was performed in 30 patients with intraductal placement and in 43 patients with transpapillary placement. The median time to RBO was significantly longer with intraductal placement (307 days) than with transpapillary placement (161 days) ( P  = 0.022). Complication rates did not differ between the two groups. In both univariate and multivariate analysis, intraductal placement was an independent factor contributing to prolonged time to RBO. In intraductal placement, time to RBO was significantly longer in SEMS placement without EST than with EST (363 days vs. 227 days, respectively; P  = 0.026). Conclusions  Intraductal SEMS placement, especially without EST for distal MBO contributed to longer time to RBO.

Inutility of endoscopic sphincterotomy to prevent pancreatitis after biliary metal stent placement in the patients without pancreatic duct obstruction

Background: The incidence of post-ERCP pancreatitis (PEP) has been reported to be significantly higher in patients without main pancreatic duct (MPD) obstruction who undergo transpapillary biliary metal stent (MS) placement than in those with ordinary ERCP setting.Objective: To evaluate the benefit of endoscopic sphincterotomy (ES) prior to MS placement in preventing PEP in patients with distal malignant biliary obstruction (MBO) without MPD obstruction.Materials and methods: In total, 160 patients who underwent initial MS placement for MBO were enrolled. Eighty-two patients underwent ES immediately prior to MS placement, whereas 78 underwent MS placement without ES. An inverse probability of treatment weighting method was adopted to adjust the differences of the patients' characteristics. The primary outcome was the incidence of PEP. The secondary outcomes included the incidence of other adverse events (bleeding, cholangitis, perforation and stent dislocation) and time to recurrent biliary obstruction.Results: The incidence of PEP was 26.8% in the ES and 23.1% in the non-ES (unadjusted odds ratio [OR] [95%CI]: 1.22, [0.60-2.51], adjusted OR [95%CI]: 1.23, [0.53-2.81], p = .63). Logistic-regression analysis revealed no factors that could be attributed to the occurrence of PEP. The incidence of other adverse events was not different between the groups. The median time to recurrent biliary obstruction was 131 (2-465) days and 200 (4-864) days in the ES and non-ES, respectively (p = .215).Conclusions: ES prior to MS placement for patients with distal MBO without MPD obstruction does not reduce the incidence of PEP.

Endoscopic Sphincterotomy before Fully Covered Metal Stent Placement Is Not Required for Distal Malignant Biliary Stricture due to a Pancreatic Head Tumor

Background/Aims

Endoscopic sphincterotomy (EST) is often performed before fully covered self-expandable metal stent (FCSEMS) placement in order to prevent pancreatitis. However, it is not clear whether EST prevents pancreatitis or affects other adverse events (AEs). This study is conducted to evaluate the necessity of EST before FCSEMS placement for distal malignant biliary strictures due to a pancreatic head tumor.

Methods

This study included 68 patients who underwent FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor. Treatment outcomes and AEs were retrospectively compared between 32 patients with EST before FCSEMS placement (EST group) and 36 patients without EST (non-EST group).

Results

The success rates of drainage for the EST and non-EST groups were 100% and 97.2%, respectively (P = 0.95). The incidence of pancreatitis in the EST and non-EST groups was 3.1% and 0%, respectively (P = 0.95). The incidence of hyperamylasemia in the EST and non-EST groups was 12.5% and 13.9%, respectively (P = 0.85). The incidence of all AEs in the EST and non-EST groups was 15.6% (pancreatitis: 1, cholecystitis: 2, and stent migration: 2) and 13.9% (cholecystitis: 3, stent migration: 2), respectively (P = 0.89).

Conclusions

EST before FCSEMS placement for distal malignant biliary stricture due to a pancreatic head tumor does not affect the successful drainage and incidence of adverse events. The necessity of EST to prevent pancreatitis before FCSEMS placement was deemed low.

Endoscopic biliary self-expandable metallic stent in malignant biliary obstruction with or without sphincterotomy: systematic review and meta-analysis

Background and aim  To assess the rate of adverse events and the technical success rate of biliary stenting with or without EBS.  Methods  A literature search up to February 2017 was performed. Studies assessing adverse events (AEs) and technical success rates of stenting with or without EBS were considered. Results  Seven studies (870 patients; 12 treatment arms) were included. Early AEs, i. e. those occurring within 30 days, were significantly lower in no-EBS vs. EBS-group (11 % vs . 20.1 %; OR: 0.36, 95 %CI: 0.13 - 1.00). Rates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis were not significantly different in the two groups (no-EBS vs . EBS: 6.1 % vs 5 %; OR: 1.33, 95 %CI: 0.68 - 2.59). The rate of bleeding was significantly lower in patients without EBS (no-EBS vs EBS: 0 % vs 5 %; OR: 0.12, 95 % CI: 0.03 - 0.45). Rates of cholangitis were significantly lower in patients without EBS (no-EBS vs . EBS: 3.3 % vs. 7.4 %; OR: 0.38, 95 %CI: 0.17 - 0.83). Both late AEs and mortality rates did not significantly differ between no-EBS and EBS patients (19.9 % vs. 18.9 %; OR: 0.93, 95 %CI: 0.56 - 1.53, and 2.5 % vs. 2.9 %; OR: 1.18, 95 %CI: 0.22 - 6.29, respectively). The technical success rate for stent insertion also did not differ (98 % vs. 97.6 %; OR: 1.05, 95 %CI: 0.42 - 2.63). Conclusion  EBS seems to be associated, in the first 30 days after the procedure, with an increased risk of cholangitis and bleeding. No difference was observed in the rate of post-ERCP pancreatitis.

How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Pancreatitis remains the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Recent advances in prophylaxis have improved but not eliminated this problem, underscoring the importance of ongoing research toward this goal. This review aims to provide an evidence-based approach to post-ERCP pancreatitis prevention through patient selection, risk stratification, procedural technique, and multimodality prophylaxis, and discusses ongoing and future research initiatives in this important area.

How to measure quality in endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called "Quality measures" which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist. Further research is required regarding quality measures improvement and information exchange in the global ERCP quality network.

Quality indicators for endoscopic retrograde cholangiopancreatography. The procedure of endoscopic retrograde cholangiopancreatography

The goal of the project encompassing the present paper is to propose useful quality procedures and indicators in order to improve quality in digestive endoscopy units. In this third part outcome procedures and indicators are suggested for endoscopic retrograde cholangiopancreatography (ERCP). First, a diagram of pre- and post-ERCP steps was developed. A group of experts in healthcare quality and/or endoscopy, under the shelter of the Spanish Society of Digestive Diseases (Sociedad Española de Patología Digestiva - SEPD), carried out a qualitative review of the literature regarding quality indicators for ERCP. Then, a paired analysis was used for the selection of identified references. A total of six specific indicators, apart from the common indicators already described, were identified, all of them process indicators (two pre-procedure and four post-procedure). Evidence quality was analyzed for each indicator using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) classification.

Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis

Pancreatitis is the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in significant morbidity, occasional mortality, and increased health-care expenditure. Accordingly, the prevention of post-ERCP pancreatitis (PEP) remains a major clinical and research priority. Strategies to reduce the incidence of PEP include thoughtful patient selection, appropriate risk-stratification, sound procedural technique, prophylactic pancreatic stent placement, and pharmacoprevention. Despite advances in all these areas, however, the incidence of PEP remains as high as 15% in high-risk cases. Thus, additional research towards the goal of eliminating PEP is necessary. Herein is an evidence-based review of strategies to prevent pancreatitis after ERCP, focusing on recent important developments in the field.

Multiple plastic biliary stent placement in the management of large and multiple choledochal stones: single center experience and review of the literature

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the first step treatment modality of choledocholithiasis. In spite of an extended sphincterotomy, 10-15% of complex choledochal stones (larger than 15 mm and/or more than 3 stones) cannot be removed and recurrent ERCP procedures may be needed.

AIM

To evaluate the role and efficiency of multiple biliary stent application in the treatment of large and multiple choledochal stones.

MATERIAL AND METHODS

Patients with complex choledochal stones and patients with inadequate choledochal clearance during ERCP were included in the study. The study group was divided into 2 groups as the placement of single (n = 27 patients) or multiple stents (n = 58 patients). After a mean time interval of 21 days (10-28), the ERCP procedure was tried for the second time and a stent was placed in case of recurrence.

RESULTS

Successful biliary drainage was provided in both groups. The decrease in the longitudinal or transverse size of the stones after stent placement was found to be statistically significant in both groups (p = 0.001). Cholestatic enzymes (alkaline phosphatase (ALP), γ-glutamyltransferase (GGT)) and bilirubin levels decreased significantly in both groups following stenting (p = 0.001). Additionally, multiple stents functioned as a bridge starting from the first ERCP to full clearance in patients with large and multiple stones which could not be removed at once and saved them from the possible morbidities of an invasive operation.

CONCLUSIONS

Endoscopic multiple biliary stent placement should be preferred in the treatment of patients with complex choledochal stones and high rates of co-morbidity, as a safe alternative to surgery.

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

BACKGROUND AND STUDY AIM

 Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds.

METHODS

 Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach.

RESULTS

 A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ.

CONCLUSION

 There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

AIM

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).

METHODS

This was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.

RESULTS

Among the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.

CONCLUSION

Limited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Rectal Indomethacin Reduces Pancreatitis in High- and Low-Risk Patients Undergoing Endoscopic Retrograde Cholangiopancreatography

BACKGROUND & AIMS

Rectal indomethacin reduces the risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Most studies of its efficacy included high-risk cohorts and excluded low-risk patients, including those with malignant biliary obstruction. We investigated the potential of rectal indomethacin to prevent post-ERCP pancreatitis (PEP) in a variety of patients.

METHODS

We performed a retrospective cohort study of 4017 patients who underwent ERCP at the Hospital of the University of Pennsylvania, from 2009 and 2015, including 823 patients with malignant biliary obstruction. After June 2012, with a few exceptions, patients received indomethacin after their procedure. We collected data from patients' records on demographic and clinical features, procedures, and development of PEP. PEP was defined by consensus criteria. Multivariable logistic regression was used to determine adjusted odds ratios (ORs) for the association between indomethacin and PEP.

RESULTS

Rectal indomethacin reduced the odds of PEP by 65% (OR, 0.35; 95% confidence interval [CI], 0.24-0.51; P < .001) and moderate-to-severe PEP by 83% (OR, 0.17; 95% CI, 0.09-0.32; P < .001). In patients with malignant obstruction, rectal indomethacin reduced the risk of PEP by 64% (OR, 0.36; 95% CI, 0.17-0.75; P < .001) and moderate-to-severe PEP by 80% (OR, 0.20; 95% CI, 0.07-0.63; P < .001). Among patients with malignant obstruction, rectal indomethacin provided the greatest benefit to patients with pancreatic adenocarcinoma: 2.31% of these patients who received rectal indomethacin developed PEP vs 7.53% who did not receive rectal indomethacin (P < .001) and 0.59% of these patients who received rectal indomethacin developed moderate-to-severe PEP vs 4.32% who did not receive rectal indomethacin (P = .001).

CONCLUSIONS

In a large retrospective cohort study of patients undergoing ERCP that included low-risk patients and patients with malignant biliary obstruction, rectal indomethacin was associated with a significant decrease in the absolute rate and severity of pancreatitis.

Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis

BACKGROUND AND AIM

Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta-analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak.

METHODS

We carried out a systematic search in several electronic databases for randomized controlled trials (RCT) and observational studies (OS) comparing the risk of PEP after biliary stenting with or without ES. The Mantel-Haenszel method was used to pool data of adverse outcomes into fixed or random effect model meta-analyses.

RESULTS

Seventeen studies (five RCT and 12 OS) with a total of 2710 patients met the inclusion criteria. No significant difference was observed in the risk of PEP with biliary stenting with and without ES (RD -0.01; 95% confidence interval [CI] -0.03, 0.01). In a subgroup analysis of stenting for biliary obstruction, no difference in the risk of PEP was observed with or without ES. However, ES was associated with lower risk of PEP in patients undergoing biliary stenting for bile leak (RD -0.05; CI -0.10, -0.01).

CONCLUSIONS

ES shows risk reduction in prevention of PEP in patients undergoing endoscopic stenting for bile leak. However, placement of biliary stent without ES is not associated with an increased risk of PEP in patients with distal bile duct obstruction with involvement of pancreatic duct.

An Update to Hepatobiliary Stents

Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.(1).

Consent, common adverse events, and post-adverse event actions in endoscopy

Endoscopy constitutes a wide range of procedures with many indications. Esophagogastroduodenoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and enteroscopy comprise the most commonly performed procedures. These examinations all carry risk to the patient, and incumbent in this is some legal risk with regard to how the procedure is conducted, decisions made based on the intraprocedure findings, and the postprocedure results, in addition to events that occur following the procedure. This article provides an overview of consent and complications of endoscopy.

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: a meta-analysis

AIM

To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.

RESULTS

Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).

CONCLUSION

EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.

Biliary sphincterotomy is not required for bile duct stent placement

BACKGROUND

The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).

PATIENTS AND METHODS

Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.

RESULTS

Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).

CONCLUSION

Single bile duct stents, both plastic and metal, can be deployed without EBS.

Covered metal stenting for malignant lower biliary stricture with pancreatic duct obstruction: is endoscopic sphincterotomy needed?

Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.

Prevention of post-ERCP pancreatitis

Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.

Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis

OBJECTIVES

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.

METHODS

A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.

RESULTS

A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).

CONCLUSIONS

ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Preventing pancreatitis after endoscopic retrograde cholangiopancreatography

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.

Endoscopic biliary stenting and pancreatitis

Endoscopic biliary stenting across the duodenal papilla can obstruct the adjacent pancreatic orifice and disturb the flow of pancreatic juice, which may result in pancreatitis. However, the relationship of endoscopic biliary stenting to post-procedure pancreatitis has not been thoroughly examined. Therefore, we have reviewed the published literature on this issue. Although biliary stenting, especially with large-bore and self-expandable metallic stents (SEMSs), has been considered a possible additional risk factor for pancreatitis following biliary stenting, most studies have not provided convincing supporting evidence; this failure may be due to inadequate study design or insufficient numbers of subjects. It also remains unclear whether endoscopic sphincterotomy (EST) performed prior to biliary stenting decreases the incidence of post-stenting pancreatitis; some recent studies have claimed that EST is not necessary before biliary stenting, even with placement of SEMSs. Well-designed studies with a large number of subjects will be needed to clarify these issues.

Lethal post-endoscopic retrograde cholangiopancreatography pancreatitis following fully covered metal stent placement in distal biliary obstruction due to unresectable cholangiocarcinoma

Biliary self-expandable metallic stent (SEMS) is the preferred and first-line therapy for unresectable malignant biliary obstruction. To date, several reports have revealed the relatively high incidence of acute complications such as pancreatitis and cholecystitis due to mechanical stent compression. In the present case, we encountered fatal pancreatitis following fully covered metal stent placement. An 85-year-old man had middle bile duct strictures due to cholangiocarcinoma. A 10-mm diameter fully covered SEMS was placed across the papilla for biliary decompression. Laboratory data and physical evidence the following day revealed acute pancreatitis. Therefore, antibiotics and protein degeneration enzyme inhibitors were given. However, his condition did not improve. Two days after the procedure, we removed the stent and returned him to his original hospital. Serum amylase level decreased below 400 mg/dL 6 h after the procedure. However, the acute pancreatitis worsened. Although we treated the patient in the intensive care unit, he died 32 days after the second admission.

Current status and issues regarding biliary stenting in unresectable biliary obstruction

In the present review, we describe the current status of biliary stenting in patients with unresectable malignant biliary strictures. Self-expandable metallic stents (SEMS) are the ideal biliary stent for both distal and hilar biliary strictures, although in terms of distal biliary strictures, there is still some debate as to the selection of covered or uncovered SEMS, suprapapillary or transpapillary stent placement, side-by-side or stent-in-stent placement, unilateral or bilateral stent placement and the necessity for sphincterotomy. Further high-quality randomized controlled trials for these procedures are warranted.

Endoscopic management of malignant bile duct strictures

Malignant biliary obstruction can arise from intrahepatic, extrahepatic, and hilar locations from either primary or metastatic disease. Biliary-enteric surgical bypass has been surpassed in the last 20 years by endoscopic balloon dilation and stenting. The goal of stenting for biliary decompression is to palliate obstructive symptoms; it has not been shown that survival is affected by stenting alone. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have been evaluated and show promise. Both therapies seem to be safe and effective in the treatment of malignant bile duct strictures but are in need of prospective studies of longer duration.

Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure with the potential for a variety of adverse events, including acute pancreatitis, perforation, bleeding, and cardiopulmonary complications, which are well-established risk factors. It has become standard that patients undergoing ERCP are carefully selected based on appropriate indications. Once an ERCP is undertaken, preprocedure and intraprocedure risks should be assessed and appropriate risk-reducing modalities, such as prophylactic pancreatic stent placement and rectal indomethacin, should be used if patient or procedural factors suggest an increased risk of post-ERCP pancreatitis.

Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

BACKGROUND

Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases.

METHODS

In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated.

RESULTS

SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups.

CONCLUSIONS

ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

Post-ERCP pancreatitis: review of current preventive strategies

PURPOSE OF REVIEW

This article reviews the most recent literature with significant findings pertaining to the prevention of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

RECENT FINDINGS

Despite several promising reports of pharmacologic agents that have demonstrated the efficacy for prophylaxis against post-ERCP pancreatitis such as nonsteroidal anti-inflammatory drugs and secretin, there are currently no universally accepted agents for use in high-risk patients. The greatest reductions in the incidence of post-ERCP pancreatitis in high-risk patients have been demonstrated through advancements in endoscopic techniques such as pancreatic duct stenting and dye-free guidewire cannulation.

SUMMARY

Pancreatitis requiring hospitalization is the most common complication of ERCP. Numerous pharmaceutical and procedure related interventions have been studied in attempts to prevent this complication; however, morbidity associated with ERCP remains significant. The most effective methods for preventing post-ERCP pancreatitis are careful patient selection and identification of risk factors prior to procedure.

Risk factors for pancreatitis following transpapillary self-expandable metal stent placement

BACKGROUND

Pancreatitis is one of complications after self-expandable metal stent (SEMS) placement. The purpose of this study was to evaluate risk factors for pancreatitis after endoscopic SEMS placement for malignant biliary obstruction (MBO).

METHODS

We retrospectively reviewed 370 consecutive patients who underwent initial transpapillary SEMS placement for biliary decompression. The characteristics of inserted SEMSs were classified according to axial and radial force.

RESULTS

Pancreatitis following SEMS insertion was observed in 22 patients (6%). All of them were mild according to consensus criteria. Univariate analysis indicated that injections of contrast into the pancreatic duct (frequency of pancreatitis, 10.3%), the placement of an SEMS with high axial force (8.3%), and nonpancreatic cancer (16.1%) significantly contributed to the development of pancreatitis, whereas female gender, a younger age, a covered SEMS, and a SEMS with high radial force or without a biliary sphincterotomy did not. In a multivariate risk model, SEMSs with high axial force (odds ratio [OR], 3.69; p = 0.022) and nonpancreatic cancer (OR, 5.52; p < 0.001) were significant risk factors for pancreatitis.

CONCLUSIONS

SEMSs with high axial force and an etiology of MBO other than pancreatic cancer were strongly associated with a high incidence of pancreatitis following transpapillary SEMS placement in patients with distal MBO.

Self-expandable metal stents for malignant distal biliary strictures

Obstructive jaundice can result from benign or malignant etiologies. The common benign conditions include primary sclerosing cholangitis, chronic pancreatitis, and gallstones. Malignant biliary obstruction can be caused by direct tumor infiltration, extrinsic compression by enlarged lymph nodes or malignant lesions, adjacent inflammation, desmoplastic reaction from a tumor, or a combination of these factors. Malignant diseases causing biliary obstruction include pancreatic cancer, ampullary cancer, cholangiocarcinoma, and metastatic diseases. This article focuses on malignant distal biliary obstruction and its management.