American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: methodology and review of evidence

Endoscopic retrograde cholangiopancreatography and endoscopic cystogastrostomy in very young children (aged <5 years): Feasibility, success, and safety

Objectives

Paucity of data and concerns about potential lower effectiveness and more adverse events limit the use of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic cystogastrostomy in younger children even in high-volume centers. We retrospectively analyzed indications, success rates, and adverse events of all the children (<18 years) who underwent ERCP and endoscopic cystogastrostomy between January 2010 to May 2024 at our center.

Methods

Data, including patient demographics, indications for the procedure, technical details, and adverse events, were collected from our prospectively kept database and compared according to age groups (<1 year, 1-5 years, 5-10 years, and 10-18 years).

Results

A total of 286 ERCP (273 therapeutic and 13 diagnostic) and 57 endoscopic cystogastrostomy were performed in 222 (138 boys) and 55 children (32 boys), respectively, during the study period with 20% ERCP procedures in under-five children. In children <5 years, the majority of the ERCPs were for biliary diseases (87%), while pancreatic duct procedures (39.5%) were done in higher numbers in children >5 years. For biliary ERCP, choledochal cyst (15, 33%) was the most common etiology in under-five children and choledocholithiasis (60, 34%) in children >5 years. Cannulation and technical success rates were 95% and 92%, respectively with no significant difference across age groups. Adverse events were noted in 36 (16%) with post-ERCP pancreatitis (8%) being the most common. All adverse events were managed conservatively with no mortality.

Conclusion

ERCP can safely be performed in all children, including those under five with various hepato-pancreato-biliary diseases with high technical success rates.

Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.

Impact of difficult biliary cannulation on post-ERCP pancreatitis: secondary analysis of the stent versus indomethacin trial dataset

BACKGROUND AND AIMS

Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors.

METHODS

This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP.

RESULTS

In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages.

CONCLUSIONS

DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.

Adverse Events Associated With Endoscopic Retrograde Cholangiopancreatography: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and health care expenditure. We aimed to assess incidences and comparisons of ERCP AEs.

METHODS

We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence.

RESULTS

A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence interval [CI], 0.1%-0.3%; I2, 44%; n = 47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI, 4.0%-5.1%; I2, 96%; n = 293,378) among all-comers and 6.5% (95% CI, 5.9%-7.1%, I2, 89%; n = 88,809) among first-time patients. Pancreatitis incidence remained stable between 2000 and 2023 (average annual percent change 0.06, 95% CI, -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%; 95% CI, 1.2%-1.7%; I2, 93%; n = 229,655), cholangitis (2.5%; 95% CI, 1.9%-3.3%; I2, 96%; n = 121,619), cholecystitis (0.8%; 95% CI, 0.5%-1.2%; I2, 39%; n = 7799), and perforation (0.5%; 95% CI, 0.4%-0.6%; I2, 90%; n = 306,378).

CONCLUSIONS

ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies.

Intra- and post-procedural patient-reported experience measures and their correlation with post-ERCP adverse events and unplanned healthcare utilization

BACKGROUND

 Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to assess potential etiologic associations between intra-/post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. METHODS : Prospective data from a multicenter collaborative were used. A 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP, and follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and AEs and UHU as outcomes, with a priori selected covariates. Odds ratios (ORs) and 95 %CIs for each PREM domain were reported.

RESULTS

 From 2018 to 2023, 3434 patients were included. A post-procedural abdominal pain score > 3 was associated with pancreatitis (OR 3.71 [95 %CI 2.37-5.73]), while a score > 6 was associated with perforation (OR 9.54 [95 %CI 1.10-59.37]). Post-procedural pain was also associated with UHU within 30 days when used as a continuous exposure (OR 1.08 per point [95 %CI 1.01-1.16]), and when partitioned at a score > 3 (OR 1.79 [95 %CI 1.13-2.74]) and a score > 6 (OR 1.93 [95 %CI 1.02-3.46]). No other intra- or post-procedural PREMs were associated with any AEs or UHU.

CONCLUSIONS

 Patient-reported abdominal pain from a Likert-based PREM at the time of discharge from ERCP was associated with pancreatitis, perforation, and UHU within 30 days. Applying PREMs could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs.

Large balloon sphincteroplasty for CBD stone removal during acute cholangitis. Single center propensity-score matched cohort study

BACKGROUND

Endoscopic biliary drainage is the mainstay of treatment for acute cholangitis. CBD stone removal can be performed in same session with biliary drainage. Our team incorporated the use of endoscopic large balloon sphincteroplasty as an alternative for conventional papillotomy for biliary access. This study aims to identify tips and pitfalls of EPLBD usage during acute cholangitis.

METHOD

From the period October 2016 to April 2021, Yan Chai Hospital has 209 patients presented with acute cholangitis had ERCP for CBD stone removal performed. Among which, 50 patients had limited papillotomy followed by endoscopic large balloon papillary dilatation for biliary access (EPLBD), while 159 patients had conventional sphincterotomy (EST) done. Propensity score matching analysis was performed in a 1:1 ratio. Primary outcome was complete CBD stone removal as defined by clearance of occlusive cholangiogram. Secondary outcomes are post-ERCP pancreatitis, minor bleeding and major bleeding, flare up of sepsis. Logistic regression analysis was performed to identify risk factors associated with one year recurrence rate. Kaplan Meier analysis was utilized for long-term recurrence rate after ERCP.

RESULT

In overall cohort, presence of large CBD stone & parapapillary diverticulum was more frequent in EPLBD group (26.0 ≤ 6.2% vs 9.4 ± 2.3%, p = 0.003) & (52.0 ± 7.1% vs 24.5 ± 3.4%, p < 0.001); they were balanced in PSM cohort. The complete CBD stone removal rate were higher in EPLBD group than EST group with statistical significance (80.0 ± 5.7% vs 54.0 ± 7.0%, p = 0.006). Major bleeding requiring reintervention was observed in 2.0 ± 2.0% vs 8.0 ± 3.8%, p = 0.169. Post ERCP pancreatitis were observed in 2.3 ± 2.2% vs 2.4 ± 2.4%, p = 0.960. 1 year recurrence rate was 14.0 ± 4.9% vs 2.0 ± 2.0 % , p = 0.027 .

CONCLUSION

Deployment of EPLBD during acute cholangitis demonstrated clinical efficacy in CBD stone clearance when compared with conventional sphincterotomy with a non-inferior safety profile. However, long term recurrence rate of acute cholangitis was observed to be higher.

Tailored Hydration With Lactated Ringer's Solution for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention: A Randomized Controlled Trial

INTRODUCTION

Aggressive hydration using lactated Ringer's solution prevents postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Concerns of this strategy are large volume and lengthy hydration. Our study aimed to evaluate the efficacy of tailored aggressive hydration (TAH) for PEP prevention.

METHODS

In this prospective, multicenter, double-blinded, randomized trial conducted across 3 tertiary Korean hospitals, patients who underwent ERCP for the first time were randomly assigned (1:1) to the tailored standard hydration (TSH) and TAH groups. The TSH group received 1.5 mL/kg/hr lactated Ringer's solution during and after ERCP, whereas the TAH group was administered a 20 mL/kg bolus post-ERCP and 3 mL/kg/hr during and after the procedure. Both groups were assessed for elevated serum amylase levels and pain 4-6 hours after ERCP. If both were absent, hydration was discontinued. If either was present, hydration was continued at the original rate until 8 hours. The primary end point was PEP development and was analyzed on an intention-to-treat analysis.

RESULTS

A total of 344 patients were randomly assigned to treatment groups (171 to the TSH group and 172 to the TAH group). PEP was observed in 9.4% (16/171) in the TSH group and 3.5% (6/172) in the TAH group (relative risk 0.37, 95% confidence interval 0.15-0.93, P = 0.03). No difference was identified between the 2 groups in PEP severity ( P = 0.80) and complications related to volume overload ( P = 0.32).

DISCUSSION

TAH according to the presence of abdominal pain or elevated serum amylase levels at 4-6 hours after ERCP is safe and prevents PEP development.

Preventive Measures and Risk Factors for Post-ERCP Pancreatitis: A Systematic Review and Individual Patient Data Meta-Analysis

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP, with limited studies comparing combined prophylactic measures and their efficacy relative to individual patient risk profiles. This study aims to perform an individual patient data meta-analysis (IPDMA) to evaluate the contribution of patient and ERCP-related risk factors to PEP development and to identify the best prophylaxis strategies according to the patient's risk profile.

METHODS

We systematically searched MEDLINE, Embase, and Cochrane databases until November 2022 for randomized controlled PEP prophylaxis trials. We invited authors to share individual patient data, including PEP risk profile and prophylaxes used. PEP incidence rates for different prophylaxis were calculated. Efficacy was compared using multilevel logistic regression and expressed as relative risk (RR). Subgroup analysis evaluated the role of patient and ERCP-related risk factors in developing PEP.

RESULTS

Data from 11 studies, including 6430 patients, were analyzed. After adjusting for risk factors, rectal NSAIDs (RR 0.69, 95%CI 0.54-0.88) and peri-procedural high-volume intravenous fluid (IVF) (RR 0.40, 95%CI 0.21-0.79) were effective in reducing PEP incidence, while no benefit was noted with pancreatic duct (PD) stents (RR 1.25, 95%CI 0.91-1.73). In patients receiving rectal NSAIDs (n = 2617), difficult cannulation (RR 1.99, 1.45-2.73), contrast injection into the pancreatic duct (PD) (RR2.37, 1.68-3.32), and prior history of PEP (RR 1.90, 1.06-3.41) were associated with increased PEP risk.

CONCLUSION

This IPDMA confirms that rectal NSAIDs and peri-procedural IVF are effective PEP prophylactic strategies. Further studies focusing on combination therapy or the development of personalized PEP risk calculators are needed to improve prophylactic strategies.

Climate Sustainability as a Catalyst for Quality and Excellence in Gastrointestinal Endoscopy: A Narrative Review

The significant contribution of greenhouse gas (GHG) emissions to global warming and the resultant negative impact on health is well established. Within the hospital setting, the endoscopy center has been ranked third-after the operating theater complex and intensive care unit-in terms of the volume of hazardous medical waste generated. Such regulated medical waste cannot be recycled, and the disposal process results in higher costs and a larger carbon footprint. There have been clarion calls to reduce the number of endoscopic procedures as a means of reducing GHG emissions. Previous studies have demonstrated the carbon footprint of inappropriate endoscopic procedures. However, endoscopy is an important diagnostic and therapeutic tool that has been shown to be cost-effective. A focus simply on reduction in procedural case volume alone raises the unintended consequences of inequitable access to endoscopy for those in need. A more nuanced approach that is aligned with the innate sense of healthcare professional aspirations and pride, in terms of seeking quality and clinical excellence, should be considered. An evidence-based approach, with a focus on quality and efficiency, as well as appropriate and timely use of new technology, will serve as a catalyst for positive behavioral change toward quality procedures and excellence. This will improve patient satisfaction, increase professional expertise and pride, and reduce carbon footprint through minimization of inappropriate and avoidable repeat procedures.

Real-world evidence comparing early and late pancreatic stent placement to prevent post-ERCP pancreatitis

Background and study aims Pancreatic stenting effectively lowers the occurrence of post-ERCP pancreatitis (PEP) and reduces its severity. However, limited research has been conducted to determine the optimal timing for pancreatic stent placement. Our objective was to evaluate whether early pancreatic stent placement (EPSP) is more effective than late pancreatic stent placement (LPSP) in preventing PEP among patients with naive papilla. Patients and methods We conducted a retrospective cohort study that analyzed 590 patients with difficult biliary cannulation using the pancreatic guidewire technique, who were divided into EPSP and LPSP groups. In the EPSP group, a pancreatic stent was placed immediately before/after endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (EST). Conversely, in the LPSP group, a pancreatic stent was placed after partial/all completion of major endoscopic procedures. Results From November 2017 to May 2023, 385 patients were in the EPSP group and 205 in the LPSP group. EPSP was associated with a decreased PEP occurrence compared with LPSP (2.9% vs. 7.3%; P = 0.012). Similarly, hyperamylasemia was lower in the EPSP group (19.7% vs. 27.8%; P = 0.026). Furthermore, sensitivity analysis using multivariable analysis and propensity score-matched (PSM) analysis also validated these findings. Conclusions Early pancreatic stent placement reduced the incidence of PEP and hyperamylasemia compared with late pancreatic stent placement. Our findings favor pancreatic stenting immediately before/after ERC or EST.

Prophylactic pancreatic duct stenting to reduce the risk of post-ampullectomy pancreatitis: a comprehensive review and meta-analysis of 1858 patients

BACKGROUND

The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications.

METHODS

Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics.

RESULTS

Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3-14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9-15.7) and without PPDS, 16.6% (CI 13.4-20.4), RR 0.8 (CI 0.51-1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3-81.1) and 25.1% (CI 19-32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively.

CONCLUSIONS

Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings.

Indomethacin Does Not Reduce Post-ERCP Pancreatitis in High-Risk Patients Receiving Pancreatic Stenting

BACKGROUND

Rectal indomethacin reduces pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, there is insufficient evidence regarding its added benefits in patients already receiving prophylactic pancreatic stenting. Our goal was to evaluate the impact of indomethacin in high-risk patients undergoing pancreatic stenting.

METHODS

A cohort study was conducted on all patients who underwent the rescue cannulation technique for challenging bile duct cannulation (selected high-risk patients). Patients were split into two groups based on the prophylaxis method for post-ERCP pancreatitis (PEP): one receiving a combination of indomethacin and pancreatic stenting, while the other received pancreatic stenting alone. Comparative analyses were carried out on PEP, hyperamylasemia, gastrointestinal bleeding, and postoperative hospital stay among post-ERCP pancreatitis patients.

RESULTS

Between November 2017 and May 2023, a total of 607 patients with native papillae were enrolled, with 140 grouped into the indomethacin plus stent group and 467 into the stent alone group. The overall PEP rate was 4.4% in the entire cohort, with no statistical differences observed between the groups in terms of PEP rates (P = 0.407), mild PEP (P = 0.340), moderate to severe PEP (P = 1.000), hyperamylasemia (P = 0.543), gastrointestinal bleeding (P = 0.392), and postoperative hospital stay (P = 0.521). Furthermore, sensitivity analysis using multivariable analysis also validated these findings.

CONCLUSIONS

Indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement. Therefore, the additional administration of rectal indomethacin to further mitigate PEP appears to be not necessary.

Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones

Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.

Double Postbulbar Block in the Prevention of Postmanipulation Pancreatitis

Abstract The problems of preventing postmanipulation pancreatitis (PMP) remain the subject of debate and a lot of research from leading scientific clinics around the world. The article is devoted to the assessment of prevention methods of PMP in patients with lesion of the pancreaticobiliary zone who underwent transpapillary interventions. Aim of the study Evaluation of the effectiveness of the author’s method of preventing PMP.

Material and methods A prospective two-center randomized study included 545 patients treated in the Department of Liver Surgery and General Surgery in 2020–2022, who underwent ERCP and endoscopic papillosphincterotomy. There were 146 (26.8%) male patients, and 399 (73.2%) female patients, aged from 18 to 92 years, the mean age 62.7±7.4 years. Patients were divided into 3 groups according to the method of preventing PMP: in the 1st group, standard drug premedication was supplemented with two postbulbar blocks with a solution of lidocaine 0.5% 10 ml before and after the intervention (RF Patent No. 2779221, 09/05/2022), in the 2nd group standard premedication was combined with placebo was used, and in the comparison group 3 no submucosal injections were performed. The monitoring of clinical manifestations of PMP and the level of amylase was carried out every 12 hours until the parameters normalized. Statistical processing was carried out using program STATISTICA 6.1 for Windows.

Results The frequency of mild pancreatitis, corresponding to the criteria for PMP, did not exceed 18% in groups 1 and 3 (p=0.3408), but was lower with pseudo postbulbar block, 9% (χ2=2.83, р=0.0926), the difference was not statistically significant. The incidence of severe pancreatitis was significantly lower in group 1 with double postbulbar block where there were no cases of pancreatic necrosis among 143 patients (χ2=6.19, р=0.0129). The mortality did not differ significantly among groups (χ2=0.15, р=0.7004). The duration of the hospital period had significant differences between groups (Student’s t-test 1.973, p=0.001). The hospital period with double postbulbar block turned out to be significantly shorter.

Conclusion 1. Double postbulbar blockade significantly reduces the risk of developing severe postmanipulation pancreatitis, regardless of existing risk factors. 2. Double postbulbar block significantly reduces the duration of the hospital period after endoscopic papillosphincterotomy. 3. Pseudo postbulbar block using saline requires further evaluation as a possible way to prevent mild pancreatitis.

Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables.

Methods

Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation.

Results

Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003.

Conclusions

We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.

Pancreatic stent migration into the main pancreatic duct during endoscopic papillary balloon dilation

We report the first case of pancreatic stent (PS) migration placed early into the main pancreatic duct (MPD) during endoscopic retrograde cholangiopancreatography (ERCP) due to subsequent endoscopic papillary balloon dilation. A 74-year-old woman who complained of fever and abdominal pain was diagnosed with acute calculous cholangitis. On ERCP, a needle-knife precut papillotomy was performed from the orifice because of difficult cannulation. Because of unintentional guidewire insertion into the MPD from the orifice, a PS with bilateral flaps was promptly placed to prevent post-ERCP pancreatitis. After successful biliary cannulation from the orifice alongside the PS, endoscopic papillary balloon dialtion was performed, leading to PS migration into the MPD during the dilation. Two days after the first ERCP, the migrated PS was successfully removed on the second ERCP. The strategy of early PS placement in the ERCP session appears theoretically promising for preventing post-ERCP pancreatitis. However, early PS placement during the ERCP session should be noted to pose the risk of migration into the MPD, especially when pushing the device into the bile duct.

Impact of preoperative endoscopic procedures on adverse event rates after surgical resection for main-duct and mixed-type intraductal papillary mucinous neoplasms (IPMNs)

BACKGROUND

Main-duct (MD-) and mixed-type (MT-) IPMNs harbor an increased risk of pancreatic cancer and warrant surgical resection. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are important in the diagnosis of IPMNs. The aim of this study was to investigate whether endoscopic procedures manipulating the MD impact postoperative adverse events in patients with MD- and MT-IPMNs.

METHODS

We performed a retrospective study of 369 patients who underwent resections for MD- or MT-IPMN at two tertiary centers (2000-2019). Multivariable logistic regression analyses were performed for postoperative adverse events to compare the risks between intervention (ERCP, EUS-FNA with branch duct (BD) aspirated, EUS-FNA with MD aspirated from the duct directly or cyst/mass arising from MD) versus no-intervention group.

RESULTS

33.1 % of patients had a preoperative ERCP and 69.4 % had EUS-FNA. Postoperative adverse events included: 30-day readmission (12.7 %), delayed gastric emptying (13.8 %), pancreatic fistula (10.3 %), abdominal abscess (5.7 %), cardiopulmonary adverse events (11.4 %), and mortality (1.4 %). The model was adjusted for potential confounders. There were no significant differences between the ERCP and no-ERCP groups for specific adverse events. Compared to no-EUS-FNA groups, groups of EUS-FNA with BD aspiration and EUS-FNA with MD aspiration from the main pancreatic duct directly or cyst/mass arising from MD did not show a significant increase in specific adverse events.

CONCLUSIONS

Postoperative adverse events were not significantly increased among patients who had ERCP or EUS-FNA before surgical resection for MD- or MT-IPMNs. Endoscopic procedures directly sampling the MD can be safely pursued for diagnostic purposes in selected cases.

Endotherapy in pediatric pancreatitis

PURPOSE OF REVIEW

Some children with acute recurrent and chronic pancreatitis stand to benefit from therapeutic endoscopic interventions. The purpose of this review is to summarize specific endoscopic therapies used for these conditions and highlight areas of future research.

RECENT FINDINGS

Multicenter collaboration and consortium efforts have provided more data now than ever on the technical outcomes and safety of therapeutic endoscopic procedures for pancreatitis in children. Indications are growing but more research is needed to help guide patient selection.

SUMMARY

Advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography, endoscopic-ultrasound guided therapies, and single-operator pancreatoscopy may be used in patients with acute recurrent or chronic pancreatitis to manage pancreatic duct obstruction or local complications including pseudocysts and walled-off necrosis. Patient and procedural factors differ between adults and children. Access to these procedures for younger children is growing, and technical outcomes and adverse event rates appear similar between adults and children.

ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs.

AREAS COVERED

This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023.

EXPERT OPINION

Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.

Incidence and Predictors of Incidental Biochemical and Radiologic Pancreatic Alterations Following Uncomplicated ERCP

Background: Despite post-ERCP pancreatitis (PEP) being a major focus of outcomes research in endoscopic retrograde cholangiopancreatography (ERCP), little is known regarding the frequency with which asymptomatic biochemical and/or radiologic pancreatic alterations occur in patients following ERCP. Methods: Adult inpatients undergoing ERCP were identified from a prospective ERCP registry. Patients with any abdominal pain, confirmed PEP, or pancreatitis or abnormal pancreatic enzymes preceding ERCP were excluded. Primary outcomes were asymptomatic lipase elevation on bloodwork within 24 h of ERCP or asymptomatic cross-sectional imaging findings consistent with acute pancreatitis in the absence of clinical PEP within 14 days. Multinomial logistic regression and multiple logistic regression were used to examine associations between exposures and lipase levels and between PEP or imaging findings, respectively. Results: In total, 646 and 187 patients were analyzed as part of the biochemical and radiologic cohorts, respectively. A total of 26.0% of patients had asymptomatic elevations in lipase above the upper limit of normal (ULN) within 24 h, and 9.4% had elevations >3× ULN. A total of 20.9% of patients had incidental findings of enlargement, inflammation/edema/fat stranding, peri-pancreatic fluid collections, and/or necrosis on cross-sectional imaging within 14 days. Pancreatic contrast injection was associated with higher odds of asymptomatic lipasemia (adjusted odds ratio, AOR, 7.22; 95% confidence intervals, CI, 1.13 to 46.02), as was the use of the double-wire technique (AOR 15.74; 95% 1.15 to 214.74) and placement of a common bile duct stent (AOR 4.19; 95% CI 1.37 to 12.77). Over 10 cannulation attempts were associated with the presence of one or more radiologic finding(s) (AOR 33.95; 95% CI 1.64, to 704.13). Conclusions: Significant rates of incidental biochemical and/or radiologic pancreatic abnormalities are present following ERCP. Clinicians should be aware of our findings to minimize misclassification and better direct healthcare utilization.