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

Predictive Factors of Post-ERCP Hepatic Decompensation in Patients with Cirrhosis: A Retrospective Case-Control Study

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial diagnostic and therapeutic procedure in patients with cirrhosis; however, it carries the risk of post-procedural hepatic decompensation. This study aims to identify predictive factors associated with post-ERCP hepatic decompensation in patients with cirrhosis to better inform clinical decision-making and minimize adverse outcomes.

METHODS

A retrospective analysis was conducted on patients with cirrhosis undergoing ERCP. Clinical, biochemical, and procedural variables were evaluated to determine their association with hepatic decompensation. Multivariate analysis was performed to identify independent predictors.

RESULTS

A total of 277 patients with cirrhosis who underwent an ERCP were included. The cohort had a mean age of 63.4 years, with a male predominance (65.3%) and various etiologies of cirrhosis, including alcohol-related (39.3%) and hepatitis C (11.4%). Post-ERCP complications occurred in 26.7% of patients. The most common complications were hepatic decompensation events (18.4%), sepsis (10.8%), and cholangitis (6.1%). Patients with complications had significantly higher baseline MELD scores, INR, chronic kidney disease (CKD) and history of ascites, hepatic encephalopathy, and hepatorenal syndrome (HRS). A Multivariate analysis revealed that factors such as higher MELD score, ascites, hepatic encephalopathy, and stent placement were associated with post-ERCP complications. Subgroup analyses indicated that patients who developed hepatic decompensation events (ascites, SBP, or HRS) had a more severe liver dysfunction at baseline, as reflected by a higher MELD score and INR, and prior episodes of ascites and hepatic encephalopathy.

CONCLUSION

Pre-procedural liver function parameters and procedural factors are crucial predictors of post-ERCP hepatic decompensation in patients with cirrhosis. Key risk factors include higher MELD score, CKD, history of ascites, and hepatic encephalopathy. Careful pre-procedural evaluation and management are essential to reduce these risks.

Influence of pediatric ERCP positioning on procedural outcomes: A single-center study

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally done in the prone position. In pediatrics, patient anatomy and anesthesia practices are considerations that affect procedural success and anesthesia time. The aim of our study was to evaluate the safety, procedural success, and efficiency of pediatric ERCP in the prone versus supine positions.

METHODS

ERCPs from September 2016 to August 2023 were reviewed at our center. Demographic and procedure variables were collected. Multivariate linear regression was performed to determine the effect of patient position on total anesthesia time.

RESULTS

Two hundred and eighty-three patients (378 ERCPs) were included. There were significant differences in fellow involvement, proportion of native papillae, procedural indication, and total anesthesia time by ERCP position. Multivariate linear regression found that supine position was associated with 9.3-min decrease in anesthesia time and American Society of Anesthesiologists Class 1 or 2 was associated with 10.6-min decrease in anesthesia time. Factors that were associated with increased anesthesia time were additional procedure, increased procedure time, and native papilla. Finally, we found a learning curve for transitioning from prone to supine position was between 10 and 40 cases. After the learning curve, we found 11-min decrease in mean procedure time and 16-min decrease in total anesthesia time in the supine position.

CONCLUSIONS

This is the first pediatric study to evaluate the role of patient positioning on ERCP outcomes and total anesthesia time. Given similar procedural outcomes, the impact of increased anesthesia time on neurodevelopment in children, and the cost to the patient, the supine position may be preferred to a prone position.

Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video)

BACKGROUND

Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce.

METHODS

34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected.

RESULTS

Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose).

CONCLUSIONS

Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.

Patient Position in Operative Endoscopy

It is well known by surgeons that patient positioning is fundamental to exposing the organs when performing an operation via laparoscopy, as gravity can help move the organs and facilitate the exposure of the surgical site. But is it also important for endoscopic procedures? This paper examines various types of endoscopic operations and addresses the issue of the patient's position. The patient's position can be changed not only by rotating the patient along the head-toe axis but also by tilting the surgical bed, as is undertaken during laparoscopic surgical procedures. In particular, it is useful to take into account the effect of gravity on lesion exposure, tumour traction during dissection, crushing by body weight, risk of sample drop, risk of damage to adjacent organs, and anatomical exposure for procedures with radiological support. The endoscopist should always keep in mind the patient's anatomy and the position of the endoscope during operative procedures, not limited to considering only intraluminal vision.