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Lyu Y, Ye S, Wang B. Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation. BMC Surg 2024; 24:61. [PMID: 38365675 PMCID: PMC10873970 DOI: 10.1186/s12893-024-02350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND AND AIMS Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear. PATIENTS AND METHODS This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events. RESULTS Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69). CONCLUSIONS NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.
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Affiliation(s)
- Yunxiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China.
| | - Shenjian Ye
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China
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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Kuraishi Y, Hara K, Haba S, Kuwahara T, Okuno N, Yanaidani T, Ishikawa S, Yasuda T, Yamada M, Mizuno N. Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography. Clin Endosc 2023; 56:490-498. [PMID: 37157966 PMCID: PMC10393574 DOI: 10.5946/ce.2022.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/26/2022] [Accepted: 06/30/2022] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND/AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique. METHODS One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated. RESULTS The median size of the papillary roof was 6 mm (range, 3-20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3-15 minutes). CONCLUSION Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shin Haba
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takafumi Yanaidani
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sho Ishikawa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsukasa Yasuda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masanori Yamada
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Chiriac S, Sfarti CV, Stanciu C, Cojocariu C, Zenovia S, Nastasa R, Trifan A. The Relation between Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis and Different Cannulation Techniques: The Experience of a High-Volume Center from North-Eastern Romania. Life (Basel) 2023; 13:1410. [PMID: 37374192 DOI: 10.3390/life13061410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/03/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania. METHODS ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database. RESULTS 233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946-1.551, p = 0.041, and OR 1.124 for a CI of 0.928-1.361, p = 0.088, respectively). No PEP-associated deaths were found. CONCLUSIONS Both PS and TPBS presented a similar risk of PEP.
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Affiliation(s)
- Stefan Chiriac
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Catalin Victor Sfarti
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Carol Stanciu
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Camelia Cojocariu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Sebastian Zenovia
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Robert Nastasa
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, 700259 Iasi, Romania
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Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open 2023; 11:E588-E598. [PMID: 37564727 PMCID: PMC10410689 DOI: 10.1055/a-2085-4565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/19/2023] [Indexed: 08/12/2023] Open
Abstract
Background and study aims Endoscopist techniques affect biliary cannulation success and the risk of adverse events during endoscopic retrograde cholangiopancreatography (ERCP). This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods Practicing endoscopists were sent an anonymous 28-question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD, respectively, before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut NKTs and likelihood of prophylactic PD stent ( P <0.001 for both). Conclusions A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques; however, almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic PD stent placement, factors known to be associated with cannulation success and adverse outcomes.
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Affiliation(s)
- Abdul Kouanda
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Alexis Bayudan
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Azhar Hussain
- Medicine, Ameer-ud-Din Medical College of PGMI, Lahore, Pakistan
| | - Patrick Avila
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Faisal Kamal
- Gastroenterology, University of Tennessee Health Science Center, Memphis, United States
| | - Muhammad Khalid Hasan
- Center for Interventional Endoscopy, Florida Hospital Orlando, Orlando, United States
| | - Sun-Chuan Dai
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | - Craig Munroe
- Gastroenterology, University of California San Francisco Medical Center at Parnassus, San Francisco, United States
| | | | - Mustafa A Arain
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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Ikeda Y, Ono M, Ohmori G, Ameda S, Arihara Y, Yamada M, Abe T, Maeda M. Clinical benefit of early precut sphincintroterotomy for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography. Surg Endosc 2023; 37:120-126. [PMID: 35851815 DOI: 10.1007/s00464-022-09426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES A precut procedure is sometimes required for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, it is unclear whether the biliary access rate has improved for early precut procedures compared to conventional techniques. This study aimed to identify the benefit of early precut sphincterotomy in cases showing difficult biliary access. METHODS Between April 2017 and August 2021, consecutive patients who underwent precutting for difficult biliary cannulation were retrospectively enrolled. The outcomes of early (≤ 10 min from start of cannulation) and delayed (> 10 min) precut groups were evaluated. All adverse events were defined according to Cotton criteria. RESULTS A total of 70 patients were enrolled in this study. The biliary cannulation rate for a first ERCP was significantly higher in the early compared to delayed precut group (95% vs. 73.3%; P = 0.015). A difference in overall cannulation rate between the two groups was not observed (97.5% vs. 83.3%; P > 0.05). Significantly higher rates of prophylactic pancreatic stents were described in the delayed compared to early precut group (36.7% vs. 12.5%; P = 0.009). Significant differences in the frequency of pancreatitis, bleeding, penetration, and perforation were not noted between the two groups. Overall, the success rate was statistically significant between the experienced and less experienced endoscopists (87.2% vs. 63.9%; P = 0.017). CONCLUSIONS Early precutting within 10 min from the start of cannulation in ERCP is safe and effective in cases with a difficult biliary cannulation, and can improve the biliary cannulation rate.
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Affiliation(s)
- Yuki Ikeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan.
| | - Michihiro Ono
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Ginji Ohmori
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Saki Ameda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Yohei Arihara
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Michiko Yamada
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Tomoyuki Abe
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Masahiro Maeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
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Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (B Aires) 2022; 58:medicina58091261. [PMID: 36143938 PMCID: PMC9502657 DOI: 10.3390/medicina58091261] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.
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9
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Zhang QS, Xu JH, Dong ZQ, Gao P, Shen YC. Success and Safety of Needle Knife Papillotomy and Fistulotomy Based on Papillary Anatomy: A Prospective Controlled Trial. Dig Dis Sci 2022; 67:1901-1909. [PMID: 34081249 DOI: 10.1007/s10620-021-06983-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Needle knife papillotomy (NKP) and fistulotomy (NKF) are the two most commonly used rescue techniques for patients with difficult biliary cannulation (DBC). Anatomy of the major duodenal papillae (MDP) influences the optimal precut technique for biliary access. However, comparative studies of the success and safety of NKP and NKF based on the anatomy of MDP have been scarce. METHODS Patients with intact MDPs for therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) in our center were enrolled. Early needle knife precuts were uniformly applied to patients with DBC. Difficult MDPs were classified into one of five types based on their endoscopic anatomy. Each type of MDP was allocated to NKP or NKF treatment. Patients with types 1 and 2 papillae always received NKF, 3 and 4 received NKP, and 5 could receive either. The safety and efficacy were analyzed between NKP and NKF, and among different types of MDPs. RESULTS A total of 188 out of 1674 patients undergoing ERCP satisfied the criteria for early precutting: 75 patients were assigned to the NKP group and 113 to the NKF group. The total initial success rate of biliary cannulation (ISRBC) of the precut techniques (both NKP and NKF) for patients with DBC was 91.5%. The ISRBC of patients of the NKP group was similar to that of the NKF group (90.7% vs 92.0%, P > 0.05). The ISRBC of the patients in the swollen MDP subgroup (96.1%) was higher than that of patients in the distorted MDP subgroup (81.8%, P = 0.030). The total and specific complications of the patients of the NKP group were similar to those of the NKF group (P > 0.05). CONCLUSIONS NKP and NKF, as selected on the basis of MDP anatomy, are equally safe and highly efficient for patients with DBC to allow biliary cannulation. Patients with swollen MDPs had a higher ISRBC than patients with distorted MDPs. Selecting a precut method based on MDP anatomy is an effective and safe strategy for patients with DBC.
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Affiliation(s)
- Qi-Sheng Zhang
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, 1279 Sanmen Road, Shanghai, 200434, China.
| | - Jian-Hua Xu
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, 1279 Sanmen Road, Shanghai, 200434, China
| | - Zhi-Qi Dong
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, 1279 Sanmen Road, Shanghai, 200434, China
| | - Peng Gao
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, 1279 Sanmen Road, Shanghai, 200434, China
| | - Yu-Cui Shen
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, 1279 Sanmen Road, Shanghai, 200434, China
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Fugazza A, Troncone E, Amato A, Tarantino I, Iannone A, Donato G, D'Amico F, Mogavero G, Amata M, Fabbri C, Radaelli F, Occhipinti P, Repici A, Anderloni A. Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem? Dig Liver Dis 2022; 54:529-536. [PMID: 34362708 DOI: 10.1016/j.dld.2021.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO). MATERIALS This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs. RESULTS A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs. CONCLUSIONS According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.
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Affiliation(s)
- Alessandro Fugazza
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy.
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome ``Tor Vergata'', Rome 00133, Italy
| | - Arnaldo Amato
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giulio Donato
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Ferdinando D'Amico
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
| | - Giuseppe Mogavero
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Michele Amata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Medical Department, Forlì-Cesena Hospitals, AUSL Romagna
| | - Franco Radaelli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Pietro Occhipinti
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
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11
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Facciorusso A, Ramai D, Gkolfakis P, Khan SR, Papanikolaou IS, Triantafyllou K, Tringali A, Chandan S, Mohan BP, Adler DG. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022; 95:60-71.e12. [PMID: 34543649 DOI: 10.1016/j.gie.2021.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons. METHODS We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence. RESULTS Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively). CONCLUSIONS Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Daryl Ramai
- University of Utah, Salt Lake City, Utah, USA
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shahab R Khan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ioannis S Papanikolaou
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, ''Attikon" University General Hospital, Athens, Greece
| | | | - Saurabh Chandan
- Gastroenterology Unit, CHI Health Creighton University Medical Center, Omaha, Nebraska, USA
| | - Babu P Mohan
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital/PEAK Gastroenterology, Denver, Colorado, USA
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12
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Fernandes J, Canena J, Alexandrino G, Figueiredo L, Rafael M, Moreira M, Araújo T, Lourenço L, Horta D, Familiari P, Dinis-Ribeiro M, Lopes L. Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study. Scand J Gastroenterol 2021; 56:1363-1370. [PMID: 34355615 DOI: 10.1080/00365521.2021.1958369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.
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Affiliation(s)
- João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal.,Cintesis, Center for Health Technology and Services Research, Porto, Portugal
| | - Gonçalo Alexandrino
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Luísa Figueiredo
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Maria Rafael
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Marta Moreira
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Tarcísio Araújo
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Luís Lourenço
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - David Horta
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Mário Dinis-Ribeiro
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Luís Lopes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Thanage R, Jain S, Chandnani S, Udgirkar S, Nair S, Debnath P, Jain S, Rathi P. Is the Combination of Rectal Diclofenac and Intravenous Ringer Lactate Superior to Individual Therapy for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective, Open-Label, Single-Center Randomized Trial. Pancreas 2021; 50:1236-1242. [PMID: 34714289 DOI: 10.1097/mpa.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
METHODS This was single-center, open-label, randomized trial. Patients who were undergoing ERCP and who were at high risk for the development of PEP were selected for the study. Patients were randomized into 3 treatment groups: diclofenac suppository group, RL group, and a combination group. RESULTS Eight of 57 patients (14.03%) in the diclofenac group, 9 of 57 patients (15.78%) in the RL group, and 6 of 57 patients (10.52%) in the combination group developed PEP. The incidence of PEP between the three groups was not statistically significant (P = 0.70). Serum amylase level of >252 U/L had 91.3% sensitivity and 92.6% specificity for the diagnosis of PEP. CONCLUSIONS Post-ERCP pancreatitis is usually mild to moderate 95% times. Female sex, age younger than 50 years, a benign indication of ERCP, and low bilirubin levels have higher chances of PEP. A combination of rectal diclofenac and hydration with RL does not offer better protection for PEP, as compared with individual prophylaxis.
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Affiliation(s)
- Ravi Thanage
- From the Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Hospital, Mumbai, India
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14
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Wang X, Luo H, Luo B, Ren G, Liang S, Wang X, Tao Q, Zhang L, Kang X, Guo X, Pan Y. Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching. J Gastroenterol Hepatol 2021; 36:1905-1912. [PMID: 33444486 DOI: 10.1111/jgh.15402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/27/2020] [Accepted: 01/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Rectal indomethacin and pancreatic duct stenting (PDS) are recommended for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN). METHODS Patients with native papilla who underwent endoscopic retrograde cholangiopancreatography in eight tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administered. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was PEP. RESULTS Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs 10.2%, P = 0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs 18.2%, P = 0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs 19.4%, P = 0.036). CONCLUSIONS The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.
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Affiliation(s)
- Xu Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bing Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qin Tao
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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15
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Han SY, Baek DH, Kim DU, Park CJ, Park YJ, Lee MW, Song GA. Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: Importance of the endoscopist’s expertise level. World J Clin Cases 2021; 9:4166-4177. [PMID: 34141779 PMCID: PMC8173434 DOI: 10.12998/wjcc.v9.i17.4166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/05/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Needle-knife fistulotomy (NKF) is used as a rescue technique for difficult cannulation. However, the data are limited regarding the use of NKF for primary biliary cannulation, especially when performed by beginners.
AIM To assess the effectiveness and safety of primary NKF for biliary cannulation, and the role of the endoscopist’s expertise level (beginner vs expert).
METHODS We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis, who underwent bile duct cannulation at a tertiary referral center. The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation. We assessed the rates of successful cannulation and adverse events.
RESULTS The baseline characteristics did not differ between the experienced and less-experienced endoscopists. The incidence rate of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy (8.9% vs 3.4% for beginner vs expert, P = 0.039), but not in those who received NKF. In the multivariable analysis, a lower expertise level of the biliary endoscopist (P = 0.037) and longer total procedure time (P = 0.026) were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time (P = 0.004) was significant risk factor of PEP in those who received NKF.
CONCLUSION Primary NKF was effective and safe in patients with prominent and bulging ampulla, even when performed by less-experienced endoscopist. We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.
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Affiliation(s)
- Sung Yong Han
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Dong Hoon Baek
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Dong Uk Kim
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Chang Joon Park
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Young Joo Park
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Moon Won Lee
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Geun Am Song
- Division of Gastroenterology and Hepatology, Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
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Sakr C, Harb M, Makhoul E. The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis. Arab J Gastroenterol 2021; 22:133-136. [PMID: 34120852 DOI: 10.1016/j.ajg.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND STUDY AIMS Postendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation. PATIENTS AND METHODS A single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital's ethics committee approval. Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone. RESULTS We could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone. When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques. CONCLUSION DGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.
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Affiliation(s)
- Charlyne Sakr
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Marc Harb
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Elias Makhoul
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon.
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Lee YS, Cho CM, Cho KB, Heo J, Jung MK, Kim SB, Kim KH, Kim TN, Lee DW, Han J, Kim HG, Kim D, Kim H. Difficult Biliary Cannulation from the Perspective of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Identifying the Optimal Timing for the Rescue Cannulation Technique. Gut Liver 2021; 15:459-465. [PMID: 32000469 PMCID: PMC8129666 DOI: 10.5009/gnl19304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/03/2019] [Accepted: 11/18/2019] [Indexed: 12/17/2022] Open
Abstract
Background/Aims Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP). Methods An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis. Results We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2=49.857, p<0.001) and inadvertent PD manipulation (χ2=8.556, p=0.010) were decisive factors. PEP occurred in 3.9%, 11.8%, and 16.2% of patients with biliary cannulation duration lasting 3 to 5 minutes, >5 minutes, and >5 minutes with inadvertent PD manipulation, respectively. Conclusions Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique. (Gut Liver 2021;15-465)
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Affiliation(s)
- Yoon Suk Lee
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - Chang Min Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jun Heo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Kyu Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Bum Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kook Hyun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Daejin Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyunsoo Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
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18
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Maharshi S, Sharma SS. Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos). Gastrointest Endosc 2021; 93:586-593. [PMID: 32615179 DOI: 10.1016/j.gie.2020.06.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Precut sphincterotomy, usually performed after prolonged and failed cannulation, is considered a risk factor for post-ERCP pancreatitis (PEP). There are limited studies on primary needle-knife precut for the prevention of PEP. The aim of this study was to assess the safety and efficacy of primary precut. METHODS A randomized controlled trial was conducted in a tertiary care setting on patients who underwent ERCP. Patients were randomized to very early precut (group A, precut after 2 failed attempts of wire-guided sphincterotome cannulation) and primary precut (group B, direct needle-knife precut). All procedures were done by an experienced endoscopist. The primary outcome of the study was to compare the incidence of PEP between the 2 groups. RESULTS Three hundred three patients were randomized to group A (n = 152, age 48.2 ± 15.4 years, 61 men) and group B (n = 151, age 46.7 ± 13.8 years, 65 men). There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Development of PEP (5.2% vs .67%; P = .04) and asymptomatic hyperamylasemia (12.5% vs 2.6%; P = .01) were lower in group B compared with group A. The bile duct cannulation time (13.8 ± 2.2 vs 7.2 ± 1.7 minutes; P = .001) was lower in group B, whereas the overall cannulation success rate (98% vs 98.6%; P = 1.0) was similar in both the groups. CONCLUSIONS Primary precut by an experienced endoscopist results in low risk of PEP. (Clinical trial registration number: CTRI/2017/08/009510.).
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
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19
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Gattani M, Pandey V, Chauhan S, Singh G. Primary precut sphincterotomy to reduce post-ERCP pancreatitis. Gastrointest Endosc 2021; 93:277-278. [PMID: 33353628 DOI: 10.1016/j.gie.2020.07.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Mayur Gattani
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Vikas Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Shamshersingh Chauhan
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Gaurav Singh
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
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20
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Wang X, Zhao J, Wang L, Ning B, Zeng W, Tao Q, Ren G, Liang S, Luo H, Wang B, Farrell JJ, Pan Y, Guo X, Wu K. Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study. J Gastroenterol Hepatol 2020; 35:2184-2191. [PMID: 32511794 DOI: 10.1111/jgh.15135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/23/2020] [Accepted: 06/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. METHODS Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. RESULTS Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio ≥ 1.5, and absence of PAD were independent risk factors for PEP. CONCLUSION Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianghai Zhao
- Department of Gastroenterology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Limei Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.,Shaanxi Second People's Hospital, Xi'an, China
| | - Bo Ning
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Zeng
- Department of Gastroenterology, Successful Hospital of Xiamen university, Xiamen, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Hnaris K, Taylor C, Hookey L, Bechara R. Fistulotomy-First Approach is Safe and Effective in Endoscopic Retrograde Cholangiography: Results of a Prospective Case Series. J Can Assoc Gastroenterol 2020; 4:173-178. [PMID: 34337317 PMCID: PMC8320265 DOI: 10.1093/jcag/gwaa025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
Background and Aims The aim of this study was to assess the safety and efficacy of using needle-knife fistulotomy (NKF) as a primary cannulation technique in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with a native papilla. Patients and Methods This prospective feasibility study enrolled 50 patients between December 2018 and June 2019. The procedure was performed by two expert endoscopists (R.B. and L.H.). The primary outcome was the incidence of post-ERCP pancreatitis. Other variables assessed included the success rate of cannulation of the common bile duct (CBD), time to successful cannulation, and incidence of adverse events. Results Between December 2018 and June 2019, 50 patients enrolled in the study. The mean age was 63.4 years (standard deviation 18.1), and there were 26 females. Indications included biliary obstruction secondary to malignancy (n = 14) and choledocholithiasis (n = 36). Successful cannulation of the CBD through the fistulotomy occurred in 49/50 cases. The time to successful cannulation was 5.1 minutes (range 0.5 to 23 minutes). Mild acute pancreatitis occurred in two cases (4%). Post-ERCP bleeding occurred in three patients (6%) Conclusions In this pilot study, NKF was used as the primary biliary access technique and it was demonstrated that it appears to be at least as safe as the traditional access technique with a sphinctertome. However, its role as a primary cannulation technique requires further investigation with multicenter, randomized control studies.
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Affiliation(s)
- Konstantinos Hnaris
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, Ontario, Canada
| | - Connie Taylor
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, Ontario, Canada
| | - Lawrence Hookey
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, Ontario, Canada
| | - Robert Bechara
- Gastrointestinal Diseases Research Unit, Queen’s University, Kingston, Ontario, Canada
- Correspondence: Robert Bechara, MD FRCPC, Division of Gastroenterology, Hotel Dieu Hospital, 166 Brock Street, Kingston, Ontario K7L 5G2, Canada, e-mail:
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Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, Hult M, Lindström O, Laine S, Karjula H, Hauge T, Sadik R, Arnelo U. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019; 90:957-963. [PMID: 31326385 DOI: 10.1016/j.gie.2019.07.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Leena Kylänpää
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Grönroos
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Arto Saarela
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Mari Hult
- Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Outi Lindström
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Karjula
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Riadh Sadik
- Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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Archibugi L, Mariani A, Capurso G, Traini M, Petrone MC, Rossi G, Testoni SGG, Testoni PA, Arcidiacono PG. Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate. Endosc Int Open 2019; 7:E1733-E1741. [PMID: 31828210 PMCID: PMC6904241 DOI: 10.1055/a-1024-3789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background and study aims With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T -test and Fisher's tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan-Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox's proportional hazards model. Results Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 - 2.50; P = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group ( P = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy,Corresponding author Livia Archibugi, MD Vita-Salute San Raffaele UniversityVia Olgettina 6020132, MilanItaly+390226435607+390226435609
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Mariaemilia Traini
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan.
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
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ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc 2019; 34:1939-1947. [PMID: 31559577 PMCID: PMC7113211 DOI: 10.1007/s00464-019-06966-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Abstract
Background Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study. Methods Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1–3) groups. Furthermore, fatal group patients’ records were reviewed. Results Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8–21.6), age over 80 years (OR 3.8, 95% CI 2.0–7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1–7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1–3 centers mortality was higher (45% vs. 21%, p = 0.024). Conclusions ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.
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Voiosu T, Voiosu A, Benguş A, Rimbaş M, Mateescu B. Trainee involvement increases precut rates and delays access to the common bile duct without an increase in procedure-related adverse events: a brave new world of ERCP training? ACTA ACUST UNITED AC 2019; 56:55-61. [PMID: 29080394 DOI: 10.1515/rjim-2017-0041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Selective cannulation of the desired duct is a key element in ERCP procedures and an important step in the training of fellows. However, there is limited data about technical success and patient safety for ERCPs conducted in a training setting.We aimed to evaluate the impact of trainee involvement on the cannulation technique and procedure related outcomes at ERCP. MATERIALS AND METHODS We conducted an observational study of all ERCP conducted in an endoscopy unit with an on-going training program. Patient related data and procedure-related data (method of cannulation, time to cannulation, degree of trainee involvement, technical success and procedure-related adverse events) were collected using a standard form. The method of cannulation, time to cannulation and procedure-related adverse events were compared between ERCPs with trainee involvement and those without. RESULTS 641 consecutive ERCPs were evaluated and 474 native papilla cases performed by 4 trainers and 3 trainees were included in the final analysis. Trainees were involved in 171 procedures (36.1%), achieving cannulation of the desired duct in 50.8% of the cases. Cannulation rates were similar in the trainee group compared to the control group (91.7% vs. 88.7%) and there was no increase in the rate of adverse events. However, cannulation time was significantly longer in the trainee group with a significant increase in the rate of precut use (32.1% vs. 23.4%, p < 0.001). CONCLUSIONS Trainee involvement resulted in longer cannulation times and increased use of precut sphincterotomy, but, was not associated with an increased risk of procedure related adverse events.
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Affiliation(s)
- Theodor Voiosu
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Andrei Voiosu
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Andreea Benguş
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Mihai Rimbaş
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
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Mariani A, Segato S, Anderloni A, Cengia G, Parravicini M, Staiano T, Tontini GE, Lochis D, Cantù P, Manfredi G, Amato A, Bargiggia S, Bernasconi G, Lella F, Berni Canani M, Beretta P, Ferraris L, Signorelli S, Pantaleo G, Manes G, Testoni PA, Prada A, Iiritano E, Lesinigo E, Mezzi GS, de Nucci G. Prospective evaluation of ERCP performance in an Italian regional database study. Dig Liver Dis 2019; 51:978-984. [PMID: 30718203 DOI: 10.1016/j.dld.2018.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prospective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare. AIM To assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice. METHODS Prospective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered. RESULTS 38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed. CONCLUSIONS The procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting.
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Affiliation(s)
- Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Simone Segato
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | | | - Marco Parravicini
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria, Ospedale di Circolo di Varese, Varese, Italy
| | - Teresa Staiano
- Digestive Endoscopy and Gastroenterology Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Italy
| | | | - Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Guido Manfredi
- Gastroenterology and Digestive Endoscopy Department, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Arnaldo Amato
- Department of Gastroenterology Unit, Valduce Hospital, Como, Italy
| | | | - Giordano Bernasconi
- Gastroenterology and Digestive Endoscopy Unit, Busto Arsizio Hospital, Busto Arsizio, Varese, Italy
| | - Fausto Lella
- Gastroenterology and Digestive Endoscopy Unit, Policlinico San Pietro, Bergamo, Italy
| | - Marcella Berni Canani
- Digestive Endoscopy and Gastroenterology Unit, ASST Vimercate, Monza e Brianza, Italy
| | - Paolo Beretta
- Gastroenterology and Digestive Endoscopy Unit, ICCS, Milan, Italy
| | - Luca Ferraris
- Gastroenterologia ed Endoscopia Digestiva ASST Valleolona PO, Gallarate, Varese, Italy
| | - Sergio Signorelli
- Gastroenterology and Gastrointestinal Endoscopy Unit, ASST, Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Pantaleo
- UniSR-Social.Lab [Research Methods], Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpiero Manes
- Department of Gastroenterology and Digestive Endoscopy, ASST Rhodense Garbagnate Milanese, Milano, Italy
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Prada
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Italy
| | - Elena Iiritano
- Gastroenterology and Digestive Endoscopy Department, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Enrico Lesinigo
- Gastroenterology and Digestive Endoscopy Unit, Busto Arsizio Hospital, Busto Arsizio, Varese, Italy
| | - Gianni Santo Mezzi
- Digestive Endoscopy and Gastroenterology Unit, ASST Vimercate, Monza e Brianza, Italy
| | - Germana de Nucci
- Department of Gastroenterology and Digestive Endoscopy, ASST Rhodense Garbagnate Milanese, Milano, Italy
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Shih HY, Hsu WH, Kuo CH. Postendoscopic retrograde cholangiopancreatography pancreatitis. Kaohsiung J Med Sci 2019; 35:195-201. [PMID: 30887733 DOI: 10.1002/kjm2.12040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.
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Affiliation(s)
- Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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Wen J, Li T, Lu Y, Bie LK, Gong B. Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology. Hepatobiliary Pancreat Dis Int 2019; 18:73-78. [PMID: 30518483 DOI: 10.1016/j.hbpd.2018.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 11/21/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. METHODS Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. RESULTS The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period. CONCLUSIONS The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.
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Affiliation(s)
- Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Tao Li
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yi Lu
- Digestive Endoscopy Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China.
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Wang J, Shen Y, Zhong Z, Wu S, Zheng L. Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis and the Effect of Octreotide Combined with Nonsteroidal Anti-Inflammatory Drugs on Preventing Its Occurrence. Med Sci Monit 2018; 24:8964-8969. [PMID: 30531679 PMCID: PMC6299780 DOI: 10.12659/msm.911914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/20/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The aim of this study was to explore the risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and investigate the effect of octreotide combined with nonsteroidal anti-inflammatory drugs on preventing its occurrence. MATERIAL AND METHODS A total of 139 patients undergoing ERCP in our hospital from May 2016 to April 2017 were retrospectively analyzed, and divided into an observation group (n=67) (octreotide + indomethacin) and a control group (n=72) (no preventive drugs). The preoperative and postoperative inflammatory cytokines such as tumor necrosis factor-α (TNF)-α, interleukin-6 (IL-6) and IL-8, and serum amylase levels were measured, and the incidence of pancreatitis and hyper amylasemia were monitored. RESULTS Serum amylase level was increased significantly 3 hours after operation in both groups with significantly higher level in the control group compared to the observation group. After 24 hours, serum amylase in the observation group was decreased to preoperative level, whereas it was still higher than preoperative in the control group (P<0.05). Regarding the levels of TNF-α, IL-6, IL-8, and visual analogue scale, they were significantly increased in both groups after operation with significantly higher levels in the control group compared to the observation group (P<0.05). Furthermore, logistic regression analysis showed that difficult intubation, pancreatic duct angiography, surgery for a long time, and the history of previous pancreatitis were risk factors for post-ERCP pancreatitis (P<0.05). CONCLUSIONS Difficult intubation, pancreatic duct angiography, surgery for a long time, and the history of previous pancreatitis were risk factors for post-ERCP pancreatitis. Octreotide combined with non-steroidal anti-inflammatory drugs can reduce the pain of patients with abdominal pain as well as the incidence of postoperative pancreatitis, indicating that they might be effective preventative approaches for pancreatitis.
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Leerhøy B, Elmunzer BJ. How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2018; 28:439-454. [PMID: 30241637 DOI: 10.1016/j.giec.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Bonna Leerhøy
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen Nielsine Nielsens Vej 11, entrance 8, Copenhagen DK-2400, Denmark
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty Street, Suite 249, Charleston, SC 29425, USA.
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Tang Z, Yang Y, Yang Z, Meng W, Li X. Early precut sphincterotomy does not increase the risk of adverse events for patients with difficult biliary access: A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. Medicine (Baltimore) 2018; 97:e12213. [PMID: 30200135 PMCID: PMC6133433 DOI: 10.1097/md.0000000000012213] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The present study was conducted to investigate whether early precut sphincterotomy (EPS) itself increases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), bleeding, and perforation, or improves the overall success rates of biliary cannulation. METHODS Four electronical databases were searched systematically for randomized controlled trials (RCTs) reporting the incidence of adverse events for difficult biliary access (DBA) between EPS groups and persistent cannulation attempts (PCA). The primary endpoint was the incidence of PEP. Secondary outcomes were the incidence of bleeding and perforation, and the overall success rates of biliary cannulation. The Mantel-Haenszel method was used to pool data on the outcomes into random-effect models. Heterogeneity, sensitivity, and stratified analyses were performed with Review Manager 5.3. Furthermore, we performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint and secondary outcomes. RESULTS Seven RCTs (999 patients with DBA of 10450, 9.5%) were included. The incidence of PEP was significantly lower in EPS groups than PCA (risk ratio [RR] = 0.57, 95% confidence interval [CI] 0.36, 0.92, P = .02). Furthermore, TSA (TSA-adjusted 95% CI 0.30-0.82, P = .0061) and subgroup analysis stratified by the fellow involvement in initial cannulation before randomization, technique of precut, and the definition of DBA confirmed this finding. Success rates of overall cannulation (RR = 1.00, P = .94), bleeding (RR = 1.22, P = .58), and perforation (RR = 1.59, P = .32) were similar in both groups; however, the results of TSA could not confirm these findings. CONCLUSION Both the quality and the quantity of evidence supporting, compared with PCA, EPS itself do not increase the risk of PEP for DBA patients. Moreover, subgroup analysis demonstrated that EPS can significantly decrease the risk of PEP when it is performed by qualified staff endoscopists with using needle-knife fistulutomy earlier for patients with DBA.
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Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | - Zhangfu Yang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital,Fudan University, and Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Shanghai
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The first Hospital of Lanzhou University, Lanzhou
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The second department of General Surgery, The first Hospital of Lanzhou University, Lanzhou, China
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Assessing Quality of Precut Sphincterotomy in Patients With Difficult Biliary Access: An Updated Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2018; 52:573-578. [PMID: 29912752 DOI: 10.1097/mcg.0000000000001077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND It is generally accepted that precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of pancreatitis. However, patients with difficult biliary access may be different. We implemented a meta-analysis to explore the effects of early and delayed precut sphincterotomy on post-ERCP pancreatitis in patients with difficult biliary access. METHODS We searched studies in PubMed, EMBASE, and the Cochrane Central Register of Randomized Controlled Trials for meeting requirement in which precut sphincterotomy was compared with persistent standard cannulation during ERCP. The primary outcomes included the overall cannulation success rate and the incidence of post-ERCP pancreatitis. The secondary outcomes included primary cannulation success and the overall complication rate. RESULTS Six studies (898 patients) were included. The present meta-analysis found no significant difference in overall cannulation success rate and overall complication rate between early precut sphincterotomy and persistent standard cannulation. However, early precut sphincterotomy not only increased the primary cannulation success rate [Mantel Haenszel test relative risk, 1.87; 95% confidence interval (CI), 1.15-3.04] but also decreased the overall risk of pancreatitis (Peto odds ratio, 0.49; 95% CI, 0.30-0.80). For persistent standard cannulation, no significant difference was observed in the pancreatitis rate between no salvage precut and delayed salvage precut sphincterotomy (Peto odds ratio, 0.96; 95% CI, 0.49-1.85). CONCLUSIONS Compared with persistent standard cannulation, an early precut sphincterotomy exhibited a reduced risk of pancreatitis. In addition, a delayed precut sphincterotomy after persistent attempts did not increase the occurrence of pancreatitis and this is the first meta-analysis to present this conclusion.
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Furuya CK, Sakai P, Marinho FRT, Otoch JP, Cheng S, Prudencio LL, de Moura EGH, Artifon ELDA. Papillary fistulotomy vs conventional cannulation for endoscopic biliary access: A prospective randomized trial. World J Gastroenterol 2018; 24:1803-1811. [PMID: 29713133 PMCID: PMC5922998 DOI: 10.3748/wjg.v24.i16.1803] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 03/12/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the cannulation success, biochemical profile, and complications of the papillary fistulotomy technique vs catheter and guidewire standard access.
METHODS From July 2010 to May 2017, patients were prospectively randomized into two groups: Cannulation with a catheter and guidewire (Group I) and papillary fistulotomy (Group II). Amylase, lipase and C-reactive protein at T0, as well as 12 h and 24 h after endoscopic retrograde cholangiopancreatography, and complications (pancreatitis, bleeding, perforation) were recorded.
RESULTS We included 102 patients (66 females and 36 males, mean age 59.11 ± 18.7 years). Group I and Group II had 51 patients each. The successful cannulation rates were 76.5% and 100%, respectively (P = 0.0002). Twelve patients (23.5%) in Group I had a difficult cannulation and underwent fistulotomy, which led to successful secondary biliary access (Failure Group). The complication rate was 13.7% (2 perforations and 5 mild pancreatitis) vs 2.0% (1 patient with perforation and pancreatitis) in Groups I and II, respectively (P = 0.0597).
CONCLUSION Papillary fistulotomy was more effective than guidewire cannulation, and it was associated with a lower profile of amylase and lipase. Complications were similar in both groups.
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Affiliation(s)
- Carlos Kiyoshi Furuya
- Department of Gastrointestinal Endoscopy Unit, University of Sao Paulo, Sao Paulo 05409001, Brazil
| | - Paulo Sakai
- Department of Gastrointestinal Endoscopy Unit, University of Sao Paulo, Sao Paulo 05409001, Brazil
| | | | - Jose Pinhata Otoch
- Department of Surgery, University of Sao Paulo, Sao Paulo 05403000, Brazil
| | - Spencer Cheng
- Department of Gastrointestinal Endoscopy Unit, University of Sao Paulo, Sao Paulo 05409001, Brazil
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de la Morena Madrigal EJ, Rodríguez García MªI, Galera Ródenas AB, Pérez Arellano E. Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:74-81. [PMID: 29271219 DOI: 10.17235/reed.2017.5175/2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques. PATIENTS AND METHODS This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed. RESULTS Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%. CONCLUSIONS The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.
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Abstract
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.
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Affiliation(s)
- B Joseph Elmunzer
- The Peter B. Cotton Endowed Chair in Endoscopic Innovation, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, USA
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Patai Á, Solymosi N, Mohácsi L, Patai ÁV. Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials. Gastrointest Endosc 2017; 85:1144-1156.e1. [PMID: 28167118 DOI: 10.1016/j.gie.2017.01.033] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Diclofenac and indomethacin are the most studied drugs for preventing post-ERCP pancreatitis (PEP). However, there are no prospective, randomized multicenter trials with a sufficient number of patients for correct evaluation of their efficacy. Our aim was to evaluate all prospective trials published in full text that studied the efficacy of diclofenac or indomethacin and were controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP. METHODS Systematic search of databases (PubMed, Scopus, Web of Science, Cochrane) for relevant studies published from inception to 30 June 2016. RESULTS Our meta-analysis of 4741 patients from 17 trials showed that diclofenac or indomethacin significantly decreased the risk ratio (RR) of PEP to 0.60 (95% confidence interval [CI], 0.46-0.78; P = .0001), number needed to treat (NNT) was 20, and the reduction of RR of moderate to severe PEP was 0.64 (95% CI, 0.43-0.97; P = .0339). The efficacy of indomethacin compared with diclofenac was similar (P = .98). The efficacy of indomethacin or diclofenac did not differ according to timing (P = .99) or between patients with average-risk and high-risk for PEP (P = .6923). The effect of non-rectal administration of indomethacin or diclofenac was not significant (P = .1507), but the rectal route was very effective (P = .0005) with an NNT of 19. The administration of indomethacin or diclofenac was avoided in patients with renal failure. Substantial adverse events were not detected. CONCLUSIONS The use of rectally administered diclofenac or indomethacin before or closely after ERCP is inexpensive and safe and is recommended in every patient (without renal failure) undergoing ERCP. (Registration number: CRD42016042726, http://www.crd.york.ac.uk/prospero/.).
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Affiliation(s)
- Árpád Patai
- Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - Norbert Solymosi
- Biometeorology Research Group, University of Veterinary Medicine, Budapest, Hungary
| | - László Mohácsi
- Department of Computer Science, Corvinus University of Budapest, Budapest, Hungary
| | - Árpád V Patai
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
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Feng Y, Navaneethan U, Zhu X, Varadarajulu S, Schwartz I, Hawes R, Hasan M, Yang A. Prophylactic rectal indomethacin may be ineffective for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in general patients: A meta-analysis. Dig Endosc 2017; 29:272-280. [PMID: 27914176 DOI: 10.1111/den.12779] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Efficacy of prophylactic indomethacin for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in general patients remains controversial. To address this, we conducted a meta-analysis of clinical trials specifically on rectal indomethacin in prevention of PEP in consecutive patients undergoing ERCP. METHODS We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases to identify randomized, double-blind, controlled clinical trials on rectal indomethacin in the prevention of PEP in consecutive patients undergoing ERCP. Primary outcome was the overall rate of PEP. Secondary outcomes were the overall rates of moderate to severe PEP and mild PEP. RESULTS Six studies, with a total of 2473 patients, were included. Overall rate of PEP was 7% (95% CI, 6-9%). No statistical difference was observed in overall rates of PEP (OR, 0.67; 95% CI, 0.46-1.00, P = 0.050) and, additionally, rates of moderate to severe (OR, 0.66; 95% CI, 0.28-1.56, P = 0.345) or mild (OR, 0.71; 95% CI, 0.45-1.10, P = 0.127) PEP between indomethacin and placebo. CONCLUSION In a contemporary meta-analysis of available randomized controlled trials of consecutive patients undergoing ERCP, rectal indomethacin did not show significant prevention effect of post-ERCP pancreatitis.
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Affiliation(s)
- Yunlu Feng
- Center for Interventional Endoscopy, Florida Hospital, Orlando, USA.,Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | | | - Xiang Zhu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, USA
| | | | - Ingrid Schwartz
- Center for Interventional Endoscopy, Florida Hospital, Orlando, USA.,Hospital Sao Lucas, Rio de Janeiro, Brazil
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, USA
| | - Muhammad Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, USA
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Reddy DN, Nabi Z, Lakhtakia S. How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2017; 152:1275-1279. [PMID: 28366733 DOI: 10.1053/j.gastro.2017.03.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Ahmed AM, Wilcox CM. Endoscopic retrograde cholangiopancreatography cannulation in the difficult duct: Which technique should you pull out of your bag? Dig Endosc 2017; 29:149-151. [PMID: 28106923 DOI: 10.1111/den.12811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Ali M Ahmed
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, USA
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, USA
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García-Cano J. What is the most cost-effective method for a difficult biliary cannulation in ERCP? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:171-173. [PMID: 28215097 DOI: 10.17235/reed.2017.4863/2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Editorial dealing with difficult biliary cannulation in ERCP. Pancreatic techniques that take advantage of a guidewire inserted in the Main Pancreatic Duct are preferred to needle-knife precut.
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El Nakeeb A, El Hanafy E, Salah T, Atef E, Hamed H, Sultan AM, Hamdy E, Said M, El Geidie AA, Kandil T, El Shobari M, El Ebidy G. Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity. World J Gastrointest Endosc 2016; 8:709-715. [PMID: 27909551 PMCID: PMC5114460 DOI: 10.4253/wjge.v8.i19.709] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 07/27/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity.
METHODS This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected.
RESULTS The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP.
CONCLUSION PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.
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Kanazawa R, Sai JK, Ito T, Miura H, Ishii S, Saito H, Tomishima K, Shimizu R, Sato K, Hayashi M, Watanabe S, Shiina S. Prior minimal endoscopic sphincterotomy to prevent pancreatitis related to endoscopic balloon sphincteroplasty. World J Gastrointest Endosc 2016; 8:663-668. [PMID: 27803773 PMCID: PMC5067473 DOI: 10.4253/wjge.v8.i18.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the efficacy of prior minimal endoscopic sphincterotomy (EST) to prevent pancreatitis related to endoscopic balloon sphincteroplasty (EBS).
METHODS After bile duct access was gained and cholangiogram confirmed the presence of stones < 8 mm in the common bile duct at endoscopic retrograde cholangiography, patients were subjected to minimal EST (up to one-third of the size the papilla) plus 8 mm EBS (EST-EBS group). The incidence of pancreatitis and the difference in serum amylase level after the procedure were examined and compared with those associated with 8-mm EBS alone in 32 patients of historical control (control group).
RESULTS One hundred and five patients were included in the EST-EBS group, and complete stone removal was accomplished in all of them. The difference in serum amylase level after the procedure was - 25.0 (217.9) IU/L in the EST-EBS group and this value was significantly lower than the 365.5 (576.3) IU/L observed in the control group (P < 0.001). The incidence of post-procedure pancreatitis was 0% (0/105) in the EST-EBS group and 15.6% (5/32) in the control group (P < 0.001).
CONCLUSION Prior minimal EST might be useful to prevent the elevation of serum amylase level and the occurrence of pancreatitis related to EBS.
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Ang TL, Kwek ABE, Song M, Li JW, Thurairajah PH. Comparative study of strategies for preventing post-ERCP pancreatitis after early precut sphincterotomy for biliary access. J Dig Dis 2016; 17:692-696. [PMID: 27556283 DOI: 10.1111/1751-2980.12401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/14/2016] [Accepted: 08/21/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Needle knife precut sphincterotomy (PS) during endoscopic retrograde cholangiopancreatography (ERCP) has been associated with a high risk of post-ERCP pancreatitis (PEP). This study aimed to examine the effect of no prophylaxis, somatostatin, rectal diclofenac and pancreatic duct (PD) stenting in reducing rates of PEP in patients who underwent early PS. METHODS This was a retrospective comparative study and the study period was from January 2006 to December 2015. A standardized approach to early PS was used: (i) inadvertent guidewire cannulation of the PD > thrice; (ii) impacted bile duct stone; (iii) inability to achieve deep cannulation within 10 min. PEP prophylactic measures included: (i) none when there was minimal papilla trauma; (ii) somatostatin infusion; (iii) rectal diclofenac; (iv) PD stent. The difference in rates of PEP between the different strategies was analysed. RESULTS During the study period, PS was performed in 191 ERCP patients (mean age 66 years; 56.5% males). The ERCP success rate after PS was 93.2% (178/191). Overall the PEP rate was 3.1% (6/191) and the severity in all cases was mild. PEP occurred in 6.1% of patients with PD cannulation but not in those without (P = 0.016). PEP rates were 1.8%, 7.3%, 1.8% and 0% in control, somatostatin, diclofenac and PD stenting groups, respectively (P = 0.209). CONCLUSIONS There was no significant difference in PEP rates after early PS whether or not prophylactic measures were adopted if there was minimal papilla trauma. A trend towards lower PEP rates was observed in patients who had either rectal diclofenac or PD stenting, compared to somatostatin.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mingjun Song
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Lee TH, Park SH. Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy. Clin Endosc 2016; 49:467-474. [PMID: 27642848 PMCID: PMC5066416 DOI: 10.5946/ce.2016.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 12/12/2022] Open
Abstract
Various endoscopic techniques have been developed to overcome the difficulties in biliary or pancreatic access during endoscopic retrograde cholangiopancreatography, according to the preference of the endoscopist or the aim of the procedures. In terms of endoscopic methods, guidewire-assisted cannulation is a commonly used and well-known initial cannulation technique, or an alternative in cases of difficult cannulation. In addition, precut sphincterotomy encompasses a range of available rescue techniques, including conventional precut, precut fistulotomy, transpancreatic septotomy, and precut after insertion of pancreatic stent or pancreatic duct guidewire-guided septal precut. We present a literature review of guidewire-assisted cannulation as a primary endoscopic method and the precut technique for the facilitation of selective biliary access.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
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