The future of ERCP

Enhancing endoscopic retrograde cholangiopancreatography safety: Predictive insights into gastric retention

Endoscopic retrograde cholangiopancreatography (ERCP) is a vital tool for diagnosing and treating biliary and pancreatic disorders, but its safety and efficacy are marred by preoperative gastric retention. Jia et al retrospectively analyzed 190 patients who underwent ERCP and found that gastrointestinal obstruction, jaundice, opioid use, female sex, and primary diseases were independent predictors and risk factors of preoperative gastric retention. Based on these findings and comprehensive analysis, a proposed predictive model offers clinicians valuable tools to tailor preoperative strategies, improving the procedural safety and efficacy of ERCP. Despite having several limitations, like single-center design and limited generalizability, the study marks a significant advancement in optimizing ERCP outcomes through predictive analytics. Further research with larger populations and prospective designs is warranted to establish these findings.

Why is the rectal route for NSAIDS favorable for preventing post-ERCP pancreatitis?

OBJECTIVE

Acute pancreatitis is a frequent, burdensome adverse event of endoscopic retrograde cholangiography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have reduced post-ERCP pancreatitis (PEP) risk by about 50 % and show greater efficacy over parenteral or oral administration, although the mechanism for its superiority remains unclear. To probe this question, we investigated in a preclinical model, the pharmacokinetics in the blood, pancreas and other tissues of the NSAID diclofenac given via the rectal, intravenous, or intragastric routes.

METHODS

The data on diclofenac was extracted from a larger study that examined a combination of diclofenac and tacrolimus. 20.8 mg diclofenac/kg body weight, which is the mouse equivalent dosing used in clinical practice for PEP prophylaxis, was administered to C57BL/6J mice via the rectal, intravenous and intragastric (oral) routes. Cross-collection of blood and tissues was done at various timepoints after administration for the evaluation of drug levels and pharmacokinetic parameters.

RESULTS

Rectal diclofenac demonstrated favorable blood pharmacokinetics and systemic bioavailability as well as sustained pancreas penetration. The total pancreas exposure to diclofenac over 24 h following rectal dosing was not significantly different as compared to intravenous and oral dosing.

CONCLUSION

Our findings suggest that the efficacy of rectal diclofenac in PEP prevention relates more to its higher and consistent systemic exposure than its absolute pancreas levels. The implications are that the rectal route provides both systemic and pancreas exposure for the full duration of PEP vulnerability.

A Study on the Spectrum of Imaging Findings of Post-ERCP-Specific Complications: A Retrospective Descriptive Study

Aim  The aim of this study was to examine the imaging manifestations of post-endoscopic retrograde cholangiopancreatography (ERCP) specific complications by computed tomography to aid in its early and successful diagnosis and timely intervention. Method  Forty-one cases of imaging having post-ERCP were complications were retrospectively collected and the spectrum of complications and their key imaging features and methods to improve their detection were analyzed. Result  The most common complication detected in computed tomography (CT) post-ERCP was the presence of intra-abdominal collections seen in 21 patients (51.2%). Pancreatitis was seen in 20 of 41 patients (48.7%), while bowel perforation was present in 9 patients (21%). Pleural effusion was present in 8 patients (19.5%), liver abscess in 6 patients (14.6%), cholangitis in 4 patients (9.7%), gallbladder perforation in 4 patients (9.7%), displaced common bile duct stent in 3 patients (7.3%), possibility of main pancreatic duct cannulation in 2 patients (4.8%), vascular injury resulting in right hepatic artery pseudoaneurysm in 1 patient (2.4%), thrombosis of portal vein or its branches in 2 patients (4.8%), superior mesenteric vein thrombosis in 1 patient (2.4%), right hepatic vein thrombosis in 1 patient (2.4%), pulmonary thromboembolism in 2 patients (4.8%), duodenal inflammation in 1 patient (2.4%), bowel ileus in 4 patients (9.6%), and bowel obstruction in 1 patient (2.4%). Conclusion  Complications after ERCP can cause significant morbidity and mortality if not diagnosed early and treated appropriately. Familiarity with normal findings post-ERCP and knowledge of the imaging appearance of these complications are vital in the early management of these conditions.

Rectal administration of tacrolimus protects against post-ERCP pancreatitis in mice

OBJECTIVE

There is an unmet clinical need for effective, targeted interventions to prevent post-ERCP pancreatitis (PEP). We previously demonstrated that the serine-threonine phosphatase, calcineurin (Cn) is a critical mediator of PEP and that the FDA-approved calcineurin inhibitors, tacrolimus (Tac) or cyclosporine A, prevented PEP. Our recent observations in preclinical PEP models demonstrating that Cn deletion in both pancreatic and hematopoietic compartments is required for maximal pancreas protection, highlighted the need to target both systemic and pancreas-specific Cn signaling. We hypothesized that rectal administration of Tac would effectively mitigate PEP by ensuring systemic and pancreatic bioavailability of Tac. We have tested the efficacy of rectal Tac in a preclinical PEP model and in cerulein-induced experimental pancreatitis.

METHODS

C57BL/6 mice underwent ductal cannulation with saline infusion to simulate pressure-induced PEP or were given seven, hourly, cerulein injections to induce pancreatitis. To test the efficacy of rectal Tac in pancreatitis prevention, a rectal Tac suppository (1 mg/kg) was administered 10 min prior to cannulation or first cerulein injection. Histological and biochemical indicators of pancreatitis were evaluated post-treatment. Pharmacokinetic parameters of Tac in the blood after rectal delivery compared to intravenous and intragastric administration was evaluated.

RESULTS

Rectal Tac was effective in reducing pancreatic injury and inflammation in both PEP and cerulein models. Pharmacokinetic studies revealed that the rectal administration of Tac helped achieve optimal blood levels of Tac over an extended time compared to intravenous or intragastric delivery.

CONCLUSION

Our results underscore the effectiveness and clinical utility of rectal Tac for PEP prophylaxis.

Preclinical safety evaluation of calcineurin inhibitors delivered through an intraductal route to prevent post-ERCP pancreatitis demonstrates endocrine and systemic safety

OBJECTIVE

There is an urgent need for safe and targeted interventions to mitigate post-ERCP pancreatitis (PEP). Calcineurin inhibitors (CnIs) offer therapeutic promise as calcineurin signaling within acinar cells is a key initiating event in PEP. In previous proof-of-concept studies using experimental models, we showed that concurrent intra-pancreatic ductal administration of the CnIs, tacrolimus (Tac) or cyclosporine A (CsA) with the ERCP radiocontrast agent (RC) prevented PEP. To translate this finding clinically, we investigated potential toxic effects of intraductal delivery of a single-dose RC-CnI formulation on endocrine pancreas function and systemic toxicities in a preclinical PEP model.

METHODS

C57BL/6J mice underwent ductal cannulation and received a single, intra-pancreatic ductal infusion of RC or RC with Tac or CsA (treatment groups) or underwent ductal cannulation without infusion ('sham' group). To assess endocrine function, intraperitoneal glucose tolerance test (IPGTT) was performed at two days before infusion and on day 2 and 14 post-surgery. To evaluate off-target tissue toxicities, renal and hepatic function-related parameters including blood urea nitrogen, plasma creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, and total bilirubin were measured at the same time-points as IPGTT. Histological and biochemical indicators of pancreas injury and inflammation were also evaluated.

RESULTS

No abnormalities in glucose metabolism, hepatic or renal function were observed on day 2 or 14 in mice administered with intraductal RC or RC with Tac or CsA.

CONCLUSION

Intraductal delivery of RC-CnI formulation was safe and well-tolerated with no significant acute or subacute endocrine or systemic toxicities, underscoring its clinical utility to prevent PEP.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with inflammatory bowel disease: a nationwide study

PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) has become a commonly utilized procedure for both diagnostic and therapeutic purposes. There is a paucity of data for patients with inflammatory bowel disease (IBD) who undergo ERCP. The aim of this study is to examine the indications, complications, and inpatient outcomes of patients with IBD undergoing ERCP.

METHODS

For this retrospective cohort study, we utilized the National Inpatient Sample database for the years 2018-2019. We compared potential indications, outcomes, ERCP-related procedures, and resource utilization in patients who underwent ERCP and had a diagnosis of IBD to that of patients who underwent ERCP without a diagnosis of IBD. We utilized a multivariate regression model that accounted for several potential confounders.

RESULTS

We identified 318,590 ERCP procedures. Among them, 3625 ERCP procedures were performed in patients with an associated diagnosis of IBD. Patients with IBD who underwent ERCP had higher odds of acute kidney injury (aOR 1.27; 95% CI: 1.01-1.60) and sepsis (aOR 1.33; 95% CI: 1.07-1.67) compared to patients without IBD. However, inpatient mortality and other complications were not statistically different between the two groups. Patients with IBD were also less likely to undergo biliary sphincterotomy (aOR 0.75; 95% CI: 0.62-0.88) but there were no other differences in performance of ERCP-related therapeutic interventions between the two groups. Adjusted costs and charges were not statistically different between the two groups.

CONCLUSION

Our study shows that ERCP is, overall, a safe procedure in patients with IBD, as inpatient morbidity and mortality are similar to patients without IBD.

Digital single-operator cholangioscopy in diagnostic and therapeutic bilio-pancreatic diseases: A prospective, multicenter study

BACKGROUND AND AIM

Digital single-operator cholangioscopy (D-SOC) is an endoscopic procedure that is increasingly used for the management of bilio-pancreatic diseases. We aimed to investigate the efficacy and safety of D-SOC for diagnostic and therapeutic indications.

METHODS

This is a multicenter, prospective study(January 2016-June 2019) across eighteen tertiary centers. The primary outcome was procedural success of D-SOC. Secondary outcomes were: D-SOC visual assessment and diagnostic yield of SpyBite biopsy in cases of biliary strictures, stone clearance rate in cases of difficult biliary stones, rate of adverse events(AEs) for all indications.

RESULTS

D-SOC was performed in 369 patients (201(54,5%) diagnostic and 168(45,5%)therapeutic). Overall, procedural success rate was achieved in 360(97,6%) patients. The sensitivity, specificity, PPV, NPV and accuracy in biliary strictures were: 88,5%, 77,3%, 83,3%, 84,1% and 83,6% for D-SOC visual impression; 80,2%, 92,6%, 95,1%, 72,5% and 84,7% for the SpyBite biopsy, respectively. For difficult biliary stones, complete duct clearance was obtained in 92,1% patients (82,1% in a single session). Overall, AEs occurred in 37(10%) cases.The grade of AEs was mild or moderate for all cases, except one which was fatal.

CONCLUSION

D-SOC is effective for diagnostic and therapeutic indications.Most of the AEs were minor and managed conservatively, even though a fatal event has happened that is not negligible and should be considered before using D-SOC.

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients With Liver Cirrhosis: Analysis of Trends and Outcomes From the National Inpatient Sample Database

GOALS

We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis.

BACKGROUND

ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis.

STUDY

Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes.

RESULTS

A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P <0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P <0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P <0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P <0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P <0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P <0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P <0.0001) and cholecystitis (1.9 vs. 3.1%; P <0.0001) compared with those who received diagnostic ERCP.

CONCLUSIONS

Use of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and postprocedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed.

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis

Background and study aims  Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods  A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results  The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions  Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.

Endoscopic retrograde cholangiopancreatography: Current practice and future research

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Advancements in Endoscopic Biliary Interventions by Gastroenterology

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.

Soft Liver Phantom with a Hollow Biliary System

Hepatobiliary interventions are regarded as difficult minimally-invasive procedures that require experience and skills of physicians. To facilitate the surgical training, we develop a soft, high-fidelity and durable liver phantom with detailed morphology. The phantom is anatomically accurate and feasible for the multi-modality medical imaging, including computer tomography (CT), ultrasound, and endoscopy. The CT results show that the phantom resembles the detailed anatomy of real livers including the biliary ducts, with a spatial root mean square error (RMSE) of 1.7 ± 0.7 mm and 0.9 ± 0.2 mm for the biliary duct and the liver outer shape, respectively. The sonographic signals and the endoscopic appearance highly mimic those of the real organ. An electric sensing system was developed for the real-time quantitative tracking of the transhepatic puncturing needle. The fabrication method herein is accurate and reproducible, and the needle tracking system offers a robust and general approach to evaluate the centesis outcome.

Novel and effective disposable device that provides 2-way protection to the duodenoscope from microbial contamination

BACKGROUND AND AIMS

Duodenoscope contamination is associated with notable patient morbidity and mortality and can occur despite high-level disinfection protocols, requiring a solution that protects against contamination of the endoscope in the first place.

METHODS

We assessed a newly cleared, single-use device to seal the distal end of duodenoscopes while preserving optics and other endoscope functionality and tested its ability to protect against contamination using dye immersion tests and microbial inoculation.

RESULTS

Dye immersion tests revealed a complete seal with no leakage. Rigorous microbial challenge tests showed the device can both protect against contamination of the endoscope by external microbes ("outside-in" protection) and shield instruments from contact with pre-existing microbial biofilm on or around the elevator that may have survived reprocessing ("inside-out" protection). Optical and mechanical performance of the endoscope was not compromised by the addition of the device.

CONCLUSIONS

The results show that this disposable device provides 2-way protection to the duodenoscope from microbial contamination, without the potential for disrupting current equipment, technique, and workflow.

Use of ERCP in the United States over the past decade

Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications.

Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders.

Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased.

Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

Novel single-use duodenoscope compared with 3 models of reusable duodenoscopes for ERCP: a randomized bench-model comparison

BACKGROUND AND AIMS

Multidrug-resistant infectious outbreaks associated with duodenoscope reuse have been documented internationally. A single-use endoscope could eliminate exogenous patient-to-patient infection associated with ERCP.

METHODS

We conducted a comparative bench simulation study of a new single-use and 3 models of reusable duodenoscopes on a synthetic anatomic bench model. Four ERCP tasks were performed: guidewire locking (single-use and 1 reusable duodenoscope only), plastic stent placement and removal, metal stent placement and removal, and basket sweeping. The study schedule included block randomization by 4 duodenoscopes, 4 tasks, and 2 anatomic model ERCP stations. Ability to complete tasks, task completion times, and subjective ratings of overall performance, navigation/pushability, tip control, and image quality on a scale of 1 (worst) to 10 (best) were compared among duodenoscopes.

RESULTS

All 4 ERCP tasks (total 14 subtasks) were completed by 6 expert endoscopists using all 4 duodenoscopes, with similar task completion times (median, 1.5-8.0 minutes per task) and overall performance ratings by task (median, 8.0-10.0). Navigation/pushability ratings were lower for the single-use duodenoscope than for the 3 reusable duodenoscopes (median, 8.0, 10.0, 9.0, and 9.0, respectively; P < .01). Tip control ratings were similar among all the duodenoscopes (median, 9.0-10.0; P = .77). Image quality ratings were lower for 1 reusable duodenoscope compared with the single-use and other 2 reusable duodenoscopes (median, 8.0, 9.0, 9.0, and 9.0, respectively; P < .01).

CONCLUSIONS

A new single-use duodenoscope was used to simulate 4 ERCP tasks in an anatomic model, with performance ratings and completion times comparable with 3 models of reusable duodenoscopes.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration

Purpose

Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy.

Methods

Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction.

Results

One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively.

Conclusions

LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Complications of endoscopic retrograde cholangiopancreatography: an imaging review

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

Yield of biliary stent cytology: Is it time to think lean?

Background and study aims  During evaluation of pancreaticobiliary strictures, it is common practice to send biliary stents for cytologic analysis. However, in recent years, complementary tissue acquisition techniques ranging from cholangioscopy to fine-needle biopsy have improved the ability to acquire tissue and diagnose malignancy. Data are limited on the current diagnostic yield and cost effectiveness of biliary stent analysis. Patients and methods  We performed a retrospective study of all pancreaticobiliary stents sent for analysis in a tertiary care academic medical center from June 2013 to September 2016. Patient demographics, stent information, and final diagnosis history were collected through chart review. Costs were determined using published reimbursement rates for Medicare. Results  Two hundred thirty-one stents from 175 patients were sent for cytologic analysis during the study period. Of the 62 stents obtained from patients ultimately diagnosed with malignancy, only one (1.6 %) had positive cytology for malignant cells, while the others were acellular/non-diagnostic (2/62, 3.2 %), negative (48/62, 77.4 %), or atypical (11/62, 17.7 %). The sensitivity of stent cytology for diagnosis of malignancy was 1.6 % (1/62). No cases were identified in which stent cytology changed clinical management. From a payer perspective, the mean estimated cost for each stent cytologic analysis is greater than $ 70.00. Conclusions  While stent cytologic analysis is a common clinical practice, the diagnostic yield and cost effectiveness of the practice must be reevaluated. With the rise of newer diagnostic technologies such as digital cholangioscopy and endoscopic ultrasound-guided fine-needle biopsy, it may be time to "think lean" and acknowledge a sunset for biliary stent cytology.