Predictors of post-ERCP complications in patients with suspected choledocholithiasis

Factors Associated with the Severity of ERCP-Related Complications: A Retrospective Single-Centre Study

Objectives: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications have been extensively studied and are well established; most complications are mild and self-limiting. This study aims to identify patients at risk of severe early post-ERCP complications. Methods: We conducted a retrospective cohort study with data from 2810 ERCP procedures performed at Ghent University Hospital between 2016 and 2022. Patient records and a maintained ERCP registry were used to identify all ERCP-related complications and possible risk factors. The AGREE classification was used to determine the severity of the complication. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of severe complications. Results: Out of 2810 procedures, 223 cases (7.9%) had post-ERCP complications, with severe complications occurring in 20.3% of cases. The most common severe complication was haemorrhage (22/49 severe complications, 44.9%), with perforation having the highest probability of being severe (10/15 cases, 67%). Independent predictors of severe complications included anticoagulative therapy (OR 6.3, 95% CI 1.4-28.3, p = 0.016) and high procedural difficulty (Schutz category 3: OR 11.5, 95% CI 2.4-54.6, p = 0.002; category 4: OR 5.9, 95% CI 1.4-23.5, p = 0.012). Conclusions: Patients on anticoagulation and those undergoing complex ERCP procedures (Schutz 3 or 4) are at particular risk of severe procedure-related complications.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Development and validation of a risk prediction model and scoring system for post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

A few models have been proposed for the prediction of the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), but many include factors that are not assessed routinely. Herein, we intend to develop and validate a predictive model for the occurrence of PEP.

Methods

Data of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) from January 01, 2016 to May 16, 2019 (training set and internal test set) and from May 17, 2019 to December 25, 2019 (external test set) were retrospectively collected. The performance of the model was validated in the two validation cohorts.

Results

A total of 342 patients were included for the external test set, and 47 (13.7%) developed PEP. The variables included in the scoring system were gastrectomy history, high direct bilirubin (DBIL), high albumin (ALB), villous type of papillary orifice, nodular type of papillary orifice, pancreatic guidewire passages, precut sphincterotomy, and high operator experience. A total score >5 indicated high risk. In the external test set, the area under the curve (AUC) was 0.718, the sensitivity was 0.723, and the specificity was 0.676. In the external test set, the probability of PEP was 6.1%, 17.0%, and 37.5% in patients with low (<0), moderate (0-5), and high (>5) risk scores, respectively.

Conclusions

This study established a scoring system for predicting the risk of PEP using routinely measured clinical variables. Its application in routine work warrants further investigation.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases

BACKGROUND

Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST.

METHODS

A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years.

RESULTS

A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%).

CONCLUSIONS

Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis

Background/Aims

To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis.

Methods

Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial.

Results

The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03).

Conclusions

Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.

Risk factors of pancreatitis after endoscopic sphincterotomy. Review of literature and practical remarks based on approximately 10,000 ERCPs

Post-endoscopic pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Depending on the presence of risk factors, PEP can occur in 4,1% to about 43% of patients. According to the European Society of Gastrointestinal Endoscopy (ESGE) guidelines, only three to patient-associated risk factors have been identified: suspected sphincter of Oddi dysfunction (SOD) (OR 4.09), female gender (OR 2.23), and previous pancreatitis (OR 2.46). Another three procedure-associated factors include cannulation attempt duration &gt; 10 minutes (OR 1.76), more than one pancreatic guidewire passage (OR 2.77, CI: 1.79 - 4.30), and pancreatic injection (OR 2.2, CI: 1.60 - 3.01). Importantly, analyses of cumulative risk due to coexistence of several factors emphasize the importance of female sex, difficult cannulation, CBD diameter &lt;5 mm, young age, and many other factors. Unfortunately, studies performed to date have included only small numbers of patients with several co-existing risk factors. Therefore, further analysis of other risk factors and the cumulative risk related to their co-occurrence is necessary. Based on current evidence, special care must be given to patients with several risk factors. Also, care should be given to proper qualification of patients, use of guidewires, early pre-cut incision, protective Wirsung's duct stenting, and rectal NSAID administration.

Brushing the distal biliary stricture in the surrounding of the papilla increased the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis: A retrospective study using propensity score analysis

Background and aims

Brushing cytology is useful for diagnosing biliary strictures. With regard to biliary stricture brushing at the distal common bile duct in the surrounding of the papilla, the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis is unknown. Our study aimed to evaluate the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis by using this procedure.

Methods

A total of 150 endoscopic retrograde cholangiopancreatography-naïve patients undergoing endoscopic retrograde cholangiopancreatography including biliary stricture brushing were retrospectively analyzed. Patients were divided into two groups: the surrounding of the papilla group (n = 25) and the other group (n = 125). The primary outcome was the post-endoscopic retrograde cholangiopancreatography pancreatitis incidence. We analyzed the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis by using inverse probability of treatment weighting based on propensity scores to adjust for selection bias.

Results

The overall incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis was 11.3%, and post-endoscopic retrograde cholangiopancreatography pancreatitis of the surrounding of the papilla group occurred significantly more frequently than in the other group (32.0% vs 7.2%, p < 0.01). Multivariate analysis showed that this procedure was a risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis (odds ratio, 10.6; 95% confidence interval, 2.82-40.2; p < 0.01). In the propensity-weighted model, this procedure was an independent risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis (odds ratio, 8.42; 95% confidence interval, 2.12-32.4; p < 0.01) by multivariate analysis.

Conclusions

Biliary stricture brushing at the distal common bile duct in the surrounding of the papilla may increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis compared with brushing other portions.

Cost-effective Decisions in Detecting Silent Common Bile Duct Gallstones During Laparoscopic Cholecystectomy

OBJECTIVE

To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy.

BACKGROUND

The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear.

METHODS

A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters.

RESULTS

In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost ($311 vs $574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost ($1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM.

CONCLUSIONS

In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.

Is ESR Important for Predicting Post-ERCP Pancreatitis?

BACKGROUND

Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP).

AIM

To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population.

MATERIALS AND METHODS

Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria.

RESULTS

Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method.

CONCLUSIONS

Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.

Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis

BACKGROUND AND AIM

Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP.

METHODS

We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP.

RESULTS

Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95 % confidence interval (CI) 0.29-0.53; P < 0.001]. Subgroup analysis stratified according to the severity of PEP showed that a PS was beneficial in patients with mild to moderate PEP (RR 0.45; 95 % CI 0.32-0.62; P < 0.001) and in patients with severe PEP (RR 0.26; 95 %CI 0.09-0.76; P = 0.01). In addition, subgroup analysis performed according to patient selection demonstrated that PS placement was effective for both high-risk and mixed case groups.

CONCLUSIONS

This meta-analysis showed that PS placement prevented PEP after ERCP as compared with no PS placement. We therefore recommend PS placement after ERCP for the prevention of PEP.

Complications of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.

Randomised clinical trial: MRCP-first vs. ERCP-first approach in patients with suspected biliary obstruction due to bile duct stones

BACKGROUND

The preferred initial investigation with either magnetic resonance (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected biliary obstruction remains controversial in many clinical settings.

AIM

To assess the effectiveness of an initial MRCP vs. ERCP in the work-up of patients at moderate likelihood of a suspected biliary obstruction.

METHODS

Patients with an unconfirmed benign biliary obstruction, based on laboratory and ultrasound findings, were randomised to an ERCP-first or MRCP-first strategy, stratified by level of obstruction. The primary outcome was the occurrence of a disease or procedure-related bilio-pancreatic adverse events within the next 12 months. Secondary outcomes were the number of subsequent bilio-pancreatic procedures, duration of hospitalisation, days away from activities of daily living (ADL), quality of life (SF-36) and mortality.

RESULTS

We randomised 126 patients to ERCP-first and 131 to MRCP-first (age 54 ± 18 years, 62% female, 39% post-cholecystectomy). In follow-up, 18/126 (14.3%) ERCP-first and 25/131 (19.1%) MRCP-first patients experienced a procedure- or disease-related complication (P = 0.30) (disease-related in 13 and 18 patients, and procedure-related in 5 and 7 patients respectively). A cause of biliary obstruction was found in 39.7% vs. 49.6% of patients (P = 0.11). Sixty-six (50%) patients in the MRCP-first group ended up avoiding an ERCP in follow-up. ERCP-first and MRCP-first patients were away from usual activities for 3.4 ± 7.7 days and 2.0 ± 4.8 days respectively (P < 0.001).

CONCLUSION

A strategy of MRCP-first decreased the need for subsequent MRCPs, but not complications. Further study is required to define factors influencing the eventual use of MRCP vs. ERCP in appropriately selected patients (ClinicalTrial.gov: NCT01424657).

Is the double-guidewire technique superior to the pancreatic duct guidewire technique in cases of pancreatic duct opacification?

BACKGROUND AND AIMS

Pancreatic duct guidewire placement (P-GW) techniques include both the injection cannulation technique with a contrast medium and wire-guided cannulation without contrast injection for selective biliary cannulation; the latter is the so-called "double-guidewire technique" (D-GW). The aim of this study was to compare the outcomes between P-GW and D-GW for biliary cannulation.

METHODS

The procedures for biliary cannulation with a naïve papilla were performed in a total of 363 cases. We divided the patients chronologically, according to the time period during which the procedures were performed, into two groups: group A, P-GW performed from March 2008 to June 2009; and group B, D-GW performed from July 2009 to December 2010. The success rates and complication rates were evaluated in each group.

RESULTS

Biliary cannulation was successful in 31 (81.6%) patients in the P-GW group and 34 patients (82.9%) in the D-GW group. The onsets of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) occurred in the P-GW and D-GW groups were four (10.5%) and three (7.3%) patients, respectively, and all were mild cases (P = 0.616). The frequency of hyperamylasemia and the serum amylase level tended to be lower in the D-GW group than in the P-GW group (P = 0.213). There was a statistically significant difference on the onsets of PEP in the GW and non-GW groups (P = 0.04, 8.9% and 1.1%, respectively).

CONCLUSIONS

Both the D-GW and P-GW techniques were equally effective for difficult biliary cannulation. Furthermore, the complication rates, including PEP, were similar in both techniques. A prospective randomized trial is warranted.

Preventing pancreatitis after endoscopic retrograde cholangiopancreatography

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

The role of magnetic resonance cholangiopancreatography in the management of acute gallstone pancreatitis

INTRODUCTION

The aim of this study was to identify whether magnetic resonance cholangiopancreatography (MRCP) can be used selectively in patients with acute gallstone pancreatitis to detect choledocholithiasis, based on liver function tests (LFTs) and ultrasonography appearance.

METHODS

All patients admitted between January 2008 and January 2011 with gallstone pancreatitis (amylase >300u/l) who underwent MRCP were included in the study. LFTs and radiology reports were obtained from the respective computer systems.

RESULTS

Overall, 173 patients with acute gallstone pancreatitis underwent MRCP and 30% (52/173) showed choledocholithiasis. The mean bilirubin level was significantly higher in those with choledocholithiasis (46 ±5μmol/l vs 36 ±3μmol/l, p=0.0388) although there was no significant difference in alkaline phosphatase (276 ±25iu/l vs 229 ±16iu/l, p=0.1154). However, sensitivity of abnormal bilirubin (>21μmol/l) for choledocholithiasis was only 62% and specificity was 41%. Sensitivity of abnormal alkaline phosphatase (>140iu/l) for choledocholithiasis was only 75% and specificity was 37%. There was a significant association between biliary dilatation on ultrasonography and choledocholithiasis on MRCP (p=0.0099) although the sensitivity of biliary dilatation for choledocholithiasis was only 44% and the specificity was 79%. Furthermore, there was no difference in the incidence of choledocholithiasis on MRCP for those patients with persistently deranged LFTs versus those whose LFTs returned to normal (relative risk: 1.07, 95% confidence interval: 0.61-1.89, p=1.00). Overall, 10% of patients with choledocholithiasis on MRCP had entirely normal LFTs on admission and no biliary dilatation or choledocholithiasis on ultrasonography.

CONCLUSIONS

All patients with acute gallstone pancreatitis should undergo specific imaging, preferably MRCP, to exclude choledocholithiasis as LFTs and ultrasonography are inaccurate in predicting common bile duct stones.

American College of Gastroenterology guideline: management of acute pancreatitis

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

Pancreatitis potentially associated drugs as a risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective cohort study

OBJECTIVES

The aim of this study was to assess the role of known risk factors and specifically evaluate the role of pancreatitis potentially associated drugs as potential risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

This was a prospective, single-center cohort study conducted in a tertiary university hospital. All eligible ERCP procedures within a 16-month period were evaluated, and all interventions, patient characteristics, and medications used were documented. The association of potential risk factor with PEP was investigated with univariable analyses. Those statistically significant were entered in a multivariable regression model.

RESULTS

Three hundred eighteen ERCP procedures were studied. Post-ERCP pancreatitis occurred in 28 patients (8.8%). Twenty-three potential risk factors were studied in univariable analyses, and 3 of them were found to be nominally statistically significant. These 3 factors were independently associated with PEP in the multivariable model and included the use of pancreatitis potentially associated drugs, belonging to Badalov classes I or II, during the last month before ERCP (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.70-5.47; P = 0.003), more than 1 guide-wire insertions in the pancreatic duct (OR, 5.00; 95% CI, 1.97-12.81; P = 0.001) and bile duct stone extraction (OR, 0.12; CI, 0.05-0.32; P < 0.001).

CONCLUSIONS

Pancreatitis potentially associated drugs used before ERCP seem to increase the risk for PEP.

Rendezvous cannulation technique reduces post-ERCP pancreatitis: a prospective nationwide study of 12,718 ERCP procedures

OBJECTIVES

The aim of this study was to investigate if intraoperative rendezvous cannulation reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) because there is no universal consensus on the optimal treatment of common bile duct stones.

METHODS

We performed a nationwide case-control study, nested within the cohort of ERCP procedures reported to the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2009. Data were collected prospectively from a web-based registry of ERCP procedures that includes variables such as patient characteristics, indication, cannulation technique, diagnostic findings, therapeutic measures, and complications. The primary outcome was PEP.

RESULTS

The registry included 12,718 ERCP procedures performed on patients without a history of previous ERCP. The risk of PEP when using the rendezvous technique compared with those who were cannulated by conventional means was reduced from 3.6 to 2.2% (odds ratio (OR) 0.5, 95% confidence interval 0.2-0.9, P=0.02). Although a significant reduction there are overall relatively few cases with PEP and the calculated numbers needed to treat to avoid one case of PEP is as high as 71. Other factors associated with increased risk of PEP were young age, prolonged procedure time, and elective ERCP.

CONCLUSIONS

Rendezvous bile duct cannulation during ERCP reduces the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.

The burden of endoscopic retrograde cholangiopancreatography (ERCP) performed with the patient under conscious sedation

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that proves burdensome to patients. Nevertheless, very little data are available on patient tolerance of this procedure that may improve practice guidelines and could aid in decreasing the burden of ERCP. This study therefore investigated the burden of ERCP performed with the patient under conscious sedation.

METHODS

Consecutive patients receiving ERCP under conscious sedation between November 2007 and December 2008 at the University Medical Center Utrecht and Erasmus MC Rotterdam (The Netherlands) were asked to participate in this study. The patients completed questionnaires on demographics, medical history, burden of ERCP (mental health, discomfort, and pain), symptoms and the EuroQol-5D (EQ-5D), including the EQ-VAS (lower EQ-5D scores and higher EQ-VAS scores represent a better quality of life). The paired t-test, the Kruskal–Wallis test, Pearson correlation, and logistic regression were used to evaluate the results.

RESULTS

The questionnaire was returned by 149 (54%) of 276 eligible patients, 139 of whom completed the entire questionnaire (54% males; mean age, 60 ± 14 years). Throat ache (p < 0.001) was the only symptom higher than baseline value 1 day after the ERCP. On day 1, about one-tenth of the patients experienced moderate to severe mental health problems, which were associated with a higher EQ-5D score before ERCP (p = 0.01). Slightly fewer than half of the patients experienced pain and discomfort during and immediately after ERCP. More discomfort was experienced by patients who underwent therapeutic ERCP (p < 0.05) and those with a higher EQ-5D score (p < 0.001) or lower VAS (p < 0.01). Pain was associated with younger age (p < 0.01), higher EQ-5D score (p < 0.001), and lower VAS (p < 0.01).

CONCLUSION

One-third to one-half of patients experience pain and discomfort during and immediately after ERCP when it is performed with conscious sedation for the patient. Other sedation strategies, such as the use of general anesthesia or propofol, may well reduce the burden of ERCP, particularly for patients with a higher EQ-5D score, younger age, or therapeutic ERCP treatment. However, randomized trials are warranted.

Prospective comparative study of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for removal of large bile duct stones in patients above 45 years of age

OBJECTIVE

Although endoscopic papillary large balloon dilation (EPLBD) with limited endoscopic sphincterotomy (ES) showed excellent outcomes for treatment of large bile duct stones, hemorrhage and recurrence of stones are problematic complications. Recent studies suggest that EPLBD alone is safe and effective for removal of large bile duct stones. This study aimed to determine the therapeutic outcomes and safety of EPLBD, compared with ES, for removal of large bile duct stones.

MATERIAL AND METHODS

Eighty-three patients above 45 years of age with bile duct stones >1 cm in diameter were randomized to EPLBD and ES groups for removal of common bile duct stones from September 2010 to August 2011. Prophylactic gabexate mesilate was given to all patients.

RESULTS

Baseline characteristics were not significantly different, except diabetes and gallbladder stones between the EPLBD group (n = 40) and ES group (n = 43). The overall complete stone removal rate in each group was 97.5% (39/40) and 95.3% (41/43), respectively (p = 0.600). Requirement of mechanical lithotripsy was not significantly different between the EPLBD and ES group (10% vs. 21%, p = 0.171). Complete ductal clearance in one session was achieved in 82.4% and 81.4% of cases in each group, respectively (p = 0.577). There were no differences in complication rates between the EPLBD and ES group; pancreatitis, 5.0% vs. 7.0%; hemorrhage, 10.0% vs. 16.3%; acute cholangitis, 5.0% vs. 2.3%, and perforation, 2.5% vs. 0%.

CONCLUSIONS

The therapeutic outcomes and complications of EPLBD for removal of large bile duct stones are comparable to those of ES.

Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography

AIM: To determine the effectiveness of pancreatic duct (PD) stent placement for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high risk patients.

METHODS: Authors conducted a single-blind, randomized controlled trial to evaluate the effectiveness of a pancreatic spontaneous dislodgement stent against post-ERCP pancreatitis, including rates of spontaneous dislodgement and complications. Authors defined high risk patients as having any of the following: sphincter of Oddi dysfunction, difficult cannulation, prior history of post-ERCP pancreatitis, pre-cut sphincterotomy, pancreatic ductal biopsy, pancreatic sphincterotomy, intraductal ultrasonography, or a procedure time of more than 30 min. Patients were randomized to a stent group (n = 60) or to a non-stent group (n = 60). An abdominal radiograph was obtained daily to assess spontaneous stent dislodgement. Post-ERCP pancreatitis was diagnosed according to consensus criteria.

RESULTS: The mean age (± standard deviation) was 67.4 ± 13.8 years and the male: female ratio was 68:52. In the stent group, the mean age was 66 ± 13 years and the male: female ratio was 33:27, and in the non-stent group, the mean age was 68 ± 14 years and the male: female ratio was 35:25. There were no significant differences between groups with respect to age, gender, final diagnosis, or type of endoscopic intervention. The frequency of post-ERCP pancreatitis in PD stent and non-stent groups was 1.7% (1/60) and 13.3% (8/60), respectively. The severity of pancreatitis was mild in all cases. The frequency of post-ERCP pancreatitis in the stent group was significantly lower than in the non-stent group (P = 0.032, Fisher’s exact test). The rate of hyperamylasemia were 30% (18/60) and 38.3% (23 of 60) in the stent and non-stent groups, respectively (P = 0.05, χ² test). The placement of a PD stent was successful in all 60 patients. The rate of spontaneous dislodgement by the third day was 96.7% (58/60), and the median (range) time to dislodgement was 2.1 (2-3) d. The rates of stent migration, hemorrhage, perforation, infection (cholangitis or cholecystitis) or other complicationss were 0% (0/60), 0% (0/60), 0% (0/60), 0% (0/60), 0% (0/60), respectively, in the stent group. Univariate analysis revealed no significant differences in high risk factors between the two groups. The pancreatic spontaneous dislodgement stent safely prevented post-ERCP pancreatitis in high risk patients.

CONCLUSION: Pancreatic stent placement is a safe and effective technique to prevent post-ERCP pancreatitis. Therefore authors recommend pancreatic stent placement after ERCP in high risk patients.

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

BACKGROUND

Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct.

OBJECTIVE

To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients.

DESIGN

Prospective, comparative-intervention single-center study.

SETTING

Tertiary referral center.

PATIENTS

Patients with biliary disease with an intact papilla were prospectively examined by ERCP.

INTERVENTIONS

Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection.

MAIN OUTCOME MEASUREMENTS

Pancreatitis rate in the GW group and the contrast injection (ConI) group.

RESULTS

PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP.

LIMITATIONS

Lack of randomization.

CONCLUSIONS

For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

Endoscopic pancreatic duct stents reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients

BACKGROUND & AIMS

Pancreatitis is the most common and potentially serious complication of post-endoscopic retrograde cholangiopancreatography (ERCP). Post-ERCP pancreatitis (PEP) is caused mostly by postprocedural papillary edema and retention of pancreatic juice. We conducted a randomized controlled trial to determine whether placement of a temporary-type, pancreatic duct stent prevents PEP and to identify risk factors for PEP.

METHODS

We analyzed data from 426 consecutive patients who underwent ERCP-related procedures at 37 endoscopic units. The patients were assigned randomly to groups that received stents (S group, n = 213) or did not (nS group, n = 213). The stent used was temporary, 5F in diameter, 3 cm long, and straight with an unflanged inner end.

RESULTS

The overall frequency of PEP was 11.3%. The frequencies of PEP in the S and nS groups were 7.9% and 15.2%, respectively; the lower incidence of PEP in the S group was statistically significant based on the full analysis set (P = .021), although there was no statistically significant differences in an intention-to-treat analysis (P = .076). There were significant differences in PEP incidence between groups in multivariate analysis for the following risk factors: pancreatography first, nonplacement of a pancreatic duct stent after ERCP, procedure time of 30 minutes or more, sampling of pancreatic tissue by any method, intraductal ultrasonography, and difficulty of cannulation (≥15 min). Patients with more than 3 risk factors had a significantly greater incidence of pancreatitis.

CONCLUSIONS

Placement of a pancreatic duct stent reduces the incidence of PEP. Several risk factors are associated with PEP.

Precut sphincterotomy, repeated cannulation and post-ERCP pancreatitis in patients with bile duct stone disease

BACKGROUND

Repeated attempts at cannulating the papilla of Vater and "needle-knife" precut sphincterotomy are independent risk factors for post-ERCP pancreatitis. Whether precut alone or repeated attempts at cannulation is the culprit factor in the development of post-ERCP pancreatitis remains controversial.

AIM

To retrospectively assess the role of precutting and multiple cannulation in the occurrence of post-ERCP pancreatitis in a consecutive series of patients with bile stone disease.

METHODS

2004 patients who had undergone endoscopic retrograde cholangio-pancreatography over a 9-year period for bile stones were evaluated. Pancreatitis rate was assessed in relation to the number of cannulation attempts (<10 and ≥10) and precutting.

RESULTS

Procedures were successful in 1878 patients (93.7%). Cannulation was done without precutting in 1717 cases and with in 161. Pancreatitis occurred in 2.7% of patients who had undergone biliary cannulation without precutting and in 6.5% with (p=0.006). It was lower with <10 attempts than with ≥10 (p<0.0001), either without (p<0.0001) or with precutting (p<0.01). Pancreatitis rate did not differ without and with precutting when <10 attempts at cannulation were done, whilst it was lower when precut was done before 10 attempts than when 10 or more attempts were made without precutting (p=0.02).

CONCLUSIONS

Pancreatitis rate was lower when precut was done with <10 attempts than when ≥10 attempts were made without precutting. In experienced hands precut biliary sphincterotomy does not seem to be an independent risk factor for post-ERCP pancreatitis in patients undergoing endoscopic retrograde cholangio-pancreatography for bile duct stones.

Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vater's papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15-35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis. This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.

Intravenous synthetic secretin reduces the incidence of pancreatitis induced by endoscopic retrograde cholangiopancreatography

OBJECTIVES

This study aimed to evaluate whether synthetic secretin is effective in reducing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

METHODS

This is a single academic medical center, prospective, randomized, double-blind, placebo-controlled trial using secretin (dose of 16 μg) administered intravenously immediately before ERCP. Patients were evaluated for the primary outcome of post-ERCP pancreatitis as diagnosed by a single investigator.

RESULTS

A total of 1100 patients were screened, of whom 869 were randomly assigned to receive secretin (n = 426) or placebo (n = 443) before ERCP and were evaluated after the procedure for efficacy of secretin. The incidence of pancreatitis in the secretin group compared with the placebo group was 36 (8.7%) of 413 patients versus 65 (15.1%) of 431 patients, respectively, P = 0.004. In the subgroup analysis, secretin was highly protective against post-ERCP pancreatitis for patients undergoing biliary sphincterotomy (6/129 vs 32/142, P < 0.001), patients undergoing cannulation of the common bile duct (26/339 vs 56/342, P < 0.001), and patients not undergoing pancreatic sphincterotomy (26/388 vs 57/403, P = 0.001). Analysis of the interaction between these groups reveals that the primary effect of secretin prophylaxis was prevention of post-ERCP pancreatitis in patients undergoing biliary sphincterotomy.

CONCLUSIONS

Synthetic secretin reduces the risk of post-ERCP pancreatitis, particularly in patients in undergoing biliary sphincterotomy.

Predictors of complications after endoscopic retrograde cholangiopancreatography: a prognostic model for early discharge

BACKGROUND

Several studies have evaluated predictors for complications of endoscopic retrograde cholangiopancreatography (ERCP), but their relative importance is unknown. In addition, currently used blood tests to detect post-ERCP pancreatitis are inconsistent. The aim of this study was to determine predictors of post-ERCP complications that could discriminate between patients at highest and lowest risk of post-ERCP complications and to develop a model that is able to identify patients that can safely be discharged shortly after ERCP.

METHODS

In a single-center, retrospective analysis over the period 2002-2007, predictors of post-ERCP complications were evaluated in a multivariable analysis and compared with those identified from a literature review. A prognostic model was developed based on these risk factors, which was further evaluated in a prospective patient population.

RESULTS

From our retrospective analysis and literature review, we selected the eight most important risk factors for post-ERCP pancreatitis and cholangitis. In the prognostic model, the risk factors (precut) sphincterotomy, sphincter of Oddi dysfunction, younger age, female gender, history of pancreatitis, pancreas divisum, and difficult cannulation accounted for a score of 1 each, whereas primary sclerosing cholangitis (PSC) accounted for a score of 2. A sum score of 4 or more in the prognostic model was associated with a high risk of developing pancreatitis and cholangitis (27%; 6/22) in the prospective patient population, whereas a sum score of 3 or less was associated with a low to intermediate risk (8%; 20/252).

CONCLUSIONS

We identified specific patient- and procedure-related factors that are associated with post-ERCP complications. The prognostic model based on these factors is able to identify patients who can be safely discharged the same day after ERCP.

Predictors of complications after endoscopic retrograde cholangiopancreatography: a prognostic model for early discharge

BACKGROUND

Several studies have evaluated predictors for complications of endoscopic retrograde cholangiopancreatography (ERCP), but their relative importance is unknown. In addition, currently used blood tests to detect post-ERCP pancreatitis are inconsistent. The aim of this study was to determine predictors of post-ERCP complications that could discriminate between patients at highest and lowest risk of post-ERCP complications and to develop a model that is able to identify patients that can safely be discharged shortly after ERCP.

METHODS

In a single-center, retrospective analysis over the period 2002-2007, predictors of post-ERCP complications were evaluated in a multivariable analysis and compared with those identified from a literature review. A prognostic model was developed based on these risk factors, which was further evaluated in a prospective patient population.

RESULTS

From our retrospective analysis and literature review, we selected the eight most important risk factors for post-ERCP pancreatitis and cholangitis. In the prognostic model, the risk factors (precut) sphincterotomy, sphincter of Oddi dysfunction, younger age, female gender, history of pancreatitis, pancreas divisum, and difficult cannulation accounted for a score of 1 each, whereas primary sclerosing cholangitis (PSC) accounted for a score of 2. A sum score of 4 or more in the prognostic model was associated with a high risk of developing pancreatitis and cholangitis (27%; 6/22) in the prospective patient population, whereas a sum score of 3 or less was associated with a low to intermediate risk (8%; 20/252).

CONCLUSIONS

We identified specific patient- and procedure-related factors that are associated with post-ERCP complications. The prognostic model based on these factors is able to identify patients who can be safely discharged the same day after ERCP.

Endoscopic papillary balloon dilation for bile duct stone removal in patients 60 years old or younger

BACKGROUND

The aim of this study was to evaluate short- and long-term outcomes in relatively young patients (≤ 60 years old) who underwent endoscopic papillary balloon dilation (EPBD) for bile duct stone removal.

METHODS

Immediate and long-term outcomes were evaluated in 311 patients who were 60 years old or younger at the time of EPBD. The stone recurrence rate was compared among four groups stratified according to gallbladder (GB) status before and after EPBD (cholecystectomy after EPBD, GB left in situ with stones, GB left in situ without stones, and cholecystectomy before EPBD).

RESULTS

Bile duct stones were completely removed via EPBD alone in 304 patients (97.7%). Post-EPBD pancreatitis occurred in 24 patients (7.7%), and was mild in 18 patients, moderate in 5 patients, and severe in 1 patient. The rate of pancreatitis was significantly higher in these patients than in patients aged more than 60 years who underwent EPBD during the same study period (4.7%). Long-term outcomes were evaluated in 217 patients who were followed for at least 1 year after complete stone removal via EPBD. During a mean follow-up period of 5.6 years (range, 1.0-13.4 years), stone recurrence was observed in 13 patients (6.0%). The cumulative stone recurrence rates at 5 and 10 years after EPBD were 5.9 and 7.1%, respectively. Patients in the cholecystectomy after EPBD group had the lowest risk of stone recurrence among the four groups (2.0%).

CONCLUSION

EPBD removes bile duct stones in the majority of younger patients without increasing the risk of severe pancreatitis. Post-EPBD pancreatitis is more likely to occur in younger patients as compared to older patients. The long-term outcomes of EPBD appear favorable, especially in patients who have undergone cholecystectomy after EPBD.

Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: a prospective multicenter study

OBJECTIVES

Prospective studies have identified a number of patient- and procedure-related independent risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, with different conclusions, so various questions are still open. The endoscopist's expertise, case volume, and case mix can all significantly influence the outcome of ERCP procedures, but have been investigated little to date.

METHODS

We identified patient- and procedure-related risk factors for post-ERCP pancreatitis and the impact of the endoscopist's experience and the center's case volume, using univariate and multivariate analysis, in a multicenter, prospective study involving low- and high-volume centers, over a 6-month period.

RESULTS

A total of 3,635 ERCP procedures were included; 2,838 (78%) ERCPs were performed in the 11 high-volume centers (median 257 each) and 797 in the 10 low-volume centers (median 45 each). Overall, 3,331 ERCPs were carried out by expert operators and 304 by less-skilled operators. There were significantly more grade 3 difficulty procedures in high-volume centers than in low-volume ones (P<0.0001). Post-ERCP pancreatitis occurred in 137 patients (3.8%); the rates did not differ between high- and low-volume centers (3.9% vs. 3.1%) and expert and non-expert operators (3.8% vs. 5.5%). However, in high-volume centers, there were 25% more patients with patient- and procedure-related risk factors, and the pancreatitis rate was one-third higher among non-expert operators. Univariate analysis found a significant association with pancreatitis for history of acute pancreatitis, either non-ERCP- or ERCP-related and recurrent, young age, absence of bile duct stones, and biliary pain among patient-related risk factors, and >10 attempts to cannulate the Vater's papilla, pancreatic duct cannulation, contrast injection of the pancreatic ductal system, pre-cut technique, and pancreatic sphincterotomy, among procedure-related risk factors. Multivariate analysis also showed that a history of post-ERCP pancreatitis, biliary pain, >10 attempts to cannulate the Vater's papilla, main pancreatic duct cannulation, and pre-cut technique were significantly associated with the complication.

CONCLUSIONS

A history of pancreatitis among patient-related factors, and multiple attempts at cannulation among procedure-related factors, were associated with the highest rates of post-ERCP pancreatitis. Pre-cut sphincterotomy, although identified as another significant risk factor, appeared safer when done early (fewer than 10 attempts at cannulating), compared with repeated multiple cannulation. The risk of post-ERCP pancreatitis was not associated with the case volume of either the single endoscopist or the center; however, high-volume centers treated a larger proportion of patients at high risk of pancreatitis and did a significantly greater number of difficult procedures.

Quality indicators, including complications, of ERCP in a community setting: a prospective study

BACKGROUND

There are no large studies documenting quality outcomes and complication rates of ERCP in community practice. The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology Task Force on Quality proposed 5 questions regarding ERCP in community practice. The ASGE Committee on Outcomes Research recommended 8 ERCP-specific quality indicators be used to provide a better accounting of quality in ERCP.

OBJECTIVE

To determine ERCP quality outcomes, including complications, in a community practice.

DESIGN

Prospective study.

SETTING

Eight community hospitals in the Minneapolis-St. Paul, Minnesota, area.

PATIENTS

Every patient undergoing ERCP by Minnesota Gastroenterology PA from December 1, 2005, through July 31, 2006.

MAIN OUTCOME MEASUREMENTS

ASGE-recommended quality indicators, especially 30-day complication rates.

RESULTS

A total of 805 ERCP procedures were performed in 696 patients. Therapeutic ERCP accounted for 78.4%. The complication rate was 5.0% (5.7% of therapeutic and 2.3% of diagnostic procedures). Pancreatitis occurred in 3.2% of procedures (3.6% of therapeutic and 1.7% of diagnostic procedures). Infection (0.75%), hemorrhage (0.62%), and perforation (0.12%) only occurred after therapeutic ERCP. Cardiopulmonary complications occurred in 2 patients (0.25%). Precut sphincterotomy was performed in 26 cases (3.2%), and sphincter of Oddi manometry in 23 cases (2.9%). Success rates were 94.0% for biliary cannulation, 87.0% for stone extraction, and 90.2% for relieving biliary obstruction. A total of 530 patient satisfaction surveys were completed and revealed that the response to the question, "Would you have the procedure done again by this physician?" was the most sensitive indicator of patient satisfaction.

CONCLUSIONS

In this community practice, complication rates compare very favorably with those of academic centers. The technical success rates achieved or exceeded rates recommended by the ASGE/American College of Gastroenterology Task Force.

Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years

BACKGROUND

Complications of ERCP are an important concern. We sought to determine predictors of post-ERCP complications at our institution.

METHODS

GI TRAC is a comprehensive data set of patients who underwent ERCP at our institution from 1994 through 2006. Logistic regression models were used to evaluate 4 categories of complications: (1) overall complications, (2) pancreatitis, (3) bleeding, and (4) severe or fatal complications. Independent predictors of complications were determined with multivariable logistic regression.

RESULTS

A total of 11,497 ERCP procedures were analyzed. There were 462 complications (4.0%), 42 of which were severe (0.36%) and 7 were fatal (0.06%). Specific complications of pancreatitis (2.6%) and bleeding (0.3%) were identified. Overall complications were statistically more likely among individuals with suspected sphincter of Oddi dysfunction (SOD) (odds ratio [OR] 1.91) and after a biliary sphincterotomy (OR 1.32). Subjects with a history of acute or chronic pancreatitis (OR 0.78) or who received a temporary small-caliber pancreatic stent (OR 0.69) had fewer complications. Post-ERCP pancreatitis was more likely to occur after a pancreatogram via the major papilla (OR 1.70) or minor papilla (OR 1.54) and among subjects with suspected SOD with stent placement (OR 1.45) or without stent placement (OR 1.84). Individuals undergoing biliary-stent exchange had less-frequent pancreatitis (OR 0.38). Biliary sphincterotomy was associated with bleeding (OR 4.71). Severe or fatal complications were associated with severe (OR 2.38) and incapacitating (OR 7.65) systemic disease, obesity (OR 5.18), known or suspected bile-duct stones (OR 4.08), pancreatic manometry (OR 3.57), and complex (grade 3) procedures (OR 2.86).

CONCLUSIONS

This study characterizes a large series of ERCP procedures from a single institution and outlines the incidence and predictors of complications.

Minimizing complications in pancreaticobiliary endoscopy

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are invaluable tools in the diagnostic and therapeutic evaluation and management of a variety of pancreatobiliary disorders. Along with a significant refinement in the equipment and techniques used has come a recent trend toward aggressive therapeutic interventions. Because of the technical nature of these procedures and the characteristics of the patients, post-procedural complications may occur, ranging from minor (requiring brief hospitalization) to severe (causing permanent disability or death). This review summarizes these complications and outlines strategies to minimize them.

Alcohol use and cigarette smoking as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND & AIMS

Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP.

METHODS

We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement.

RESULTS

The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001).

CONCLUSIONS

Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.

Evaluation of recombinant platelet-activating factor acetylhydrolase for reducing the incidence and severity of post-ERCP acute pancreatitis

BACKGROUND

Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Platelet-activating factor (PAF) has been implicated in the pathophysiologic events associated with acute pancreatitis. Animal and human studies suggested that recombinant PAF acetylhydrolase (rPAF-AH) might ameliorate the severity of acute pancreatitis.

OBJECTIVE

Our purpose was to determine whether prophylactic rPAF-AH administration reduces the frequency or severity of post-ERCP pancreatitis in high-risk patients.

DESIGN

Randomized, multicenter, double-blind, placebo-controlled study.

INTERVENTIONS

Patients received rPAF-AH at a dose of either 1 or 5 mg/kg or placebo. Patients were administered a single intravenous infusion over 10 minutes of study drug or placebo <1 hour before ERCP.

MAIN OUTCOME MEASUREMENTS

Standardized criteria were used to diagnose and grade the severity of post-ERCP pancreatitis. Adverse events were prospectively recorded.

RESULTS

A total of 600 patients were enrolled. There were no statistically significant differences among the treatment groups with respect to patient demographics, ERCP indications, and patient and procedure risk factors for post-ERCP pancreatitis with the following exceptions: the rPAF-AH 5 mg/kg group had significantly fewer patients younger than 40 years old and scheduled to undergo a therapeutic ERCP involving the pancreatic sphincter or duct. Post-ERCP pancreatitis occurred in 17.5%, 15.9%, and 19.6% of patients receiving rPAF-AH (1 mg/kg), rPAF-AH (5 mg/kg), and placebo, respectively (P = .59 for rPAF-AH 1 mg/kg vs placebo and P = .337 for rPAF-AH 5 mg/kg vs placebo). There was no statistically significant difference between the groups with regard to the severity of pancreatitis, frequency of amylase/lipase elevation more than 3 times normal, or abdominal pain.

CONCLUSIONS

There was no apparent benefit of rPAF-AH treatment compared with placebo in reducing the incidence of post-ERCP pancreatitis in subjects at increased risk.

Imaging assessment of acute pancreatitis: a review

Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.

Risk factors for ERCP-related complications: a prospective multicenter study

OBJECTIVES

To investigate the potential risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complications and to identify whether the risk factors are different for pancreatitis and asymptomatic hyperamylasemia.

METHODS

Consecutive ERCP procedures were studied at 14 centers in China from May 2006 to April 2007. The complications after the patients' first-only procedures were evaluated. Multivariate analysis based on the first-only procedures was used to identify the risk factors.

RESULTS

A total of 3,178 procedures were performed on 2,691 patients. Overall, complications developed in 213 (7.92%) patients, pancreatitis in 116 (4.31%), and asymptomatic hyperamylasemia in 396 (14.72%). In the multivariate analysis, female gender (adjusted odds ratios (ORs): 1.52, 95% confidence interval (CI): 1.14-2.02, P=0.004), periampullary diverticulum (OR: 2.02, 95% CI: 1.49-2.73, P<0.001), cannulation time >10 min (OR: 1.51, 95% CI: 1.08-2.10, P=0.016), > or =1 pancreatic deep wire pass (OR: 1.80, 95% CI: 1.33-2.42, P<0.001), and needle-knife precut (OR: 2.70, 95% CI: 1.42-5.14, P=0.002) were risk factors for overall complications. Female gender (OR: 1.84, 95% CI: 1.25-2.70, P=0.002), age < or =60 year (OR: 1.59, 95% CI: 1.06-2.39, P=0.025), cannulation time>10 min (OR: 1.76, 95% CI: 1.13-2.74, P=0.012), > or =1 pancreatic deep wire pass (OR: 2.77, 95% CI: 1.79-4.30, P<0.001), and needle-knife precut (OR: 4.34, 95% CI: 1.92-9.79, P<0.001) were risk factors for pancreatitis. Cannulation time>10 min (OR: 1.96, 95% CI: 1.52-2.54, P<0.001), > or =1 pancreatic deep wire pass (OR: 2.24, 95% CI: 1.74-2.89, P<0.001), needle-knife precut (OR: 2.34, 95% CI: 1.32-4.14, P=0.004), and major papilla pancreatic sphincterotomy (OR: 1.71, 95% CI: 1.23-2.37, P=0.001) were risk factors for asymptomatic hyperamylasemia.

CONCLUSIONS

Patient-related factors are as important as procedure-related factors in determining high-risk predictors for post-ERCP overall complications and pancreatitis. However, the risk factors for asymptomatic hyperamylasemia may be mostly procedure related.

Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report

Introduction

Endoscopic retrograde cholangiopancreaticography has been the treatment of choice for stones in the common bile duct. Although the procedure is usually safe, procedure-related complications do occur.

Case presentation

A case of pancreatitis following endoscopic retrograde cholangiopancreaticography is described in a 55-year-old woman. After an uneventful recovery the patient's condition deteriorated rapidly 16 days after the endoscopic retrograde cholangiopancreaticography, and the patient died within 1 hour. Post-mortem examination revealed massive intrapulmonary fat embolism. The complications of endoscopic retrograde cholangiopancreaticography and pancreatitis are described.

Conclusion

Fat embolism can occur after the remission of pancreatitis and pancreatic necrosis may be overlooked on contrast-enhanced computed tomography scanning.

ERCP as an outpatient treatment: a review

BACKGROUND

ERCP on an outpatient basis could be as safe as on an inpatient basis and may also reduce medical costs.

OBJECTIVE

To review the available literature to determine the safety of an ERCP performed on an outpatient basis.

DESIGN

A review of the published literature was performed by searching PubMed, the Cochrane Library, EMBASE, and the Web of Science.

PATIENTS

Patients who were undergoing an ERCP.

INTERVENTIONS

An ERCP on an inpatient or outpatient basis.

MAIN OUTCOME MEASUREMENTS

Patient and treatment characteristics, complications, and prolonged hospital admissions and readmissions.

RESULTS

Eleven studies were included in this review, of which 5 were comparative studies, 5 were prospective studies, and 1 was a retrospective study. In these series, a total of 2483 patients underwent an ERCP on an outpatient basis and 2320 patients were admitted overnight after an ERCP. Complications were seen in 184 of 2483 outpatients (7%), of which 72% of complications (107/149) presented within 2 to 6 hours, 10% (15/149) within 6 to 24 hours, and 18% (27/149) more than 24 hours after the ERCP. Three percent of the inpatients (82/2320) developed a complication, of which 95% of complications (78/82) presented within 24 hours and 5% (4/82) presented more than 24 hours after the ERCP. A prolonged hospital stay after an ERCP was indicated in 6% of the designated outpatients (148/2483), whereas 3% of outpatients (74/2149) and <1% of inpatients (4/2320) were readmitted after discharge.

LIMITATIONS

Limited data available.

CONCLUSIONS

This review shows that, with a selective policy, an ERCP on an outpatient basis seems as safe as when performed on an inpatient basis.

Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials

BACKGROUND

Early endoscopic retrograde cholangiopancreatography (ERCP) should be performed in all patients with acute biliary pancreatitis (ABP) and coexisting acute cholangitis. In patients without cholangitis and predicted mild ABP it is generally accepted that early ERCP should not be performed. Nevertheless, there is a controversy regarding the role of early ERCP in the treatment of patients with predicted severe ABP without cholangitis. We reviewed randomized trials on early ERCP versus conservative management in patients with ABP without acute cholangitis.

METHODS

Relevant publications in 3 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were systematically reviewed and meta-analyzed.

RESULTS

Seven randomized trials on ERCP in acute pancreatitis were found, of which 3 including a total of 450 patients (230 in the invasive arm and 220 in the control arm) qualified for a meta-analysis according to predefined criteria. In all patients with ABP (predicted mild and severe), early ERCP was associated with a nonsignificant reduction in overall complications [risk ratio (RR) 0.76; 95% confidence interval (CI) 0.41-1.04; P = 0.38] and a nonsignificant increase in mortality (RR 1.13; 95% CI 0.23-5.63; P = 0.88). Subgroup analysis based on predicted severity did not affect these outcomes (overall complications: predicted mild: RR 0.86; 95% CI 0.62-1.19; P = 0.36; predicted severe: RR 0.82; 95% CI 0.32-2.10; P = 0.68; mortality: predicted mild: RR 1.90; 95% CI 0.25-14.55; P = 0.53; predicted severe: RR 1.28; 95% CI 0.20-8.06; P = 0.80).

CONCLUSION

In this meta-analysis, early ERCP in patients with predicted mild and predicted severe ABP without acute cholangitis did not lead to a significant reduction in the risk of overall complications and mortality.