Acute distal common bile duct angle is risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis in beginner endoscopist

Relationship of difficult endoscopic retrograde cholangiopancreatography cannulation and visual characteristics of papilla

Background and Aim

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used to diagnose and treat bile duct and pancreatic disorders. Successful cannulation of the papilla is crucial for the effectiveness of ERCP; however, sometimes, it can be challenging to achieve. This study explores the relationship between net difficult ERCP cannulation with bile visibility, papilla orifice visibility, and papilla position and compares it with successful cannulation.

Methods

These data were collected from the ERCP database at the Center for Liver Disease, Holy Family Hospital, Rawalpindi, between November 2019 and November 2022. IBM SPSS version 26.0 software was used for statistical analysis.

Results

The study included 329 patients, with 186 (56.6%) female and 143 (43.5%) male participants. Most patients were in the 39-48 age group (28.3%), with a mean age of 51 ± 1. Bile visibility was noted in 268 (81.5%) cases, papilla orifice visibility in 296 (90%) participants, atypical papilla in 20 (6.1%), and typical papilla in 309 (93.9%) participants. Bile visibility (P = 0.004) and papilla orifice visibility (P = 0.006) were significantly associated with successful cannulation, while papilla position (P = 0.116) was not. Significant associations were also found between difficult cannulation and bile visibility (P = 0.000), papilla orifice visibility (P = 0.000), and papilla position (P = 0.000).

Conclusion

Understanding this relationship can improve success rates and reduce complications associated with difficult cannulation during ERCP procedures. Further research is needed to establish clear correlations and guidelines for endoscopists to plan appropriate strategies for challenging cases.

Impact of center and endoscopist ERCP volume on ERCP outcomes: a systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes.

METHODS

We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I2 = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I2 = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I2 = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I2 = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I2 = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I2 = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates.

CONCLUSIONS

HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

BACKGROUND

At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.

AIM

To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.

METHODS

Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard" (short position) or "non-standard" (e.g., long, semi-long).

RESULTS

Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 (P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) (P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) (P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques (P < 0.03 for each).

CONCLUSION

Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.