Safety and Efficacy of ERCP in Patients With Periampullary Diverticulum at a General Hospital in Singapore

Abstract

Introduction: It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) in the presence of a periampullary diverticulum (PAD) may be associated with more difficulty, morbidity and complications. The safety and efficacy of ERCP in the setting of a periampullary diverticulum in Singapore is not known. The aim of the study is to investigate and compare the success rate, procedure difficulty (ERCP grade, cannulation difficulty, procedure time) and complication rate between patients with and without PAD undergoing ERCP at a single center in Singapore. Methods: This is a retrospective, single center cross-sectional study. A total of 548 ERCP procedures were performed at our endoscopy center from January 2015 to December 2016. Patients with previous ERCP intervention (i.e., sphincterotomy, stent insertion) or an abandoned procedure were excluded. Clinical and endoscopic data were collected from the electronic medical record. A total of 357 procedures in 351 patients were included in the analysis. Results: Of 357 procedures, 116 (32.5%) were found to have PAD. The ampulla was located within the diverticulum in 10 (8.9%), on the edge of the diverticulum in 44 (38.9%), and near the diverticulum in 59 (52.2%) cases. Patients with PAD were significantly older (69 vs. 60 years, p<0.001) and more likely to undergo ERCP for choledocholithiasis as the procedure indication (93.9% vs 83.8%, p<0.007). There was no statistically significant difference in the success and complication rates between the two patient groups. On multivariate logistic regression analysis, younger age was associated with higher cannulation success (p=0.023); older age and indication other than choledocholithiasis were associated with higher cannulation difficulty (p=0.01 and p=0.04 respectively). Patients with PAD were 3.3 times more likely to have common bile duct stones compared to patients without PAD (p=0.006). Conclusion: At a single ERCP center in Singapore, the frequency of PAD in patients undergoing ERCP is 33%. Choledocholithiasis is more prevalent in the PAD group of patients undergoing ERCP. Success and safety of ERCP in patients with and without PAD is comparable. In patients with PAD, older age and procedure indication other than choledocholithiasis are associated with higher ERCP difficulty.