Biliary ERCP Research Articles

Prognostic Factors for Severe-to-Fatal Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Prospective Cohort Study.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.

III BRAZILIAN CONSENSUS STATEMENT ON ENDOSCOPIC ULTRASOUND.

•Since its inception in the 1980s, endoscopic ultrasound has increased relevance and usefulness in clinical practice. •Endoscopic ultrasound has evolved from solely diagnostic imaging to a valuable method for tissue sampling and therapeutic procedures, such as drainage of pancreatic fluid collections and creating gastrointestinal anastomoses under EUS guidance. •Given the rapid advancements in EUS and new devices, an update to the last Consensus must include recent developments. •Experts evaluated and discussed the best evidence on EUS-guided procedures and devices for tissue sampling, pancreatic and liver disease management, and biliary drainage. In the past decades, endoscopic ultrasound has developed from a diagnostic tool to a platform for many therapeutic interventions. Various technological advancements have emerged since the last Brazilian Consensus, demanding a review and update of the recommendations based on the best scientific evidence. A group of 32 renowned echoendoscopists selected eight relevant topics to be discussed to generate clinical questions. After that, a literature review was conducted to answer these questions based on the most updated evidence. Thirty-three statements were formulated and voted on by the experts to reach a consensus. The Oxford System was used to grade the level of evidence. There is mo-derate evidence to support that the needle shape, gauge, or aspiration technique does not influence the yield of endoscopic ultrasound (EUS)-guided tissue sampling of pancreatic solid lesions. There is moderate evidence to support using EUS-TTNB of the cyst wall to differentiate between mucinous and non-mucinous cystic neoplasms. There is little evidence to support the EUS-guided treatment of gastric varices. There is a high level of evidence to support that EUS-guided biliary drainage and ERCP present similar outcomes in patients with distal malignant biliary obstruction. There is a high level of evidence for using EUS to diagnose neoplastic pancreatic cysts and detect necrosis before indicating drainage. There is moderate evidence to support EUS-GE over duodenal stent for malignant gastric outlet obstruction in patients with a life expectancy higher than 2 months. There is a high level of evidence to support the use of RFA in treating both functioning and non-functioning types of NET.

Subtotal Cholecystectomy Results in High Peri-operative Morbidity and Its Risk-Profile Should be Emphasised During Consent

BackgroundSubtotal cholecystectomy aims to reduce the likelihood of bile duct injury but risks a multitude of less severe, yet significant complications. The primary aim of the present study was to report peri-operative outcomes of subtotal laparoscopic cholecystectomy (SLC) relative to total laparoscopic cholecystectomy (TLC) to inform the consent process.MethodAll laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. The peri-operative outcomes of SLC (n = 87) and TLC (n = 2650) were reported. Pre-operative variables were compared between the two groups to identify risk factors for SLC. The outcomes between the SLC and TLC were compared using univariate, multivariate and propensity analysis.ResultsRisk factors for SLC included higher age, male gender, cholecystitis, increased biliary admissions, ERCP, cholecystostomy and emergency cholecystectomy. Following SLC, rates of post-operative complication (45.9%), imaging (37.9%) intervention (28.7%) and readmission (29.9%) were significant. The risk profile was vastly heightened compared to that of TLC: intra-operative complications (RR 9.0; p < 0.001), post-operative complications [bile leak (RR 58.9; p < 0.001), collection (RR 12.2; p < 0.001), retained stones (RR 7.2; p < 0.001) and pneumonia (RR 5.4; p < 0.001)], post-operative imaging (RR 4.4; p < 0.001), post-operative intervention (RR 12.3; p < 0.001), prolonged PLOS (RR 11.3; p < 0.001) and readmission (RR 4.5; p < 0.001). The findings were consistent using multivariate logistic regression and propensity analysis.ConclusionThe relative morbidity associated with SLC is significant and high-risk patients should be counselled for the peri-operative morbidity of subtotal cholecystectomy.

ID: 3520660 RISK FACTORS AND PREVENTIVE MEASURES FOR POST-ERCP PANCREATITIS IN BILIARY ERCP: A MULTICENTER PROSPECTIVE COHORT STUDY IN JAPAN

Background and Aims: The development of post-ERCP pancreatitis (PEP) is one of the most serious ERCP-related complications. The reported incidence of PEP varies between 1.6% and 15% due to differences in clinical settings, definitions and study design. Because ERCP procedures for patients with prior sphincterotomy are easy to access bile duct and low risk, patients with intact papilla are important population. Pancreatic ERCP and biliary ERCP are different in significance of pancreatic procedures such as pancreatic contrast injection and pancreatic stenting; therefore we think that they should be discussed separately. The aim of this study was to identify the risk factors and preventive measures for PEP associated with biliary ERCP in patients with intact papilla.

EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review.

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP for distal biliary obstruction in expert hands. Various routes for EUS-guided access in distal biliary obstruction include EUS choledochoduodenostomy, EUS-guided rendezvous, and EUS-antegrade (EUS-AG) stent placement. While percutaneous transhepatic biliary drainage and ERCP are established modalities in management of malignant hilar biliary obstruction, the role of EUS-BD is emerging. Various methods of drainage in hilar obstruction include EUS hepaticogastrostomy, EUS hepaticoduodenostomy, EUS-guided bridging stent placement, and combined ERCP and EUS-guided biliary drainage. In this review, we discuss the role of EUS-BD in malignant hilar biliary obstruction with the currently available evidence, along with the limitations and challenges to the use of this modality in management of these patients.

Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: A systematic review and meta-analysis

EUS-guided biliary drainage (EUS-BD) has been used as a salvage modality for relief of malignant biliary obstruction (MBO) after a failed ERCP. Multiple recent randomized controlled trials (RCTs) and observational studies have been published to assess the suitability of EUS-BD as a first-line modality for achieving palliative BD. We aimed to perform a systematic review and meta-analysis comparing primary EUS-BD versus ERCP for MBO. We searched PubMed, Medline, and Embase up to January 1, 2019, to identify RCTs and observational studies evaluating the efficacy and safety of primary EUS-BD (without a prior attempted ERCP) versus ERCP. Quality of RCTs and observational studies was assessed using Jadad and Newcastle–Ottawa scores, respectively. The outcomes of interest were technical success, clinical success, odds of requiring a repeat intervention, and procedure-related adverse events. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. Meta-analysis was performed using the random effects model in RevMan 5.3 (the Cochrane Collaboration, the Nordic Cochrane Centre, Copenhagen, Denmark). Five studies (three RCTs and two observational studies) with 361 patients were included. Both procedures achieved comparable technical success (OR: 1.20 [0.44–3.24], I2 = 0%) and clinical success (OR: 1.44, confidence interval [CI]: 0.63–3.29, I2 = 0%). The overall adverse outcomes (OR: 1.59 [0.89–2.84]) did not differ between the two groups. In the ERCP group, 9.5% of patients developed procedure-related pancreatitis versus zero in the EUS group (risk difference = 0.08%, P = 0.02). There was no statistically significant difference in nonpancreatitis-related adverse events. The odds of requiring reintervention for BD (1.68 [0.76–3.73], I2 = 42%) did not differ significantly. The ERCP group had significantly higher odds of requiring reintervention due to tumor overgrowth (5.35 [1.64–17.50], I2 = 0%). EUS-BD has comparable technical and clinical success to ERCP and can potentially be used as a first-line palliative modality for MBO where expertise is available. ERCP-related pancreatitis which can cause significant morbidity can be completely avoided with EUS.

Early Laparoscopic Cholecystectomy After Acute Biliary Pancreatitis and ERCP Single Center Results

Early Laparoscopic Cholecystectomy After Acute Biliary Pancreatitis and ERCP Single Center Results

EUS Biliary Drainage vs. ERCP

EUS Biliary Drainage vs. ERCP

IgG4-Related Cholangiopathy and Its Mimickers: A Current Review and Report Highlighting the Importance of Early Diagnosis

Immunoglobulin (Ig) G4 (IgG4) related disease is a recently described clinical entity that can involve multiple organs. It is an autoimmune disorder characterized by a dense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis. A key distinguishing factor is its dramatic response to steroid therapy. It is crucial to differentiate IgG4-related cholangiopathy from its mimickers such as primary biliary cholangitis (PBC), secondary biliary cholangitis (SBC), primary sclerosing cholangitis (PSC), secondary sclerosing cholangitis (SSC) and cholangiocarcinoma, as treatment modalities and outcomes of IgG4-related cholangiopathy differ significantly from these disorders. A 72 year-old man presented as a transfer with obstructive jaundice and was found to have elevated total bilirubin (5 mg/dL), alkaline phosphatase (315 mg/dL) and liver enzymes (AST of 77 mg/dL and ALT of 45 mg/dL). MRI of the abdomen revealed contrast filling the biliary tree and ERCP showed a stricture extending from the bifurcation of the hepatic duct into the right hepatic duct. He also had sausage-like strictures of the intra hepatic ducts, which were concerning for cholangiocarcinoma. Percutaneous transhepatic cholangiogram revealed a hepatic duct bifurcation stricture that involved the right intra hepatic duct. The differential diagnosis included cholangiocarcinoma, primary biliary cholangitis (PBC), secondary biliary cholangitis (SBC), PSC, inflammatory myofibroblastic tumor, and IgG4-related cholangiopathy. Due to concerns for hilar cholangiocarcinoma by cholangiography, the patient underwent right hepatectomy and left hepaticojejunostomy. Shown are gross images of the right lobe of the liver (Figures 1A and 1B), with an arrow indicating the intra-hepatic bile duct and arrowhead indicating the hilar mass (Figure 1B). On microscopy, there was periductal fibrosis (arrow), edema (arrowhead) and a rich lymphoplasmacytic inflammatory infiltrate (black arrow) (Figure 1C). A portal vein was found to be obscured by inflammatory cells (Figure 1D). There were areas of inflammatory cell encroachment upon portal veins. Obliterative phlebitis, or occlusion of portal veins by inflammatory cell infiltrates were evident. There was storiform fibrosis with notable eosinophils. This particular case demonstrated bile duct involvement and morphologically greater than 40% of plasma cell infiltrates were positive for IgG4. The patient subsuquently improved with oral steroid therapy.FigureTable: Table. Potential treatment regimens for IgG4-related disease

Mo1503 International Multicenter Comparative Trial of EUS-Guided Biliary Drainage vs. Enteroscopy-Assisted ERCP in Patients With Surgical Anatomy and Biliary Obstruction

Mo1503 International Multicenter Comparative Trial of EUS-Guided Biliary Drainage vs. Enteroscopy-Assisted ERCP in Patients With Surgical Anatomy and Biliary Obstruction

Risk factors for post-ERCP pancreatitis in wire-guided cannulation for therapeutic biliary ERCP

Wire-guided cannulation (WGC) was reported to decrease post-ERCP pancreatitis (PEP), but risk factors for PEP in WGC are not fully elucidated. To evaluate the incidence and risk factors of PEP in WGC. Single-center retrospective study. Academic center. A total of 800 consecutive patients with a native papilla. Biliary therapeutic ERCP by using WGC. The rate of PEP and its risk factors. Biliary cannulation was successful by using WGC alone in 70.5%, and the final cannulation rate was 96.1%. Unintentional guidewire insertion and contrast material injection into the pancreatic duct (PD) during cannulation occurred in 55.3% and 21.8%, respectively. The incidence of PEP was 9.5% (mild 5.6%, moderate 2.9%, severe 1.0%). Multivariate analysis revealed a common bile duct (CBD) diameter of<9mm (odds ratio [OR] 2.03; P= .006) and unintentional guidewire insertion into the PD (OR 2.25; P= .014) as risk factors for PEP. PD opacification was not a risk factor for PEP (OR 1.15; P= .642), but the incremental increase of the PEP rate was seen in patients with CBDs<9mm: 4.6% without any PD manipulation, 8.3% with contrast material alone, 16.9% with guidewire alone, and 22.1% with both contrast material and guidewire. Retrospective design in a single center. Unintentional PD manipulation was not uncommon in WGC. Guidewire insertion into the PD and a small CBD were risk factors for PEP in biliary therapeutic ERCP with the use of WGC.

A novel second-generation multibending backward-oblique viewing duodenoscope in ERCP

Introduction: Successful access to the papilla and cannulation of the desired duct can be technically challenging. A novel second-generation multi-bending backward-oblique viewing duodenoscope (2nd M-D scope) was developed to overcome this difficulty. The aim of the present study was to evaluate the utility of 2nd M-D scope during biliary ERCP. Material and methods: This was a retrospective review of 53 patients with native papilla who underwent biliary ERCP with the 2nd M-D scope. Results: Biliary cannulation and interventional procedures were successfully completed in all patients. In two of these patients, ERCP was initially attempted with a conventional single bending duodenoscope, but biliary cannulation was unsuccessful; one had Billroth-I gastrectomy, and the other had a Type III choledochal cyst. However, with the 2nd M-D scope, biliary cannulation and interventional procedures were successfully achieved. Finally, in nine patients, upward or downward angulation of the proximal bending portion in addition to the distal bending portion was used during ERCP, and the operator’s comments demonstrated that it was helpful for obtaining an appropriate en face view to look up to the papilla and facilitate successful biliary cannulation. Conclusion: The newly developed 2nd M-D scope could safely facilitate biliary cannulation in selected patients during ERCP.

Early precut fistulotomy for biliary access: time to change the paradigm of “the later, the better”?

The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). Single-center, prospective cohort study. University-affiliated hospital. A total of 350 patients with a naïve papilla. Standard biliary cannulation followed by needle-knife fistulotomy (NKF). Biliary cannulation rate, NKF success, adverse events, and ERCP duration. The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P< .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P< .0001). Single-center study design, referral center. If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.

Su1682 Risk Factors for Post-ERCP Pancreatitis in Therapeutic Biliary ERCP Using Wire-guided Cannulation

Wire-guided cannulation (WGC) reportedly improves biliary cannulation and decreases post-ERCP pancreatitis (PEP) by preventing contrast injection to the pancreatic duct (PD). However, little is known whether unintentional guidewire (GW) insertion into PD increases PEP or not. The aim of the study is to evaluate risk factors for PEP in therapeutic ERCP using WGC.

Mo1361 EUS-Guided Interventions Decrease the Rate of Therapeutic Biliary ERCP Failures: Comparison of ERCP Outcomes At Centers With and Without Interventional EUS

Mo1361 EUS-Guided Interventions Decrease the Rate of Therapeutic Biliary ERCP Failures: Comparison of ERCP Outcomes At Centers With and Without Interventional EUS

Ultrasound quiz 2.

A 40-year-old patient, complaining of the right epigastrium pain related to eating, came to have a consultative US examination performed. According to the patient, the discomfort was similar to the one she had experienced before the laparoscopic cholecystectomy performed 5 years before. Three months before because of this reason the patient had been hospitalized in the internal medicine ward of one of the local hospitals where, in spite of performing endoscopic examination of the upper digestive tract, abdominal cavity ultrasound examination and a full set of biochemical blood tests, the reason of the complaint was not explained. After returning home the pain attacks recurred. Despaired general practitioner performed another ultrasound examination by himself and diagnosed two concrements in the common bile duct (CBD). As a result the patient had endoscopic retrograde cholangio-wirsungography performed in the voievodal center. There were no complications after the examination and the result was: biliary duct ERCP revision negative. In the abdominal cavity ultrasound examination performed by myself the area of porta hepatis looked as in fig. 1 (two projections). It shows: concrements in the CBD; concrements in the residual gallbladder; concrements in the peritoneal cavity which fell out during cholecystectomy; metal clips placed during cholecystectomy; phleboliths in hepatoduodenal ligament? Fig. 1

448 A Prospective Randomized Multicenter Trial Comparing Early Precut and Standard Approach for Cannulating the Common Bile Duct: An Interim Analysis

Precut technique is a validated risk factor for post-ERCP pancreatitis (PEP). However, it is unclear if the risk is associated with technique or with difficult papillary cannulation that anticipates precut. The aim of this study was to evaluate the success and complication rates of early precutting and standard cannulation to access to the common bile duct. Material and methods: Over a 7-month period (January-July 2011) in 6 Italian centers patients referred for therapeutic biliary ERCP were considered for inclusion in the study.

A pilot study of the novel offset-tip papillotome for selective biliary cannulation in ERCP

Introduction:We developed a new offset-tip papillotome to facilitate biliary cannulation and reduce the incidence of unintended contrast injection into the pancreatic duct during ERCP. The aim of the present retrospective cohort study was to evaluate the utility of the novel offset-tip papillotome in achievement of biliary cannulation, and prevention of unintended contrast injection into the pancreatic duct during ERCP, compared with a standard straight-tip catheter. Material and methods:Patients with native papilla who required biliary ERCP were retrospectively reviewed. Biliary ERCPs were performed by two experienced endoscopists using either the offset-tip papillotome or a standard catheter. Patients in whom ERCP involved fellows in training were excluded. Results:Eighty-five patients were included and divided into two cohorts: The offset-tip papillotome (OT; n = 40) and the standard straight-tip cohort (ST; n = 45). Biliary cannulation success rates in OT and ST cohort were 92.5% and 88.9%, respectively. The frequency of unintended contrast injection into the pancreatic duct and time to biliary cannulation of the OT cohort during biliary cannulation were significantly less than those of the ST cohort (0.56 vs. 1.65 times and 103.3 vs. 287.9 seconds). Conclusion:The novel offset-tip papillotome could reduce the incidence of unintended contrast injection into the pancreatic duct and the time to biliary cannulation.

Impact of introduction of wire‐guided cannulation in therapeutic biliary endoscopic retrograde cholangiopancreatography

Wire-guided cannulation (WGC) might increase the biliary cannulation rate and decrease the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We assessed the learning curve for WGC in therapeutic biliary ERCP (study 1) and compared WGC and conventional contrast-assisted cannulation (CC) by a matched case-control study (study 2). Prospectively collected data of 500 therapeutic biliary ERCP cases (250 consecutive cases of WGC and 250 matched controls of CC) were retrospectively studied. Rate and time of biliary cannulation, total procedure time, PEP, and hyperamylasemia were analyzed. In study 1, biliary cannulation by WGC was successful in 96% of the first 50 cases, with a median time to cannulation of 3 min. Rates of hyperamylasemia were within 10% after 100 WGC. In study 2, there were no significant differences in the overall cannulation rate and PEP between WGC and CC, but the total procedure time was shorter in WGC (30 vs 35 min, P = 0.059). Rates of hyperamylasemia and the change in serum amylase levels was lower (9% vs 14%, P = 0.069, and + 62.8 U/L vs+ 169.5 U/L, P = 0.043) in WGC, which was more prominent in experienced endoscopists (9% vs 17%, P = 0.025, and + 68.9 U/L vs+ 229.3 U/L, P = 0.014). The introduction of WGC was effective in the first 50 cases and did not increase the rate of PEP in biliary therapeutic ERCP.

Female gender and post-ERCP pancreatitis: Is the association caused by difficult cannulation?

Objective. Female gender is a well-known risk factor for the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the underlying mechanism for this increased risk has remained unknown. We hypothesize that cannulation difficulty might play a part in this association. The aim of the current study was to determine whether the female papilla is more difficult to cannulate than the male papilla. Material and methods. Prospective data collection with emphasis on cannulation was conducted in 364 consecutive biliary ERCP procedures performed by very experienced ERCP endoscopists through native papilla in a tertiary referral university hospital. Results. Although the cannulation times seemed to be longer and alternative cannulation techniques seemed to be needed more frequently for successful cannulation in female than male patients, no statistically significant differences (p = 0.061 and 0.054, respectively) in the cannulation process could be found between the genders. Conclusions. The study was not able to confirm that the cannulation of the female papilla is more troublesome than the cannulation of the male papilla.