Cannulation Of Common Bile Duct Research Articles

Does the Time of Day have an Effect on the Success and Complications of ERCP?

Abstract: Background: In ERCP, if modifiable risk factors can be minimized, indirectly, the rates of complications will also decrease. Objective: In the present study, the aim is to investigate whether the timing of ERCP (morning versus afternoon) was associated with the success of cannulation and procedure-related complications in patients with bile duct stones undergoing ERCP. Materials and Methods: This is a retrospective study of patients who underwent ERCP for common bile duct (CBD) stones. We compared the complication rate and the success of CBD cannulation between procedures conducted in the morning and those carried out in the afternoon during ERCP. Result: A total of 402 patients were enrolled. The mean age of patients was 64.4 ± 19 years with a total bilirubin value of 7.5 ± 11.6 mg/dL, direct bilirubin value of 4.9 ± 8.6 mg/dL, and CBD of 11±2.4 mm. 201 (50%) of the patients underwent ERCP in the morning and 201 (50%) in the afternoon. The rates of post-ERCP pancreatitis, bleeding, and the success of cannulation were 5.5%, 10%, and 96.5% in the morning ERCP group and 5%, 13.4%, and 93% in the afternoon ERCP group, respectively. There were no statistically significant differences between groups in post-ERCP pancreatitis (p=0.606), bleeding (p=0.277), and the success of CBD cannulation (p=0.117). Conclusion: Between morning and afternoon ERCP procedures, no statistically significant difference was detected. Keywords: ERCP, Ampulla vateri cannulation, ERCP complication, Time-of-day, ERCP timing, Cholangitis, Choledocholithiasis.

S1257 Selective Common Bile Duct Cannulation Time During Endoscopic Retrograde Cholangiopancreatography: Effects of Dexamethasone

S1257 Selective Common Bile Duct Cannulation Time During Endoscopic Retrograde Cholangiopancreatography: Effects of Dexamethasone

Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusionPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Morfología de la papila de Vater como factor que influye en el éxito en canulación durante el entrenamiento del Residente en Endoscopia Avanzada. Estudio clínico prospectivo

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusiónPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

Retrospective Analysis of Characteristics, Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Tertiary Referral Center in Saudi Arabia.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia. Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database. Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Board-certified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563(96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22(3.1%) followed by post-sphincterotomy bleeding in 16(2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patienthad procedure-related mortalitysecondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in theinternational literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients.

Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures. All consecutive patients undergoing LERV for CCL between January2014 and December2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed. 181patients were included (61elective LERVs, 120emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35min, and LOS of 4.00 ± 2.82days. POC included 7Clavien-Dindo type 1, 11type2, and 3type3 cases. Seven patients presented with CBD stone recurrence: 2 within 30days after discharge, 3 within 6 months after discharge, and 2patients at 1year. No statistically significant difference was found between elective and emergency patients. LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.

I –GEL FOR ERCP UNDER DEEP SEDATION:OUR EXPERIENCE IN 100 PATIENTS AT TERTIARY CARE CENTER - AN RETROSPECTIVE STUDY

Background: Use of deep sedation for ERCP is increased due to safer anaesthesia drugs and equipments. Still there are high chances of desaturation,obstructed airway ,respiratory depression requiring skilled airway support with high chances of morbidity and mortality. So we designed a multivariate study for airway management in ERCPwith I –gel under deep sedation. Aim: Gastroenterologist's procedural comfort with respiratory instability leading to desaturation requiring intervention. Objectives: Success in terms of depth of sedation, hemodynamics and recovery time. Method:100 adults of either gender, age of 20 to 60 years, ASAgrade I, II or III, MPC I or II, weight 40-80 kg for elective ERCPlasting up to 90 min were included. Premedication with Inj Glycopyrollate 0.004mg/kg ,Inj Fentanyl 1µg/kg .Inj Propofol 1mg per kg over 3 to 5 min was given and maintenance with infusion 100 µg/kg/min was started after insertion of I gel in prone position. Parameters such as number of patients having desaturation, leading to intubation gastroenterologist's procedural comfort with regard to scope insertion & manipulation and common bile duct (CBD) cannulation were recorded. Also depth of sedation,hemodynamic stability and recovery time were recorded. SPSS 20.0 was used for statistical analysis.Only frequency and percentage were calculated. Results- 1% patient had desaturation who required intubation and GA . Gastroenterologist's comfort for scope insertion was extremely easy in 62%, scope manipulation was extremely easy in 84% patients and for CBD cannulation it was extremely easy in 84% patients. Scope insertion was challenging in 3% patients who needed general anaesthesia with intubation. Depth of sedation was adequate in 94% patients and in 6% patients inadequate. Recovery time was 10-15 min in 65%patients. Conclusion : Use of I –Gel for ERCP under deep sedation signicantly decreases incidences of desaturation and emergency intubation with satisfactory gastroenterologist's comfort

Success Rate of Wire Control-Assisted ERCP Sphincterotomy Versus Non-assisted ERCP Cannulation of Common Bile Duct in a Secondary Care Unit During the First COVID-19 Peak: A Retrospective Observational Study of 281 Patients

BackgroundThe British Society of Gastroenterology (BSG) recommended that during the COVID-19 pandemic, endoscopy units perform endoscopic retrograde cholangiopancreatography (ERCP) for obstructive biliary pathologies in an emergency. We assessed the local performance of ERCP during the first wave of COVID-19 at our local endoscopy center, in particular the technique to common bile duct (CBD) cannulation.MethodologyAll ERCP procedures performed from January to June 2020 were retrospectively assessed and compared with procedures performed between January and June 2019 at the Royal Lancaster Infirmary. The indications for ERCP, success rate, and complications were studied separately. Correlation analysis was conducted using Spearman's rank correlation coefficient. The binary logistic regression model was used to compute the factors associated with successful ERCP. Significance was established when the two-sided P-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 25 for Windows (SPSS Inc., Chicago, IL, USA, 2017).ResultsA total of 281 ERCP were included in this study, with 169 and 112 performed during the first six months of 2019 and 2020, respectively. A statistically significant (0.0087) higher proportion of cases with liver dysfunction presented for ERCP before the COVID-19 outbreak (152, 89.94%). All patients before COVID-19 underwent wire control-assisted ERCP, while 82 (73.21%) received assisted ERCP during the first wave (P < 0.001). There was no statistically significant difference (P = 0.10) in the number of patients who underwent sphincterotomy before and during the first wave of COVID-19, with 97 (57.39%) and 76 (67.85%), respectively. The success rate of ERCP before COVID-19 was relatively high, accounting for 146 (86.39%) patients in contrast to 87 (77.67%) patients during the first wave (P = 0.074). Sphincterotomy (β = 2.800, P = 0.028) and stent insertion (β = 0.852, P = 0.046) were statistically significant predictors of ERCP outcomes. There was no statistically significant impact of cholangitis on the success of ERCP (β = 1.672, P = 0.109).ConclusionThe first wave of COVID-19 had a statistically proven negative impact on the expected standards of ERCP performance. Although the complication rate was significantly higher during the first wave case difficulty, the American Society of Anesthesia (ASA) status was not assessed on an individual basis. Both ASA status and case difficulty are now included in our endoscopy selection process. We recommend adding the complexity of cases and ASA to the local and national recording databases. This is a rare study on UK-based hospitals.

Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience.

Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.

Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study.

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in the prone or supine position. We compared the technical success and other outcomes between these positions.MethodsThis was a retrospective cohort study using the Clinical Outcomes Research Initiative database. Demographics, procedure and fluoroscopy time, visualization of main structures, and technical success rates were compared between the supine and prone positions. Univariate and multivariate regressions were performed to adjust for age, sex, ethnicity and clinical setting.ResultsA total of 21,090 patients who underwent ERCP were included, of whom 1769 (8.4%) were supine and 19,321 (91.6%) were prone. The common bile duct (CBD) was visualized and cannulated in 89.1% of supine vs. 91.4% of prone positions (P=0.017), while the ampulla was visualized in 97.1% of supine vs. 97.7% of prone (P=0.414). The ERCP was incomplete in 10% of supine vs. 5% of prone cases (P<0.001). On multivariate analysis, supine position required shorter procedure times than prone (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.98-0.98; P<0.001). The supine position also yielded lower odds of CBD visualization and cannulation (aOR 0.63, 95%CI 0.44-0.91; P=0.011) and higher odds of an incomplete examination (aOR 1.84, 95%CI 1.46-2.30; P<0.001) vs. prone.ConclusionsThe supine position leads to shorter procedures but is more likely to result in poorer visualization and cannulation of the CBD and an incomplete examination. This may reflect the technical difficulty of performing ERCP in the supine position for the endoscopist. Our study supports recommendations for an individualized ERCP approach.

Impact of COVID-19 pandemic on key performance indicators in pancreatobiliary endoscopy: prioritise, minimise risk, keep scoping and training

BackgroundThe COVID-19 pandemic has profoundly affected endoscopy services including pancreatobiliary (PB) endoscopy across the UK. The British Society of Gastroenterology and Joint Advisory Group have issued guidance for managing endoscopy...

S2379 A Unique Approach in Selective Guidewire Cannulation of a Complex Malignant Biliary Stricture

INTRODUCTION: Digital single-operator cholangioscopy (D-SOC), such as Spyglass DS, represents newer technology that can improve the diagnostic and therapeutic capabilities of ERCP. In the case below, we present how the use of Spyglass aided in the decompression of a complex malignant biliary stricture. CASE DESCRIPTION/METHODS: 52 year old male presented with epigastric pain, and obstructive jaundice. Patient has known portal vein thrombosis, and metastatic adenocarcinoma to the liver and lungs. The primary is suspected to be of upper GI or pancreatobiliary origin.CBC, PT INR, and BMP were within normal limits. T Bili is 17 mg/dL, D Bili 12.5 mg/dL, Alk Phos 1441 units/L, AST 300 units/L, ALT 251 units/L, AFP 11.5 ng/mL, CEA 249.8 ng/mL, and CA 19–9 113,888 units/mL. MRCP: Abrupt cut off of the distal common hepatic duct with intrahepatic bile duct dilatation.ERCP found 2 high grade biliary strictures. Conventional guidewire cannulation of the strictures were unsuccessful.A second ERCP was performed with the aid of Spyglass DS. Under direct visualization from Spyglass and fluoroscopy, guidewire cannulation of the high-grade common bile duct and hepatic duct strictures were achieved. A fully covered 10 Fr x 80mm metal stent was advanced over the guidewire and deployed across both strictures. Then, the waist of the stent was balloon dilated to 6 mm. Biliary drainage was confirmed upon scope retraction. Patients bilirubin downtrended and he was discharged with oncology follow up. DISCUSSION: The incidence of malignancy related biliary obstruction is increasing. The majority of these patients will benefit from biliary decompression in order to improve quality of life. Given the complications associated with percutaneous transhepatic biliary drains and stenting of biliary strictures, therapeutic ERCP is the favored approach. However, even the most experienced endoscopists fail to cannulate malignant strictures 5-10% of the time with conventional ERCP. Based on our experience, the utility of Spyglass DS might be of benefit when managing difficult malignant biliary strictures. Upon our literature review, the use of D-SOC guided cannulation of these strictures were found in only 11 patients, with 64% having cholangiocarcinoma. With the aid of D-SOC, the success rate of cannulation was 46%. Given limited literature, more research for this procedural indication should be considered as D-SOC could be a viable approach in improving the effectiveness of endoscopic management of these complex malignant strictures.

Su1441 PRIMARY NEEDLE KNIFE SPHINCTEROTOMY FOR BILIARY ACCESS IN SELECTED PATIENTS WITH HIGH RISK FOR POST-ERCP PANCREATITIS: A PROSPECTIVE PRELIMINARY FEASIBILITY STUDY

Needle knife fistulotomy may be useful as the first line of procedure for biliary access to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) based on recent clinical data. We aimed to evaluate the safety, effectiveness, and feasibility of primary needle knife sphincterotomy (NKS) for biliary cannulation in patients with a high risk of PEP. A total of 40 patients who need ERCP using primary NKS for biliary disease in our institution between June 2018 and November 2019 were prospectively enrolled in this study. The procedures were conducted by two expert biliary endoscopists (S.J. and J.S.P.) who had experience of ERCPs. They had one or more of the following risk factors of PEP; young age (<50 years), female gender, normal common bile duct (CBD) diameter (≤9 mm), normal serum total bilirubin level (0.2-1.2 mg/dL), obesity (body mass index: >30), or history of pancreatitis. The success rate of biliary cannulation, time to biliary cannulation, and the occurrence rate of PEP, as well as other post-ERCP complications, were assessed. Of 40 patients enrolled, 34 patients underwent primary NKS. Nine patients had 1 risk factor of PEP, seven had 2, eight had 3, seven had 4, and three had 5. The success rate of CBD cannulation using NKS was 94.1% (32/34). The median time for biliary cannulation was 243 seconds (range, 32-1,514 seconds). None of the patients experienced post-ERCP pancreatitis, cholangitis, and perforation. One case of minor bleeding (2.9%, 1/34) and 1 asymptomatic hyperamylasemia (2.9%, 1/34) occurred. Primary NKS might be safe, effective and feasible for biliary access in patients with high risk for PEP if the procedure is performed by expert hands.

Endoscopic Extraction of CBD Stone: single centre experience in tertiary care centre

Background and Aims: Introduction: Endoscopic Retrograde Cholangiopancreatography(ERCP) has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to presence of a large stone, multiple stones, periampullary diverticula or CBD stricture. The aim of this study was to evaluate the success of CBD cannulation, Endoscopic Sphincterotomy(EST) and CBD clearance in initial attempt, identify the failures of stone extraction and assess the post-ERCP complications.&#x0D; Methods: A prospective study was carried out over the period of January 2019 to January 2020 on 100 consecutive patients with CBD stones. ERCP was done and the stone size and number recorded. EST was performed using a diathermy unit with a cutting current and stones were extracted using a Balloon catheter or a Dormia basket.&#x0D; Results: Of the 100 patients, 44 were male and 56 were female with mean age of 52}17years. Selective CBD cannulation and cholangiogram was achieved in 90%, EST was successful in 90% and complete stone clearance was achieved in first attempt in 46 patients (59%). 52 patients had difficult CBD stone. There were nine complications, most of which rapidly resolved on conservative treatment (four post-ERCP pancreatitis, three bleeding and one retroperitoneal perforation) and one mortality in an old lady due to PSVT that couldn’t be directly attributed to ERCP. Among patients with Stone less than 15 mm in diameter(n=58), stone was removed successfully in 45 patients(78%) whereas in patients with stones over 15 mm (n=20) only one was removed successfully (5%) at initial attempt. Of these 32 patients with residual stones, 13 were referred for surgery and 19 had insertion of biliary stent to be followed by repeat ERCP.&#x0D; Conclusion: Endoscopic therapy is a simple, effective and safe method of treatment in patients with CBD stone.

Can Early 'Shallow' Needle-knife Papillotomy be the First Choice in ERCP?

Needle-knife sphincterotomy, known as 'precut' is recommended as the second option in the case of difficult cannulation due to its potential higher complication (bleeding and perforation) rates. The aim of this study was to present our experience on early shallow needle-knife papillotomy (eSNKP) as the first-line choice independently of standard technique with or without difficult cannulation. A total of 70 patients underwent therapeutic endoscopic retrograde cholangiopancreatography. A standard eSNKP and guidewire cannulation technique was routinely preferred as a first-line intervention. Deep biliary cannulation rate and timing were recorded, as well as intraoperative and postoperative complication rates. Successful deep biliary cannulation was performed in 66 (94.3%) patients during the first procedure. In 4 patients (5.7%), the procedure was terminated due to failed cannulation and repeated successfully after 72 hours. Minor complications were observed in 3 (4.3%) patients. No mortality was seen. eSNKP is a safe, time-saving, and effective technique as the first-line of endoscopic retrograde cholangiopancreatography for common bile duct cannulation.

Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale

BackgroundTranspancreatic biliary sphincterotomy (TPBS) is an advanced cannulation method for accessing common bile duct (CBD) in endoscopic retrograde cholangiopancreatography (ERCP). If CBD cannulation is difficult, an endoscopist can open the septum between the pancreatic and biliary duct with a sphincterotome to gain access. Long-term results of this procedure are unclear. We wanted to evaluate the short- and long-term complications of TPBS on patients with native papilla and benign indication for ERCP.Patients and MethodsERCPs performed in Helsinki University Hospital between 2007 and 2013 were reviewed. The study group comprised 143 consecutive patients with TPBS and 140 controls (CG). Data were collected from patient records and a phone survey was performed as a follow-up ≥ 4 years after the index ERCP.ResultsPost-ERCP pancreatitis (PEP) developed in seven patients (4.9%) in TPBS and one patient (0.7%) in CG (p = 0.067). The rates of other acute complications were similar between the groups. ERCP ended with no access to CBD in four cases (2.8%) in TPBS. The median length of follow-up was 6 years in TPBS and 7 years in CG. During this period, three patients (2.1%) in TPBS and six patients (4.3%) in CG suffered from acute pancreatitis (AP) (p = 0.238). One (0.7%) patient in CG and none in TPBS developed chronic pancreatitis (CP). Abdominal pain was suffered by ten patients (6.9%) in TPBS and twelve patients (8.6%) in CG daily, whereas by six patients (4.2%) in TPBS and twelve patients (8.6%) in CG weekly.ConclusionTPBS is a useful procedure, with acceptable complication rates. No significant difference occurred between the groups when evaluating the short-term or long-term complications with a follow-up period of four to 10 years. Additionally, no significant differences occurred in upper abdominal pain, episodes of AP, or development of CP.

The best plastic pancreatic stent to prevent post-ERCP pancreatitis.

We consider very interesting the comments made by Serrano Díaz et al. on pancreatic stents inserted as prophylaxis for acute post-ERCP pancreatitis. As we recently stated in an editorial related to the prevention of this frequent complication, the aggressive way in which the pancreatic gland may respond to contact with the devices that are used for common bile duct cannulation via the papilla of Vater is almost philosophically surprising. It is our opinion that, usually, a pancreatic stent should only be inserted if the guidewire has spontaneously entered the main pancreatic duct (MPD). In ERCPs aiming at bile duct drainage, even when bile duct cannulation has been troublesome with extensive papillary manipulation, attempting cannulation of the MPD with the sole purpose of stent insertion can be more harmful than beneficial.

OUTCOME OF ERCP (ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY) IN MILITARY HOSPITAL RAWALPINDI.

To describe the indications, endoscopic findings and complications of Endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary care hospital. Study Design: Retrospective analysis of data collected from all patients underwent ERCP in the year 2015. Setting: Gastroenterology department, Military Hospital Rawalpindi. Period: From 1st January 2015 to 31ST December 2015. Materials and Methods: The main outcomes were technical success, safety and complications. Results: Total 469 patients underwent ERCP inmilitary hospital Rawalpindi in year 2015. Common bile duct (CBD) cannulation was achieved in 437 (93.1%) patients. CBD stones were found in 182 (38%) and CBD stricture in 79 (16.8%). Sphincteroplasty was needed for extraction of large stones in 13 (2.7%) cases. CBD stricture with co-existing stones above was seen in 25 cases (5.3%). Large stones not amenable to endoscopic extraction were seen in 24 cases (5.1%). Total 25 cases of ampullary growth (5.3%) and 15 cases (3.1%) of CBD leak post cholecystectomy were noted. 6 cases (1.27%) were identified as choledochal cyst with CBD Stones. PD stones with dilated PD identified in 5 cases (1.06%) and post-cholecystectomy CBD clipped in 3 cases (0.63%). 3 cases of displaced PD stent ended up in successful retrieval. 21 cases developed acute pancreatitis (4.4%) out of which 3 were found to have severe pancreatitis having fluid collections. 3 cases (0.6%)had retroperitoneal perforation (2 were managed conservatively and 1 through surgery). 4 cases (0.8%)had significant post procedure bleed requiring re-scope with adrenal injection at bleeding site, and hemostasis achieved. Conclusions: ERCP in Combined Military Hospital Rawalpindi hospital was associated with a high degree of technical success and a low risk of complications.