Cannulation Rate Research Articles

Low-grade Cortisol Cosecretion Has Limited Impact on ACTH-stimulated AVS Parameters in Primary Aldosteronism

In primary aldosteronism, cosecretion of cortisol may alter cortisol-derived adrenal venous sampling indices. To identify whether cortisol cosecretion in primary aldosteronism alters adrenal venous sampling parameters and interpretation. Retrospective case-control study. A tertiary referral center. 144 adult patients with primary aldosteronism who had undergone both adrenocorticotropic hormone-stimulated adrenal venous sampling and dexamethasone suppression testing between 2004 and 2018. Adrenal venous sampling indices including adrenal vein aldosterone/cortisol ratios and the selectivity, lateralization, and contralateral suppression indices. 21 (14.6%) patients had evidence of cortisol cosecretion (defined as a failure to suppress cortisol to ≤50 nmol/L post dexamethasone). Patients with evidence of cortisol cosecretion had a higher inferior vena cava cortisol concentration (P = .01) than those without. No difference was observed between the groups in terms of selectivity index, lateralization index, lateralization of aldosterone excess, or adrenal vein cannulation rate. Cortisol cosecretion alters some parameters in adrenocorticotrophic hormone-stimulated adrenal venous sampling but does not result in alterations in patient management.

This Month in Anesthesiology

This Month in Anesthesiology

Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training.

Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P=0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).

Comparison between transpancreatic sphincterotomy and needle-knife fistulotomy in difficulty biliary access, a retrospective study in Taiwan

BackgroundSelective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy (TPS), and needle knife fistulotomy (NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF.MethodsA total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed.Results31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2%) in the TPS group and 39 (83.0%) in the NKF group (P = 0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred.ConclusionsBoth TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

Estudio de cohortes prospectivo sobre el manejo y las complicaciones del catéter venoso periférico en pacientes ingresados en Medicina Interna

ObjectiveTo analyse compliance with the recommendations on the insertion-maintenance of peripheral venous catheter (PVC) and the incidence of complications according to the healthcare department that inserted the PVCs. Patients and methodsWe conducted a prospective cohort follow-up study of PVCs, from their insertion in the emergency or internal medicine (IM) department until their withdrawal. ResultsWe monitored 590 PVCs, 274 from the emergency department and 316 from IM. In terms of compliance with the process indicators, there was a cannulation rate in the antecubital fossa of 3.5 and 1.6 per 100 catheters-day (P<.001) in the emergency and IM departments, respectively. The sterile placement rates were 1.6 and 12.4 (P<.001), and the rate for transparent dressing was 2.1 and 11.5 (P<.001) per 100 catheters-day in the emergency and IM departments, respectively. The complications rates showed no differences between the departments. The most common complication was phlebitis (95 cases, 16.1%). ConclusionsCompliance with the insertion-maintenance recommendations for PVC showed differences between the departments; however, the incidence of complications was similar.

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.

Su1547 OUTCOMES OF PRECUT NEEDLE KNIFE FISTULOTOMY BASED ON THE ENDOSCOPIC MORPHOLOGY OF THE AMPULLA OF VATER AND OF THE SIZE OF BILE DUCT

Previous studies have suggested that the success and complications of precut needle knife fistulotomy (NKF) for achieving biliary access is largely dependent of the endoscopic morphology of the ampulla of Vater and also of the bile duct size. However, no study has addressed this topic. This study evaluated the outcomes of NKF on the basis of the morphology of the major papilla and of the size of the bile duct. This was a prospective multicenter study of all consecutive patients who were submitted to early NKF attempt for biliary access between August 2017 and August 2019. We evaluated the success rate and complications of NKF based on the following parameters: transverse and longitudinal measures of the papilla obtained using a visual method; diameter of the terminal CBD (t-CBD) measured 1 cm from the papilla using fluoroscopic images. Papilla were classified using a previously validated international classification of the major papilla into 7 categories. Outcomes were evaluated by a binary response regression models. We included 275 patients submitted to NKF, median age 75 years (17-97), 158 women(57.45%). NKF were performed in: 46 flat type papillas(16,67%), 102 prominent tubular non-pleated (37,21%), 74 prominent tubular pleated(26,74%), 27 prominent bulging(9,69%), 3 intradiverticular(1,09%) , 10 diverticular border(3,64%), 13 unclassified(4,65%). The cannulation rate was 97,07%. The post-ERCP complications rate were 9,09% (n= 25), with pancreatitis rate=6,18% (n=17) and no deaths. Cannulation success and complications were not significantly different among the seven papilla categories. In the regression model, cannulation and complications were not explained by the papilla morphology and the CBD diameter(Overall F-Test=0,46;p<0,80). The biliary cannulation and post-ERCP complications are not associated with papillary morphology or the distal size of CBD. The decision to use NKF for biliary access should not be conditioned by the papillary morphology.

Su1567 OUTCOMES OF NEEDLE KNIFE FISTULOTOMY AS AN INITIAL METHOD OF BILIARY CANNULATION

A previous feasibility study has suggested that needle knife fistulotomy (NFK) as an initial method for biliary access in patients with stones is associated with high levels of success and low rate of complications. This study evaluated the outcomes of NKF as an initial method for biliary access, in a large number of patients with any type of biliary pathology (tumors and stones), on the basis of success rate, complications and factors associated with success and complications. This was a prospective multicenter study of all consecutive patients who were submitted to NKF attempt as an initial method of biliary cannulation between August 2017 and November 2019 . We evaluated the success rate and complications of NKF based on the following parameters: morphology of the major papilla, biliary pathology, diameter of the terminal CBD (t-CBD) measured 1 cm from the papilla using fluoroscopic images while the patient was in a prone or supine. Papilla were classified using a previously validated international classification of the major papilla: flat type, prominent tubular non-pleated, prominent tubular pleated, prominent bulging, intradiverticular, diverticular border, unclassified papilla. Outcomes were evaluated a probit binary response regression models. We included 111 patients submitted to primary NKF, median age 70 years (17-97), 59 women (53,15%). In first ERCP, biliary cannulation rate=97.29% (108/111). The post-ERCP complications was 4,50% (n= 5), with pancreatitis rate of 3,60% (n=4) and no severe complications. Mean time to achieve cannulation was 6,25 min (sd 3,37) and mean ERCP duration=18,16 min (sd 5,58). In the regression model, complications were not explained by the papilla morphology, CBD diameter, biliary pathology (Overall F-Test=0,70;p=0,6725). When feasible NFK as initial method is associated with short time for gaining biliary access, high rate of success and low risk of complications, namely pancreatitis. The success of NFK is not related with the morphology of the papilla, t-CBD diameter, or underlying biliary pathology.

Arteriovenous Access superficialization: A New Technique and Review of Options

Up to 30% of autogenous cephalic vein arteriovenous fistulas (AVFs) are too deep for reliable cannulation. Techniques to superficialize these AVFs have been described previously. This study describes a new surgical technique for AVF superficialization and provides a review of the alternative techniques. The path of the fistula is marked using ultrasound, and transverse incisions are made along this path. The underlying tissue is separated from the dermis over this area to expose the fistula outflow vein. The mobilized vein is then elevated and "trapped" directly under the dermis by closing the superficial fascia and adipose tissue beneath it. Between March 2016 and February 2019, 23 patients underwent superficialization using this technique at two centers. The mean time between AVF creation and superficialization was 6.3months, and the time to first use for hemodialysis after superficialization was 38.8±27.9days. The average presuperficialization depth was 7.1±2.4mm and average postsuperficialization depth was 3.7±2.7mm (P=0.002). Sixteen fistulas were successfully accessed for a cannulation rate of 89%. 94.7% of fistulas remained patent at last visit, with only one thrombosed 8-10weeks after superficialization. This technique appears to be both safe and effective, and results in a vein that is immediately subdermal without major contour deformity. Early outcomes are comparable to those alternative methods described in the literature.

SUN-175 Repeat Unstimulated AVS with Aid of Plasma Metanephrines Identifies Unilateral Primary Aldosteronism When Initial AVS and Metomidate PET-CT Fails To

IntroductionAdrenal venous sampling (AVS) is the reference test for identifying unilateral primary aldosteronism (PA). However, in patients with corticol co-secreting adrenal nodules, elevated cortisol levels may affect the interpretation of aldosterone-cortisol (AC) ratios. ACTH-stimulation may further confound results. In such patients, the use of plasma metanephrines instead of cortisol as a correcting factor may be helpful.Case SummaryA 54 year old lady presented with 8 years of hypertension and hypokalaemia (nadir 2.2mmol/L) while on amlodipine 10mg and valsartan 80mg daily. PA was confirmed by a post-saline infusion aldosterone 1075pmol/L. CT identified a 2.4cm right lipid rich adrenal adenoma. Serum cortisol post 1mg overnight dexa-suppression test was unsuppressed at 63mmol/L.First AVS was done sequentially under ACTH stimulation and suggested lateralization to the right, with lateralization ratio (LR) 3.4. However, this was <4, and there were bilaterally low AC ratios compared to peripheral vein. Metomidate PET-CT scan then showed increased uptake over the nodule, but lower than the contralateral gland. In view of these findings, repeat AVS was done simultaneously without ACTH stimulation. Given the possibility of a co-secreting adenoma, plasma metanephrines were also measured. Second AVS showed right-sided lateralization (LR 11.8). Using metanephrines as a correction factor, the LR was even more elevated at 22.3, with contralateral suppression.She underwent right adrenalectomy and was cured of hypertension and hypokalaemia at 6 months post surgery. Aldosterone renin ratio has normalized: aldosterone <4ng/dL, plasma renin activity 0.6ng/ml/hr.Clinical LessonsWhile ACTH stimulation helps to improve success rates of cannulation by increasing cortisol gradients, most studies show that it lowers LR. Furthermore, this would be concerning in patients with cortisol co-secreting adenomas. In this case, repeat AVS without ACTH demonstrated improved lateralization to the right. The use of metanephrine as a correcting factor appears to be a better indicator of right sided disease. However, while plasma metanephrines have been shown to be useful to indicate correct catheter placement, it has not been adopted as a correction factor for dilution yet. Finally, in addition to affecting AVS results, cortisol-cosecreting tumors may also affect 11C-Metomidate PET-CT imaging.ConclusionIn patients with suspected cortisol co-secreting adenomas, unstimulated AVS and use of plasma metanephrines may help to identify unilateral PA even when conventional AVS and metomidate scans fail to. Further studies on using metanephrines as a correcting factor for lateralisation would be helpful.

Impact of a Novel Oblique-Tip Papillotome for Biliary Cannulation during ERCP: A Nonrandomized Coarsened Exact Matching Study.

Background We developed a novel oblique-tip papillotome (OT-papillotome) to facilitate biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate the utility of the OT-papillotome for contrast-guided cannulation (CGC) and wire-guided cannulation (WGC) during ERCP, compared with standard cannulation by WGC using a standard-tip papillotome (ST-papillotome). Methods A prospective study was performed at two centers. CGC with the OT-papillotome (OT-CGC group) was performed at Jikei University Hospital, while WGC was done with the OT-papillotome and ST-papillotome (OT-WGC and ST-WGC groups, respectively) at the University of Malaya Medical Centre. The results of the OT-CGC and OT-WGC groups were compared with those of the ST-WGC group after performing coarsened exact matching (CEM) to reduce bias due to nonrandomized and center-based patient allocation. Results Eighty patients were enrolled in each of the OT-CGC, OT-WGC, and ST-WGC groups. After CEM, the successful biliary cannulation rate was significantly higher in the OT-CGC and OT-WGC groups than in the ST-WGC group, while rescue cannulation was reduced. The mean number of unintended pancreatic access events in the OT-WGC and OT-CGC groups was similar to the ST-WGC group. However, it was significantly lower in the OT-WGC group than in the OT-CGC group. Multivariate analysis revealed that the OT-papillotome was independently associated with less frequent rescue cannulation and a higher successful biliary cannulation rate. Conclusions Although use of the OT-papillotome in biliary cannulation did not reduce unintended pancreatic access events or PEP compared to the ST-papillotome, the OT-papillotome increased the successful biliary cannulation rate, while reducing the frequency of rescue cannulation procedures. Combining the OT-papillotome with WGC might be the best cannulation technique for minimizing unintended pancreatic access.

An observational comparison of distal radial and traditional radial approaches for coronary angiography.

BackgroundSeveral studies have recently reported regarding feasibility and safety of distal transradial access (d-TRA) in the anatomical snuff-box (ASB); however, literature comparing it with the conventional TRA at the wrist (w-TRA) is sparse. This study compares the technical efficiency and safety of ASB and wrist approaches for TRA for coronary angiography (CAG) and evaluates the radial artery (RA) anatomy at these sites.MethodsTwo hundred consecutive patients undergoing CAG via w-TRA or d-TRA (100 in each group) were investigated. The primary endpoint was comparison of procedural efficiency of the two methods, defined as CAG completion from the intended access site. The secondary endpoints assessed d-TRA approach in terms of achievement of successful cannulation, arterial puncture, access time (AT), and total procedure time (TPT) in comparison with the conventional method. Safety endpoints included radiation parameters and complications. Furthermore, in 112 normal adults, RA anatomy was assessed at wrist and at ASB.ResultsIn d-TRA group, 77% patients achieved primary endpoint compared with 93% in w-TRA group (p = 0.004). The success of arterial puncture was comparable for d-TRA and w-TRA (93% and 99%, respectively; p = 0.065), but the cannulation rate was lower for d-TRA. Safety endpoints were similar in both the groups. AT and TPT were longer for d-TRA.ConclusionsThe ASB approach for CAG lowers the success rate and prolongs AT and TPT. The RA at ASB is smaller, has a curved course, and more anatomical variations than the RA at the wrist.

Subcutaneous Nitroglycerin for Radial Arterial Catheterization in Pediatric Patients: A Randomized Controlled Trial.

Pediatric radial artery cannulation is challenging because of the small vessel size. Nitroglycerin is a potent vasodilator and facilitates radial artery cannulation by increasing the internal diameter and preventing the vasospasm in adult patients. The authors hypothesize that subcutaneous nitroglycerin injection will improve the success rate of pediatric radial artery cannulation. This double-blind, randomized, controlled, single-center study enrolled pediatric patients (n = 113, age less than 2 yr) requiring radial artery cannulation during general anesthesia. The participants were randomized into the nitroglycerin group (n = 57) or control group (n = 56). After inducing general anesthesia, nitroglycerin solution (5 μg/kg in 0.5 ml), or normal saline (0.5 ml) was subcutaneously injected above the chosen radial artery over 10 s with ultrasound guidance. Three minutes later, the ultrasound-guided radial artery cannulation was performed. Radial artery diameter was measured before and after the subcutaneous injection and after cannulation. The primary outcome was the first-attempt successful cannulation rate. The secondary outcomes included the diameter of the radial artery and the overall complication rate including hematoma and vasospasm. A total of 113 children were included in the analysis. The nitroglycerin group had a higher first-attempt success rate than the control group (91.2% [52 of 57] vs. 66.1% [37 of 56]; P = 0.002; odds ratio, 5.3; 95% CI, 1.83 to 15.6; absolute risk reduction, -25.2%; 95% CI, -39.6 to -10.7%). Subcutaneous nitroglycerin injection increased the diameter of the radial artery greater than normal saline (25.0 ± 19.5% vs. 1.9 ± 13.1%; 95% CI of mean difference, 16.9 to 29.3%; P < 0.001). Overall complication rate was lower in the nitroglycerin group than in the control group (3.5% [2 of 57] vs. 31.2% [18 of 56]; P = 0.001; odds ratio, 0.077; 95% CI, 0.017 to 0.350; absolute risk reduction, 28.6%; 95% CI, 15.5 to 41.8%). Subcutaneous nitroglycerin injection before radial artery cannulation improved the first-attempt success rate and reduced the overall complication rates in pediatric patients.

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.

Endoscopic Ampullectomy of Benign Ampullary Lesions: Outcomes From a Single Center Study.

Endoscopic ampullectomy (EA) offers an insignificantly intrusive strategy for viably treating mucosal and occasionally submucosal lesions of the ampulla of Vater and encompassing periampullary area with high achievement and is more secure. The aim of this study was to present safety, efficacy, and outcomes of EA in the treatment of benign lesions of ampulla Vater performed by single experienced endoscopists in a high volume center. This retrospective study was conducted in patients referred to our hospital (Turkey High Speciality Training and Research Hospital, Turkey) for endoscopic evaluation of ampullary benign lesions over an 8-year period (between October 2011 and September 2019). Success rate was defined as complete resection of lesions. Twenty-nine patients with a median age of 64 years were included. Twenty-five patients had lesions confined to the ampulla vateri (86.2%). Accordingly, 2 lesions had intraductal extension adenoma (IDA) (6.9%) and 2 were lateral spreading adenoma (6.9%). The median size of the lesion was 17.5 mm (10 to 36 mm). Nineteen lesions (65.5%) were resected en bloc and 10 lesions (34.5%) were resected in piecemeal manner. Complete resection was achieved in 21 of 23 patients with benign ampullary lesions. The procedure success rate was 91.3%. Complications occurred in 6 patients (20.6%) of these 3 had (10.3%) bleeding, 2 (6.8%) had pancreatitis, and 1 had (3.4%) perforation. Four patients (13.7%) had a recurrence. Deep resection of the benign ampullary lesions increases the complete resection rate, cannulation rate of the pancreatic duct, and stenting rate of the pancreatic duct. EA is a safe and successful procedure in patients with benign lesions of ampulla vater.

Predictors of successful ultrasound-guided lead implantation.

Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P=.03), increased vein depth at 3.84versus 2.85cm (P=.003), more right-sided implants (P=.03), higher weight at 104.6versus 85.3kg (P=.017), higher body mass index at 35.6versus 29.2kg/m2 (P=.049), and higher body surface area at 2.24versus 1.99 m2 (P=.013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth.

A prospective, randomized study comparing ultrasound versus fluoroscopic guided femoral arterial access in noncardiac vascular patients

ObjectiveThe aim of our prospective, single-center, randomized study was to compare the procedural outcomes and complication rates of ultrasound (US)-guided common femoral artery (CFA) access to fluoroscopic guidance in noncardiac procedures. MethodsA total of 635 patients undergoing femoral access for noncardiac diagnostic or interventional procedures were randomized 1:1 to receive either fluoroscopic or US-guided access. The primary end point of the study was successful CFA cannulation. Secondary end points included the first-pass success rate, time to sheath insertion, and accidental venipunctures rate. Both short (24 hours) and midterm (30-90 days postprocedure) access complications were assessed by practitioners blinded to patient randomization. ResultsSuccessful CFA cannulation occurred in 93% of US-guided procedures compared with 86% of fluoroscopy-guided access (P = .002). US guidance was associated with increased rates of first-attempt success (74% vs 42%; P < .001), fewer inadvertent venipunctures (2% vs 10 %; P < .001), and decreased median time to cannulation (80 vs 100 seconds; P < .001) compared with fluoroscopy. Rates of complications did not differ at 24 hours (1% vs 1%; P = .99) or 30 to 90 days (2% vs 4%; P = .15) in fluoroscopy vs US-guided access. When access was performed by vascular surgery trainees (residents and fellows), US guidance retained superior rates of successful CFA cannulation compared to fluoroscopy guided access (n = 298; 96% vs 89%; P = .03). Trainees' time to achieve CFA cannulation was similar to attendings' when using US guidance (median, 85 vs 77 seconds; P = .14); however, with fluoroscopy, trainees' times were significantly longer than those of attendings (137 vs 86 seconds; P = .001). ConclusionsIn comparison to fluoroscopy, US-guided CFA cannulation had a higher rate of success, faster cannulation, and fewer venipunctures in the absence of increased complications.

Impact of Hospital Volume and the Experience of Endoscopist on Adverse Events Related to Endoscopic Retrograde Cholangiopancreatography: A Prospective Observational Study.

Background/AimsFew studies have addressed the relationship between the occurrence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) and hospital case volume or endoscopist’s experience with inconsistent results. The aim of our study was to investigate the impact of hospital case volume and endoscopist’s experience on the AEs associated with ERCP and to analyze patient- and procedure-related risk factors for post-ERCP AEs.MethodsFrom January 2015 to December 2015, we prospectively enrolled patients with naïve papilla who underwent ERCP at six centers. Patient- and procedure-related variables were recorded on data collection sheets at the time of and after ERCP.ResultsA total of 1,191 patients (median age, 71 years) were consecutively enrolled. The overall success rate of biliary cannulation was 96.6%. Overall, 244 patients (20.5%) experienced post-ERCP AEs, including pancreatitis (9.0%), bleeding (11.8%), perforation (0.4%), cholangitis (1.2%), and others (0.9%). While post-ERCP pancreatitis (PEP) was more common when the procedure was performed by less experienced endoscopists, bleeding was more common in high-volume centers and by less experienced endoscopists. Multivariate analysis showed that a less experience in ERCP was significantly associated with PEP (odds ratio [OR], 1.630; 95% confidence interval [CI], 1.050 to 2.531; p=0.030) and post-ERCP bleeding (OR, 1.439; 95% CI, 1.003 to 2.062; p=0.048).ConclusionsOur study demonstrated that overall AEs following ERCP were associated with the experience of the endoscopist. To minimize post-ERCP AEs, rigorous training with a sufficient case volume is required, and treatment strategies should be modified according to the endoscopist’s expertise.

A prospective nationwide study on the impact of the level of sedation on cannulation success and complications of endoscopic retrograde cholangiopancreatography.

BackgroundDifficult or unsuccessful cannulation of the papilla of Vater is associated with complications during endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate whether deep sedation facilitates the cannulation and reduces the complication rate.MethodsNationwide data from ERCP procedures were registered prospectively in the web-based Swedish Registry for Gallstone Surgery and ERCP (GallRiks). These data were used for a case-control study comparing the outcomes when using propofol sedation (PS) or basic sedation (BS) with midazolam in combination with opioids.ResultsWe analyzed 31,001 ERCP procedures in patients who had no previous ERCP. Of these, 14,907 were performed using PS and 16,094 using BS. The cannulation rate was higher in the PS group than the BS group: 89.0% vs. 86.7%, P<0.0001. The procedure time was longer in the PS group than in the BS group: 35.7 vs. 31.2 min, P<0.0001. The rate of intra-procedural complications was lower in the PS group than in the BS group: 2.9% vs. 3.7%, P<0.0001. The total frequency of post-procedural complications was 13.0% in the PS and 12.6% in the BS group (P=0.2607). The frequency of post-ERCP pancreatitis (PEP) was higher in the PS group than in the BS group: 4.6% vs. 4.0%, P=0.0136.ConclusionsPS in ERCP leads to a significantly higher cannulation success rate and fewer intra-procedural complications, but there was no significant difference in total post-ERCP complications. The procedure time was longer, and PEP was more common in the PS group. A plausible explanation could be that deep sedation might lead to more aggressive attempts to cannulate the papilla, resulting in a higher risk for PEP.

Endoscopic management and clinical outcomes of obstructive jaundice.

This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.