Complexity Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Risk factors for ERCP-related complications and what is the specific role of ASGE grading system.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the main therapeutic and sometimes diagnostic methods in biliary and pancreatic diseases. A grading system for the difficulty of ERCP (grade one to four, the higher grade represents the more complexity of the procedure) has been developed by the American Society for Gastrointestinal Endoscopy (ASGE). This study aimed to assess the prevalence of ERCP-related complications, their common risk factors, and specifically the role of difficulty of the procedure based on ASGE grading. This cross-sectional study was performed on 620 ERCP-operated patients over 4 years in two tertiary referral centers affiliated with Isfahan University of Medical Sciences. Data about the difficulty of procedures based on the ASGE grading scale, complications including pancreatitis, bleeding, infection, perforation, arrhythmia, respiratory suppression, aspiration, and major common risk factors were collected. The overall prevalence of complications was 11.6% including pancreatitis 8.2%, perforation 0.8%, gastrointestinal bleeding 1.3%, cholangitis 2.4%, and cardiopulmonary problems 0.5% (arrhythmia 0.3% and respiratory depression 0.2%). Patients with pancreatic contrast injection (66.7% vs. 11.3% P = 0.04) and sphincter of Oddi dysfunction (SOD) (44.4% vs. 11.1%; P = 0.01) showed a statistically significant higher overall complication rate. The association of these risk factors remained significant in multivariable logistic regression analysis. Patients with pancreatic contrast injection also showed a statistically significant higher prevalence of post-ERCP pancreatitis (66.7% vs. 11.3% P = 0.04). Furthermore, a significantly higher prevalence of arrhythmia (3.6% vs. 0; P = 0.008) was observed among patients with difficult cannulation. Based on the ASGE difficulty grading score, most of the patients were classified as grade 2 (74.2%) and 3 and 4 (23.4%). No statistically significant difference was noted between the difficulty-based groups in terms of complications. The current study showed that the most critical risk factors of ERCP-induced complications were pancreatic contrast injection and SOD. ASGE grading scale for ERCP complexity did not predict the occurrence of complications in our study population.

Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low-volume Endoscopists.

Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP. We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High-volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low-volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year. Three hundred eighty-five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age <4 years or >16 years at the time of ERCP (P < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT. Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

Development of an Online App to Predict Post-Endoscopic Retrograde Cholangiopancreatography Adverse Events Using a Single-Center Retrospective Cohort

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure with a high risk for adverse events (AEs). Aim: evaluate patient- and procedure-related risk factors for ERCP-related AEs and develop an online app to estimate risk of AEs. Methods: retrospective study of 1,491 consecutive patients who underwent 1,991 ERCPs between 2012 and 2017 was conducted. AEs definition and severity were classified according to most recent ESGE guidelines. Each variable was tested for association with occurrence of overall AEs, post-ERCP pancreatitis (PEP) and cholangitis. For each outcome, 2 regression models were built, from which an online Shiny-based app was created. Results: Overall AE rate was 15.3%; in 19 procedures, >1 AE occurred. Main post-ERCP AE was PEP (7.5%), followed by cholangitis (4.9%), bleeding (1.3%), perforation (1%), cardiopulmonary events (0.9%), and cholecystitis (0.3%). Seventy-eight percent of AEs were mild/moderate; of severe (n = 55) and fatal (n = 20) AEs, more than half were related to infection, cardiac/pulmonary AEs, and perforation. AE-related mortality rate was 1%. When testing precannulation, procedural covariates, and ERCP findings, AE occurrence was associated with age (odds ratio [OR] 0.991), previous PEP (OR 2.198), ERCP complexity grade III/IV (OR 1.924), standard bile duct cannulation (OR 0.501), sphincterotomy (OR 1.441), metal biliary stent placement (OR 2.014), periprocedural bleeding (OR 3.024), and biliary duct lithiasis (OR 0.673). Conclusion: Our app may allow an optimization of the patients’ care, by helping in the process of decision-making, not only regarding patient or endoscopist’s selection but also definition of an adequate and tailored surveillance plan after the procedure.

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography.

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure. A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis. The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group. ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

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

BACKGROUNDAt our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period. AIMTo evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.METHODSDemographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as “standard” or “advanced” and duodenoscope position was labeled as “standard” (short position) or “non-standard” (e.g., long, semi-long).RESULTSPatients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 (P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) (P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) (P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques (P < 0.03 for each).CONCLUSIONComplexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

S0905 Prospective Multicenter International Trial Evaluating Performance of Disposable Elevator Cap Duodenoscope During Endoscopic Retrograde Cholangiopancreatography (deCAP Trial)

INTRODUCTION: Persistent contamination of elevator mechanism despite reprocessing has resulted in outbreaks of infection with multidrug-resistant organisms following Endoscopic Retrograde Cholangiopancreatography (ERCP). Novel duodenoscope with disposable elevator cap (DEC) might reduce these infections. We tested performance of DEC-duodenoscope in patients undergoing ERCP. METHODS: We conducted a prospective case-series study of outcomes of ERCP using DEC duodenoscope at two academic medical centers. Six endoscopists (experience 1 to 10+ years) and nurse/technicians participated in the study. Outcomes analyzed included evaluation of pre-procedure set up, post procedure reprocessing by nurse/technicians. ERCP outcomes included successful completion of ERCP, endoscopist rating on ERCP performance characteristics as well as ERCP maneuvers, and adverse events. RESULTS: This is an interim analysis of 108 consecutive ERCPs (Female 66%, 71/108) performed during the study period of May and June 2020. Most common indication was choledocholithiasis (60%, 65/108) and a majority of patients had native papilla (65%, 70/108). 32% of procedures were performed by fellows, while 68% of procedures were performed by attending physicians. Majority of ERCPs were of ASGE ERCP complexity Grade 2 (73%, 79/108). The mean cannulation time was 5.85 mins (SD: ± 7.97 mins) while the mean time to complete the procedure was 26 mins (SD: ± 17.66 mins). All ERCPs were performed under propofol guided deep sedation or general endotracheal anesthesia. All ERCPs were successfully completed without need to change scope . In one case, given inability to pass the instrument via the elevator channel, ERCP scope was removed, same cap was reattached, and then procedure could be successfully completed. Overall performance rating for DEC duodenoscope was 99%-100% in 17 ERCP performance characteristics and 100% in 10 ERCP maneuvers (Table 1). When evaluated by nurse or technician, overall performance rating of DEC duodenoscope was 97%-99% in various pre-procedure, intraprocedural and post-procedure tasks (Table 2). CONCLUSION: We conclude that most endoscopists with varying level of experience, could easily complete various complex ERCP tasks with DEC duodenoscope. This innovative design has the potential to reduce ERCP related infectious outbreak.Table 1.: Rating on ERCP Performance Characteristics and ERCP ManeuversTable 2.: Rating by nurse of technician for pre-procedure set up, intraprocedural performance and post-procedure reprocessing steps

The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital.

The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice. Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded. A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01). The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.

The H.O.U.S.E. classification: a novel endoscopic retrograde cholangiopancreatography (ERCP) complexity grading scale

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging endoscopic procedure, harboring a wide range of complexities within every single investigation. Classifications of the complexity of ERCP have been presented, but do not include modern endoscopic treatment modalities. In order to be able to target resources and compare the results of different endoscopic centers, a new complexity grading system for ERCP is warranted. This study launches a new complexity grading scale for ERCP–the H.O.U.S.E.-classification.MethodsThe medical record of every patient undergoing ERCP 2009–2011 at the Karolinska University Hospital was reviewed, regarding the complexity of the procedure, and categorized into one out of three-grades in the HOUSE classification system, and concomitantly graded according to the Cotton grading system. All ERCP-procedures were also registered in the Swedish registry for gallstone surgery and ERCP (GallRiks) and correlations between the grading systems and procedure related variables as well as outcomes were made.ResultsBetween 2009 and 2011, 2185 ERCPs were performed at the Karolinska University Hospital, Huddinge. One thousand nine hundred fifty-four of those were index-ERCPs. Another 23 patients were excluded due to lack of postoperative complication registrations, leaving 1931 ERCP procedures to be analyzed. The procedure times were 40 ± 0.7, 65 ± 1.5 and 106 ± 3.2 min, respectively (HOUSE 1–3). The corresponding pancreatitis rates were 3.4, 7.0 and 6.8% and the postoperative complication rates 11.1, 15.7 and 12.8%, respectively.ConclusionsThe HOUSE-classification is a novel grading scale for ERCP-complexity. The system can be implemented in clinical practice to allocate resources and allow the comparisons of results between different endoscopic centers. Further studies are warranted to further sharpen this instruments validitity and general clinical relevance.

Impact of introduction of endoscopic ultrasound on volume, success, and complexity of endoscopic retrograde cholangiopancreatography in a tertiary referral center.

Background and Objectives:Endoscopic ultrasound (EUS) is commonly used to examine pancreaticobiliary disorders. We hypothesize that the introduction of EUS service may change the pattern and the complexity of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. The aim of this study is to assess the impact of introducing EUS on the volume, success, and complexity of ERCP.Materials and Methods:This is a single-center retrospective data review of ERCP procedures done “before” and “after” the introduction of EUS (before EUS and after EUS). Patients' demographics, ERCP indications, types of sedation, therapeutic interventions, outcomes, complications, and complexity of ERCP were collected. The categorical and continuous variables were compared using Fisher's exact test and the unpaired t-test, respectively. Multivariable logistic regression analysis was used to compare ERCP outcomes.Results:A total of 945 ERCPs performed over a 3-year period between January 2010 and January 2013 (411 and 534 in the “before EUS” and “after EUS” time periods, respectively) were included in this study. There was a 30% relative increase in the volume of ERCPs after the introduction of EUS. ERCP success rate was higher after the introduction of EUS, even after adjusting the complexity grade [odds ratio (OR) = 4.54, P = 0.001]. Significant increase in the complexity of ERCP was observed after the introduction of EUS service. The OR of performing grade 4 ERCP was 4.44 (P = 0.0005) after the introduction of EUS.Conclusions:The introduction of a new EUS service in our tertiary referral university medical center is associated with an increase in the volume, success, and complexity of ERCP procedures. EUS expertise may be valuable for better ERCP outcomes.

Anatomical Location of Pathology Is Predictive of Prolonged Fluoroscopy Time During ERCP: A Multicenter American Study.

Different factors have been associated with prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP). We hypothesize that FT depends on both the anatomical location of the pathology managed during ERCP and the complexity of the ERCP. Three centers participated in a retrospective multi-center cohort study. Data on patient demographics, ERCP complexity, and the location of pathology were collected. The relationships between FT and the location of pathology, ERCP complexity, patient demographics, and ERCP maneuvers, respectively, were analyzed. Prolonged FT was defined as a FT > 10 min. A total of 442 cases underwent ERCP in three different centers (301 cases, 76 cases, and 65 cases in centers A, B, and C, respectively) by six endoscopists. The median FT for all cases was 282 (range 8-3,516) s. Mean FT increased progressively according to anatomical location in the order extrahepatic cases {n = 298; mean FT 292 [95 % confidence interval (CI) 263-322] s}, pancreatic cases [n = 27; mean FT 359 (95 % CI 200-517) s], and intrahepatic cases [n = 117; mean FT 736 s (95 % CI 635-836) s]. Mean FT increased progressively with the complexity scale, with mean FT for Grade I, 218 (95 % CI 138-299) s; Grade II, 295 (95 % 261-329) s; Grade III, 586 (95 % CI 508-663) s; Grade IV, 636 (95 % CI 437-834) s. Multivariable analysis confirmed that prolonged FT was independently associated with anatomical location of the targeted pathology during ERCP-but not with ERCP complexity and endoscopy center. Prolonged FT during ERCP is associated most strongly with intrahepatic cases. FT can be used most effectively as a quality measure if it is stratified according to presence or absence of intrahepatic cases.

The Impact of Introduction of a New Endoscopic Ultrasound (EUS) Service on the Volume, Success, and Complexity of Endoscopic Retrograde Cholangiopancreatography (ERCP) Performed in a Tertiary Referral Center

Introduction: Endoscopic ultrasound (EUS) can aid in biliary duct cannulation where conventional ERCP techniques fail, improving the success rate in complex ERCPs. The introduction of EUS service may change the pattern of ERCPs, which has never been systematically studied in the past. The aim is to assess the impact of introducing EUS service on the volume, outcome, and complexity of ERCP in a tertiary referral medical center. Methods: A retrospective data review of all ERCP procedures was performed during 1.5-year time periods, before and after the introduction of EUS service (before EUS and after EUS) from January 2010 to January 2013. Patients’ demographics, ERCP indications, types of sedation, therapeutic interventions, outcomes, and complexity of ERCP (following the ASGE complexity grade) were collected. The categorical and continuous variables between the 2 time periods were compared using Fisher’s exact test and unpaired t-test, respectively. Multivariable logistic regression analysis was used to compare ERCP outcomes after adjusting the complexity grade. Results: A total of 945 ERCPs (411, 43.4% before the introduction of EUS; 534, 56.5% after introduction of EUS) were included. There was a 30% relative increase in the volume of ERCPs after the introduction of EUS. Five hundred sixty-seven (60%) patients in our study were females with a mean age of 51.5 years. The 2 most common indications of ERCP were jaundice (before EUS 37%; after EUS 34%) and choledocholithiasis (before EUS 25.6%; after EUS 26%). There was an increase in the frequency of precut sphincterotomy (0.97% vs. 5.43%; p=0.0002), metal stent placement (1.95% vs. 5.43%; p=0.0062), pancreatic stent placement (5.6% vs. 10.11%; p=0.0119), and EUS-guided biliary cannulation “rendezvous” (0% vs. 1.5%; p=0.0127) after the introduction of EUS. The complexity of ERCP was increased after the introduction of EUS. The odds ratio (OR) of grade 4 ERCP was 4.44 (95% CI 1.92-10.24; p=0.0005) after EUS introduction (Table 1). ERCP success rate was higher after the introduction of EUS even after adjusting the complexity grade (OR 4.54; 95% CI 1.85-11.14; p=0.001). The complication rate was 4.6 times higher in the after EUS period when compared to the before EUS period (OR 4.63; 95% CI 1.90-11.3; p=0.0007).Table 1: Comparison of ERCP Complexity Grade and ERCP Outcome (Success) Between the Two Time Periods (“After EUS” and “Before EUS”)Conclusion: The introduction of a new EUS service in our tertiary referral university medical center was associated with an increase in volume, success, and complexity of ERCP procedures. EUS expertise is valuable for better ERCP outcomes.

Procedural time of day: A predictor of ERCP outcomes?

Emerging data suggest time of day of endoscopic procedures may affect outcome due to endoscopist fatigue and decreased concentration. We therefore investigated whether afternoon endoscopic retrograde cholangiopancreatography (ERCP) adversely affects patient outcome. One thousand and six consecutive inpatient and outpatient ERCPs performed at the Mayo Clinic, Rochester from August 2010 to April 2011 were identified and the medical records were reviewed for demographic, clinical, and procedural data. The primary outcome was adverse event (AE) rate. The secondary outcome was procedural success rate. ERCP complexity was graded using published consensus guidelines. Univariate and multivariate analyses were performed to assess for predictors of and differences between am and pm ERCP outcomes. Of the 1006 ERCPs included, 512 (50.8%) were performed in the am and 494 (49.1%) in the pm. All ERCPs were performed with monitored anesthesia care. In univariate analysis, AE rates were not significantly different between am and pm ERCPs, 8.4% versus 8.7%, respectively (P = 0.85). Procedural success rates were also not significantly different between am and pm ERCPs, 96.1% versus 96.2%, respectively (P = 0.95). These differences remained nonsignificant for inpatient and outpatient ERCPs as well as in patients with surgically altered anatomy. By multivariate analysis, the time of day remained a nonsignificant predictor of AE and procedural success rates; performance of a sphincterotomy and individual endoscopist were found to impact AE rate. Based on this large, retrospective study, it appears there are no significant differences between am and pm ERCP AE rates and procedural success rates. Future studies should investigate the impact time of day has on endoscopic procedural outcomes in other practice settings, where scheduling practices, use of anesthesia support, endoscopist experience, and safeguards to minimize endoscopist fatigue may be different.

Colangiopancreatografía retrógrada endoscópica en pacientes con asa en Y-de-Roux

Endoscopic retrograde cholangiopancreatography in Roux-en-Y patients The reconstruction of the digestive tract with a Roux-en-Y anastomosis has been performed more fre- quently in the last years mainly due to the overgrowth in the surgical treatment of obesity by gastric bypass in Roux-en-Y. The obesity pandemic is also associated with an increase in both the preoperative and postoperati- ve diagnosis of gallstones in this population. Bearing in mind the greater complexity of endoscopic retrograde cholangiopancreatography in these circumstances, the authors have reviewed the various endoscopic appro- aches available, evaluating 249 articles published between 1990 and 2010 obtained from Medline, Cochrane and Scielo, excluding case reports and articles outside the specifi c scope of this study. Endoscopic techniques with high success rates include the use of enteroscope, colonoscope, enteral and transgastric access combined with surgery. Even with the technological progress already made, further development of the instruments used will be necessary if greater comfort and safety is to be achieved with this procedure.

Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography?

Recently, a patient presented with severe acute pancreatitis after biliary self-expandable metallic stent (SEMS) placement for palliation of an unresectable pancreatic cancer. This case induced us to consider the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The use of biliary SEMS represents the best therapeutic option for the treatment of neoplastic obstructive jaundice because it has a lower mortality and morbidity than surgery. It does not pose as a risk factor for inducing postERCP acute pancreatitis (PEAP) or other complications but increases only the risk of cholangitis [1]. However, SEMS is considered to be the first therapeutic palliation procedure for patients with unresectable pancreatic cancer. It offers better results than surgical palliation in terms of lower procedure-related complications and improves life quality [2, 3] Moreover, studies have shown the feasibility of simultaneous SEMS positioning for treating combined biliary and duodenal obstructions [4, 5]. We thought the PEAP in our case may have been attributable either to obstruction of the Wirsung caused by SEMS positioning or to direct damage due to the stent expansion, although no evidence for this exists in the literature. However, the causes more likely were a prolonged manipulation of the papilla due to a difficult cannulation or an excessive main pancreatic duct opacification. In a recent study, Cotton et al. [6] showed that the cited maneuvers can increase fatal post-ERCP complications. Although Schutz and Abbott [7] state that only technical success depend on the ERCP degree of difficulty and that complications do not, Cotton et al. [6] think that complicated procedures (grade 3 of the modified Madhotra classification [8]) pose higher risk for the development of complications because the approach to the papilla can be extremely complex. We think that large neoplasms (diameter, [4 cm) modifying the common bile duct (CBD) anatomy (kinking, coiling, stretching) also should be considered as a factor increasing the complexity of ERCP and thus the possibility of procedure-related pancreatitis. However, but at this writing, no author considers this to be a risk factor. To simplify the CBD cannulation, Ito et al. [9] recently have suggested inserting a pancreatic guidewire to achieve a selective biliary cannulation. This still needs a randomized study. Several authors have stated that the use of pancreatic stents probably is the best way to prevent PEAP [10–16]. Different series have shown that the use of this device reduces the incidence of PEAP from a range of 11.1% to 66.7% for patients with no stent to a range of 5% to 14.4% for patients with a stent. When the main pancreatic duct cannulation is obtained first, as often happens if the neoplastic lesion does not involve the duct, the clinician should place a pancreatic stent at once before proceeding to the CBD. The use of small-caliber (maximum, 5 Fr) short (2–3 cm) stents [17] and elimination of flaps before insertion [18] allow a spontaneous migration in 2 to 3 weeks without the need for endoscopic removal. Pancreatic stent positioning G. Fanello (&) M. Benedetti G. Martino M. Marengo R. L. Meniconi F. Papini P. Chirletti Department of Surgery, ‘‘F. Durante’’–General Surgery Unit, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy e-mail: gianfranco.fanello@uniroma1.it