Consecutive Endoscopic Retrograde Cholangiopancreatography Procedures Research Articles

Efficacy and safety of endoscopic retrograde cholangiopancreatography in the very elderly by using a combination of intravenous midazolam, ketamine and pethidine.

The number of therapeutic endoscopic procedures in elderly individuals keeps increasing and this population has a high risk of adverse events related to sedation and general anesthesia. However, there is a paucity on data about the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in this population. In total, 417 consecutive ERCP procedures were performed in 362 patients between September 2018 and January 2020. Of these, 59 patients (74 sessions) were aged ≥80 years (Group A) and 173 patients (193 procedures) were aged ≤65 years (Group B). We analyzed the prospectively collected data of patient- and procedure-related variables. The procedure time was significantly longer in Group A (P < 0.05). The prevalence of comorbidities, use of anticoagulants and American Society of Anesthesiologists (ASA) physical status classification levels were significantly higher in Group A (P < 0.05). The incidence of periampullary diverticula, malignancy, rate of difficult cannulation, mean number of stones, use of biliary stents and stent dysfunction was also significantly higher in Group A (P < 0.05). The medication doses used were significantly higher and emergence symptoms were significantly more frequent in Group B (P < 0.05). The rates of bleeding, pancreatitis, perforation, cholangitis, hypoxia, hypotension and the length of hospital stay did not significantly differ between the two groups. The overall success rate of the procedure was comparable in the two groups (P=0.874). ERCP can be safely performed in elderly patients using a combination of midazolam and ketamine without propofol. The incidence of complications is comparable with that observed in younger patients. Geriatr Gerontol Int 2021; 21: 887-892.

Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial.

Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events. This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis. 21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %; P = 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %; P > 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %, P = 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event. Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.

Efficacy and safety of endoscopic procedures for common bile duct stones in patients aged 85 years or older: A retrospective study.

The Endoscopic procedures for common bile duct (CBD) stones are reportedly safe in the elderly patients. However, the definition of the elderly is different in each report. If the elderly are defined as people aged 85 years or older, data on the effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones are limited. This study investigated the efficacy and safety of endoscopic procedures for CBD stones in patients aged 85 years or older. 1,016 consecutive ERCP procedures were performed at our institution from January 2009 to December 2014. Of these, 235 cases with CBD stones were finally analyzed. Group A patients were younger than 85 years and Group B patients were 85 years or older. Patient background, details of endoscopic therapy, complications, and related factors were retrospectively reviewed for 185 cases in Group A, and 50 cases in Group B. Patients in Group B showed high rates of dementia and cerebrovascular disorders and larger CBD stones and diameters, in comparison with patients in Group A. The complete removal rate of bile duct stones was slightly higher in Group A. However, there was no difference between the two groups in recurrence rate of CBD stones, complication and mortality rates, and length and cost of hospitalization. Despite some differences between the two groups, endoscopic procedures for CBD stones in patients aged 85 years or older can be performed effectively and safely without increasing medical costs.

Risk Factors for ERCP-Related Complications: A Prospective Multicenter Study in Guayaquil, Ecuador

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. A reported complication rate a! er ERCP varies between 5 % and 10 %. The aim of the present study was to investigate the potential risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complications and to identify whether the risk factors are different for pancreatitis and asymptomatic hyperamylasemia. Methods: Consecutive ERCP procedures were studied at three centers in Guayaquil, Ecuador from October 2013 to May 2017. The complications after the patients' first-only procedures were evaluated. Multivariate analysis based on the first-only procedures was used to identify the risk factors Results: A total of 652 procedures were performed. The mean number of ERCP procedures performed at each center ranged from 2.1 to 6.0 per endoscopist per week. Overall, complications developed in 52 (7.92%) patients, pancreatitis in 28 (4.31%), and asymptomatic hyperamylasemia in 96 (14.72%). In the multivariate analysis, female gender (adjusted odds ratios (ORs): 1.52, 95% confidence interval (CI): 1.14-2.02, P=0.004), periampullary diverticulum (OR: 2.02, 95% CI: 1.49-2.73, P10 min (OR: 1.51, 95% CI: 1.08-2.10, P=0.016), > or =1 pancreatic deep wire pass (OR: 1.80, 95% CI: 1.33-2.42, P10 min (OR: 1.76, 95% CI: 1.13-2.74, P=0.012), > or =1 pancreatic deep wire pass (OR: 2.77, 95% CI: 1.79-4.30, P10 min (OR: 1.96, 95% CI: 1.52-2.54, P or =1 pancreatic deep wire pass (OR: 2.24, 95% CI: 1.74-2.89, P Conclusion: In conclusion, patient-related risk factors are as important as procedure-related ones in determining the risk for overall post-ERCP complications and pancreatitis. I ese & ndings emphasize the importance in the avoidance of high-risk procedures such as unintentional pancreatic deep wire pass, prolonged cannulation time, and needle-knife precut, especially in high-risk patients such as younger women and patients with periampullary diverticulum. However, the risk factors for asymptomatic hyperamylasemia may be mostly procedure related. I e diJ erence in patient-related factors between pancreatitis and asymptomatic hyperamylasemia suggests that the host susceptibility represents an important factor in the mechanism by which post-ERCP pancreatitis develops.

New classification system for indications for endoscopic retrograde cholangiopancreatography predicts diagnoses and adverse events

Background: Indications for endoscopic retrograde cholangiopancreatography (ERCP) have received little attention, especially in scientific or objective terms.Aim: To review the prevailing ERCP indications in the literature, and to propose and evaluate a new ERCP indication system, which relies on more objective pre-procedure parameters.Methods: An analysis was conducted on 1758 consecutive ERCP procedures, in which contemporaneous use was made of an a-priori indication system. Indications were based on the objective pre-procedure parameters and divided into primary [cholangitis, clinical evidence of biliary leak, acute (biliary) pancreatitis, abnormal intraoperative cholangiogram (IOC), or change/removal of stent for benign/malignant disease] and secondary [combination of two or three of: pain attributable to biliary disease (‘P’), imaging evidence of biliary disease (‘I’), and abnormal liver function tests (LFTs) (‘L’)]. A secondary indication was only used if a primary indication was not present. The relationship between this newly developed classification system and ERCP findings and adverse events was examined.Results: The indications of cholangitis and positive IOC were predictive of choledocholithiasis at ERCP (101/154 and 74/141 procedures, respectively). With respect to secondary indications, only if all three of ‘P’, ‘I’, and ‘L’ were present there was a statistically significant association with choledocholithiasis (χ2(1) = 35.3, p < .001). Adverse events were associated with an unusual indication leading to greater risk of unplanned hospitalization (χ2(1) = 17.0, p < .001).Conclusions: An a-priori-based indication system for ERCP, which relies on pre-ERCP objective parameters, provides a more useful and scientific classification system than is available currently.

Follow-up to determine unplanned hospitalization and complications after endoscopic retrograde cholangiopancreatography.

Studies of endoscopic retrograde cholangiopancreatography (ERCP)-related complications are inconsistent and sometimes have insufficient patient follow-up. The aim of this study was to investigate risk factors for ERCP-related events, leading to hospitalization in the case of outpatients and prolonged hospital stay in the case of inpatients, using assiduous follow-up and contemporaneous recording of data. Prospectively collected data of 1000 consecutive ERCP procedures performed by a single endoscopist at a tertiary referral centre in Canberra, Australia, were studied and the complications evaluated. Intense short-term follow-up with same evening and next day phone calls/consultations was undertaken with contemporaneous recording of indications, results and complications. Of 1000 procedures, 87 patients required unplanned hospitalization or prolongation of hospital stay. Risk factors for prolonged hospital stay included unusual indication (odds ratio (OR): 3.26, confidence interval (CI): 1.36-7.79, P = 0.008), age <50 (OR: 2.05, CI: 1.30-3.23, P = 0.002), procedure time >30 min (OR: 1.85, CI: 1.17-2.94, P = 0.009), being an outpatient (OR: 1.78, CI: 1.13-2.81, P = 0.012), inability to access the bile duct (OR: 1.98, CI: 1.03-3.82, P = 0.038) and placement of a pancreatic stent (OR: 1.93, CI: 1.08-3.45, P = 0.025). Of these, all but procedure time and placement of a pancreatic stent were risk factors if multivariate analysis was used. A total of 26 patients (30% of those with unplanned hospitalization) developed self-limiting pain without apparent complications. Both patient-related and procedure-related factors are important risk factors for determining the likelihood of unplanned post-ERCP hospitalization. There are a significant number of patients who experience self-limiting pain following ERCP, without evidence of recognized complications.

Endoscopic retrograde cholangiopancreatography-related adverse events in patients with type 1 autoimmune pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed for the diagnosis and treatment of type 1 autoimmune pancreatitis (AIP). However, the prevalence of ERCP-related adverse events in patients with type 1 AIP has not been evaluated. We aimed to clarify the feasibility of ERCP in patients with type 1 AIP. We retrospectively reviewed 82 consecutive ERCP procedures performed in patients with type 1 AIP from 2004 to 2014 in one university hospital and three tertiary-care referral centers. One hundred four ERCP procedures in chronic pancreatitis and 1123 in non-AIP cohort were enrolled as control groups. We compared the incidence of post-ERCP pancreatitis (PEP) between type 1 AIP and control groups. We evaluated the incidence of ERCP-related adverse events and various predictive factors for hyperamylasemia after ERCP. Pancreatography and cholangiography by ERCP were obtained in 78 (95.1%) and 76 (92.7%) patients, respectively. The incidence of PEP, cholangitis, and bleeding was 1.2% (1/82), 0%, and 1.2%, respectively. PEP occurred in type 1 AIP patient with diffuse parenchymal imaging, and the severity was mild. The incidences of PEP were 2.9% (3/104) and 5.4% (61/1123) in chronic pancreatitis and normal cohort, respectively. The incidence of PEP was slightly lower in type 1 AIP than non-AIP cohort (1.2% vs 5.8%, p = 0.119). There were no significant predictive factors for hyperamylasemia after ERCP in type 1 AIP. The incidence of ERCP-related adverse events is low in patients with type 1 AIP. ERCP-related procedures are feasible in the diagnosis and treatment of AIP.

Periampuller divertikül ERCP'de pankreatiti artırır kanamayı arttırmaz

Giriş ve Amaç: Periampuller divertiküllü hastalarda endoskopik retrograd kolanjiopankreatikografi işleminin normal hastalara göre daha zor ve komplikasyon açısından daha riskli olduğu sanılmaktadır. Genelde, endoskopik retrograd kolanjiopankreatikografi yapılan hastalarda periampuller divertikül prevelansı %5-32 arasında saptanmıştır. Çalışmamızda, çeşitli nedenlerle endoskopik retrograd kolanjiopankreatikografi endikasyonu konan hastalarımızda periampuller divertikül sıklığı ve periampuller divertikülün endoskopik retrograd kolanjiopankreatikografi yapılan hastalarda komplikasyon oranlarını artırıp arttırmadığının retrospektif değerlendirilmesi amaçlandı. Gereç ve Yöntem: Temmuz 2009 ile Ekim 2010 arasında ünitemizde yapılan endoskopik retrograd kolanjiopankreatikografi işlemleri retrospektif olarak değerlendirildi. Endoskopik retrograd kolanjiopankreatikografi yapılan hastalar periampuller divertikül bulunup bulunmamasına göre iki gruba ayrıldı. Periampuller divertikül mevcudiyetine göre endoskopik retrograd kolanjiopankreatikografi komplikasyonları değerlendirildi. Bulgular: Çeşitli nedenlerle endoskopik retrograd kolanjiopankreatikografi yapılan 216 hastanın 31'inde (%14,6) periampuller divertikül vardı. Bu hastalara yapılan toplam 258 işlem değerlendirmeye alındı. Periampuller divertikülü olan hastaların ortalama yaşı (71.4±12.4 yıl), periampuller divertikülü olmayan hastalardan (58.3±17.3 yıl) yüksekti (p

ERCP in a cohort of 759 cases: A 6-year experience of a single tertiary centre in Libya

Background and study aimsThe aim of this study was to review the indications, findings, technical success, and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures in a large cohort of patients admitted to a single tertiary centre in Libya. Patients and methodsA total of 759 consecutive ERCP procedures were performed in 704 patients from January 2005 through December 2010 at the Endoscopy Unit of Central Hospital, Tripoli, Libya. The patients’ demographic characteristics, clinical information, ERCP indications, laboratory parameters, and post-ERCP complications were reviewed. Formal written consent was obtained from all patients prior to each procedure. ResultsThe study included 280 (36.9%) males and 479 (63.1%) females with mean age±standard deviation (SD) of 56.8±18.7years. Papillotomy was performed in 670 (88.3%) cases of the ERCP procedures. Common bile duct (CBD) stones were reported in 389 (51.3%) cases and were more frequent in females (234 cases, 60.1%) than males (155, 39.9%) (p=0.01). The majority of the CBD stones were successfully retrieved with balloon extraction (304 cases, 78.2%), while mechanical lithotripsy (67 cases, 17.2%) and Dormia basket (11 cases, 2.8%) were used for difficult stones. Only seven (1.8%) cases were referred for surgery. Malignancy was found in 151 (19.9%) of the cases and was significantly more common in males than females (102, 67.5% vs. 49, 32.5%, respectively, p=0.001). Stents for bile drainage were inserted in 26 (17.2%) of these cases. The complications encountered were acute pancreatitis in 30 cases (3.9%), minor bleeding in nine cases (1.2%), major bleeding in one case (0.15%), cholangitis in four cases (0.52%), and perforation in one case (0.15). Mortality was reported in three cases (0.4%). ConclusionThe ERCP indications and the related complications, in our centre in Libya, are comparatively consistent with those reported data in other countries. Successful biliary cannulation was achieved in most of the patients, and post-ERCP complications were uncommon except for pancreatitis, which occurred more frequently.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study in upper Egypt

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) has become widely available for diagnosis and treatment of pancreatic and biliary diseases. Pancreatitis is the most common and serious complication to occur after ERCP resulting in substantial morbidity and occasional mortality. The aim of this study was to evaluate the potential patient and procedure-related risk factors for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in a prospective multicenter study. Patients and methods Consecutive ERCP procedures were prospectively studied at five centers (two universities, three private). Data were collected on patient characteristics and endoscopic techniques before the procedure, at the time of procedure, and 24-72 h after discharge. PEP was diagnosed and its severity graded according to consensus criteria. Results Pancreatitis occurred after 104 (8.9%) of 1162 consecutive ERCP procedures and was graded mild in 66 (63.5%), moderate in 30 (28.8%), and severe in eight (7.7%) cases. On univariate analysis, 11 of 18 evaluated variables were found to be significantly associated with PEP. On multivariate analysis, significant risk factors with adjusted odds ratio (OR) were: difficult cannulation (OR: 10.2), previous PEP (OR: 8.1), previous pancreatitis (OR: 7.9), at least two pancreatic duct injections (OR: 3.1), pancreatic duct cannulation (OR: 2.7), difficult stone extraction (OR: 2.2), and precut sphincterotomy (OR: 1.2). Conclusion Technique-related risk factors are probably more numerous and potent than patient-related ones in determining high-risk predictors for PEP.

Patient-reported outcome measures after endoscopic retrograde cholangiopancreatography: a prospective, multicentre study

Objective. While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences. Methods. From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded. Results. Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure. Conclusions. Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.

The Impact of Endoscopic Retrograde Cholangiopancreatography Education on Radiation Exposure to Experienced Endoscopist: “Trainee Effect”

Endoscopic retrograde cholangiopancreatography(ERCP), as with other fluoroscopic procedures, carries the risk of exposure of staff to radiation. However, over the last two decades, only a few studies have investigated this risk. The aim of this work was to evaluate the dose of radiation exposure to staff participating in ERCP procedures in a busy teaching hospital that performs more than 1,850 procedures annually. The entire ERCP staff consisted of the experienced endoscopist, the assistant, and two nurses who were responsible for monitoring patients as well as keeping their heads in position during the procedure. RAD DOSE NEB.226 dosimeters, which were provided by the Turkish Atomic Energy Authority, were used for this study. Data on 110 consecutive therapeutic ERCP procedures was recorded. The mean fluoroscopy time was 5.65 ± 4.71 min. The mean fluoroscopy time of the 61 procedures performed by an experienced endoscopist alone was 5.41 ± 4.65 min, whereas the mean fluoroscopy time for the 49 procedures during which an assistant was involved was 5.94 ± 4.81 min (p = 0.56). In terms of median dose of ionizing radiation exposure to the eyes, the dose measurement per procedure in which the primary endoscopist participated alone was 72 microsievert (μSv), compared to 92 μSv when an assistant took part in theproceedings. Considering that the recommended annual equivalent dose limit to the lens of the eye is 150 mSv, by performing 1,850 procedures annually, the primary endoscopist exceeds this limit. Based on our results, taking into consideration the heavy workload in our hospital, it would seem that more experienced endoscopists are required to help provide training in ERCP, and that the use of lead acrylic goggles is required to decrease radiation exposure to the eyes.

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

BackgroundPancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD). MethodsA total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively. ResultsThe overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES. ConclusionsInvasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.

Deep Cannulation of the Common Bile Duct at Endoscopic Retrograde Cholangiopancreatography: How Challenging Is It?

Background: A key step in endoscopic retrograde cholangiopancreatography (ERCP) is to cannulate the common bile duct (CBD) and/or pancreatic duct (PD). Despite the advances in endoscopic techniques, cannulation remains an invariably technical challenge at times. A review of the literature revealed that no studies have been carried out to document the degree of difficulty in cannulation. Aim: To provide data to document the degree of difficulty in cannulation at ERCP. Methods: A prospective study to precisely document the time spent on each step during ERCP, including position time (the time from esophageal intubation to the time of appropriate positioning in order to attempt the cannulation of the ampulla), PD cannulation time (the time from initiating cannulation to the time of obtaining a pancreatogram), initial common bile duct (ICBD) cannulation time (the time from initiating cannulation to the time of obtaining an initial cholangiogram) and deep common bile duct (DCBD) cannulation time (the time from initiating cannulation to the time of the positioning of a cannulator deep inside the CBD). Results: Fifty-eight consecutive successful ERCP procedures were enrolled in the study. PD and ICBD cannulation rates were 96% and 90% respectively. DCBD cannulation rate was 78% (45 cases). The average time to complete an ERCP procedure was 46.65 minutes. The average position time was 3.9 minutes. The average time taken to perform PD cannulation was 2.66 minutes (6% of the entire procedure time). The average times taken to perform initial and deep cannulation of the CBD were 12.2 and 30.2 minutes respectively. This constituted 26% and 65% of the entire procedure time respectively. The degree of difficulty of DCBD cannulation was defined by three categories: failure to cannulate (22% of the cases), significant difficulty to cannulate defined as longer than thirty minutes to achieve that end point (31% of the cases), and easy/relative easy to cannulate (47% of the cases). There was a statistically significant difference when comparing PD or ICBD cannulation times to that of the DCBD (p value<0.001). Conclusion: DCBD cannulation was the longest step in ERCP. DCBD cannulation is still a technical challenge in some cases even in experienced hands. Hence, Solutions resulting in a shortening of the DCBD cannulation time will significantly shorten the ERCP procedure time.

Success of repeat ERCP by the same endoscopist

Background: The success rate of repeat endoscopic retrograde cholangiopancreatography (ERCP) by the same endoscopist after a failed initial attempt is unknown. It has been suggested that a repeat examination at a tertiary referral center be performed after an unsuccessful attempt. Our aim was to determine the success rate of repeat ERCP at a different endoscopic session by the same endoscopist and the outcomes among patients with a failed index procedure. Methods: A review of 500 consecutive ERCP procedures was performed at a teaching institution. Results: The overall initial success rate for cannulation of the duct of interest was 90.8% at index endoscopy. Endoscopy was repeated after 51% unsuccessful procedures, and access to the desired duct was achieved in 87.5% of repeat attempts. A needle knife was used in 21% instances, and its use facilitated cannulation of the duct of interest in 80%. No complications occurred with repeat ERCP. Of the 3 patients who underwent failed repeated ERCP, 1 was not available for the follow-up study, 1 had metastatic cancer, and the other had pancreas divisum. The outcomes among patients who did not undergo repeat ERCP included malignant disease diagnosed with other imaging techniques (35% of patients) and no further admissions or emergency room visits for suspected pancreaticobiliary symptoms (39% of patients). Conclusions: Repeat ERCP by the same endoscopist yields an 87.5% success rate. This leads to an overall success rate of 95%. (Gastrointest Endosc 1999;49:58-61.)