Endoscopic Retrograde Cholangiopancreaticography Research Articles

Dexmedetomidine as an Adjunct to Propofol in Patients Undergoing Elective Endoscopic Retrograde Cholangio-Pancreaticography - A Double-blind Randomized Controlled Study.

Propofol is the drug of choice for procedural sedation. The addition of α2 agonist dexmedetomidine may improve the safety profile of the procedure by providing stable hemodynamics, better sedation quality, and decreasing the side effects of each drug during elective endoscopic retrograde cholangio-pancreaticography (ERCP). Eighty patients aged between 18 and 60 years were distributed randomly into two groups. The dexmedetomidine + propofol group (group DP) received an injection of dexmedetomidine at the dose of 1 mcg/kg in 100 mLsaline, and the propofol group (group P) received plain 100 mL normal saline over 10 min. Subsequently, both groups received a bolus dose of injection propofol 1 mg/kg as sedation, and a modified observer's assessment of alertness/sedation score (MOASS) score was assessed, followed by infusion at the rate of 50 mcg/kg/min during the procedure. A rescue bolus dose (20 mg) of propofol was administered when the patient showed signs of inadequate sedation or analgesia in both groups. Cardiovascular and respiratory parameters were recorded every 10 min throughout the procedure. Post-procedure modified Aldrete score was evaluated for 30 min, and the endoscopist's score was noted at the end of the procedure. There was a significant difference (P = 0.001) in the additional number of rescue doses of propofol administered in group DP (3.47 ± 0.77) as compared to group P (8.78 ± 1.11). The total dose of propofol was lower in group DP (316.59 ± 43.29 mg) than in group P (443 ± 41.1 mg) with P value = 0.001. Statistically significant differences in the hemodynamic values were observed in group DP during infusion (P value < 0.05) of dexmedetomidine and throughout the procedure (P < 0.05) when compared with group P. Endoscopists graded the satisfaction score as very high (3.477 ± 0.77) in group DP. The addition of dexmedetomidine to propofol during ERCP provided better and safer sedation.

Prevention of peri-interventional hypothermia during endoscopic retrograde cholangiopancreatography using a forced-air heating system.

Background and study aims Perioperative hypothermia is associated with significant complications and can be prevented with forced-air heating systems (FAHS). Whether hypothermia occurs during prolonged endoscopic sedation is unclear and prevention measures are not addressed in endoscopic sedation guidelines. We hypothesized that hypothermia also occurs in a significant proportion of patients undergoing endoscopic interventions associated with longer sedation times such as endoscopic retrograde cholangiopancreaticography (ERCP), and that FAHS may prevent it. Patients and methods In this observational study, each patient received two consecutive ERCPs, the first ERCP following current standard of care without FAHS (SOC group) and a consecutive ERCP with FAHS (FAHS group). The primary endpoint was maximum body temperature difference during sedation. Results Twenty-four patients were included. Median (interquartile range) maximum body temperature difference was -0.9°C (-1.2; -0.4) in the SOC and -0.1°C (-0.2; 0) in the FAHS group ( P < 0.001). Median body temperature was lower in the SOC compared with the FAHS group after 20, 30, 40, and 50 minutes of sedation. A reduction in body temperature of > 1°C ( P < 0.001) and a reduction below 36°C ( P = 0.01) occurred more often in the SOC than in the FAHS group. FAHS was independently associated with reduced risk of hypothermia ( P = 0.006). More patients experienced freezing in the SOC group ( P = 0.004). Hemodynmaic and respiratory stability were comparable in both groups. Conclusions Hypothermia occurred in the majority of patients undergoing prolonged endoscopic sedation without active temperature control. FAHS was associated with higher temperature stability during sedation and better patient comfort.

Factors causing conversion in laparoscopic cholecystectomy

Introduction and purpose: Laparoscopic cholecystectomy (LC) is the gold standard surgical procedure in the treatment symptomatic gall bladder disease. Conversion is not a failure or complication. It is only a step taken to ensure patient safety and to avoid complications. The objective of our study was to investigate the rate and the causative preoperative and intraoperative factors of conversion and to help surgeons have an idea about potential intraoperative challenges. Materials and methods: Laparoscopic cholecystectomy procedures performed on 4433 patients with signs and symptoms of cholelithiasis-cholecystitis who were diagnosed with abdominal ultrasonography were retrospectively reviewed. The patients were grouped on the basis of age, gender, length of hospitalization, history of preoperative endoscopic retrograde cholangiopancreaticography (ERCP), diabetes mellitus (DM), chronic fibrotic cholecystitis, gall bladder polyps, and urgent-elective surgery. The rate and causative factors of conversion were investigated. Statistical analyses were carried out using IBM SPSS for Windows, version 17.0 (IBM statistics for Windows version 17, IBM Corparation, Armonk, New York, United States) software package. Result: In our study, the conversion rate was 0.85%. Male gender, advanced age, increased length of hospitalization, history of preoperative ERCP, urgent surgery (acute-hydropic cholecystitis), and chronic fibrotic cholecystitis were the significant risk factors for conversion. DM had no effect on conversion. Conclusion: Conversion should not be necessarily regarded as a complication in laparoscopic cholecystectomy. Identifying patients with significant risk factors for conversion can significantly minimize the complications of the laparoscopic procedure. This may assist in identifying high-risk patients and reviewing surgical strategy in this patient group.

The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study

IntroductionIn acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. MethodsThis was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. ResultsThe discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). ConclusionsCLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.

Veiled Right Kidney Sign in Endoscopic Retrograde Cholangiopancreaticography

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Biliary papillomatosis.

Biliary papillomatosis (BP) is a rare disorder of the biliary tract characterized by the presence of multiple papillary adenomas spread along the biliary tree. Although benign, it carries a significant risk of malignant transformation. Due to low sensitivity and specificity of conventional radiologic modalities, the diagnosis as well as estimation of disease extent is difficult. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP) are superior although direct peroral cholangioscopy (POC) is currently the most accurate diagnostic method. Mainly because it provides more detailed information and makes targeted histological diagnosis possible. The treatment of biliary papillomatosis consists of surgical resection, liver transplantation (LT) or a combination of both. Unfortunately, the recurrence rate after radical surgery without LT remains high due to the diffuse distribution of the disease.

Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean.

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).

Magnetic resonance cholangiography in the diagnosis of dominant strictures in pediatric-onset primary sclerosing cholangitis

BackgroundMagnetic resonance cholangiopancreaticography (MRCP) has become the primary imaging modality in primary sclerosing cholangitis (PSC). Endoscopic retrograde cholangiopancreaticography (ERCP) is recommended when a dominant stricture (DS) of bile ducts is suspected in MRCP. However, MRCP criteria for DS are lacking. AimsTo evaluate the diagnostic accuracy of MRCP in the diagnosis of DS in patients with pediatric-onset PSC. MethodsERCP and MRCP images of patients with pediatric-onset PSC (n=36) were evaluated for the presence of DS applying the diameter-based ERCP criteria. The diagnostic accuracy of MRCP in detecting DS was calculated using ERCP as the gold standard. ResultsThe sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and accuracy of MRCP for detecting DS were 62%, 89%, 5.6, 0.43, and 81%. Most common reasons for incongruent ERCP/MRCP assessment were (1) MRCP stenosis not fulfilling the diameter criteria of ERCP, resulting in false negative MRCP evaluation, and (2) lack of filling pressure in MRCP, resulting in false positive MRCP evaluation. ConclusionThe high positive likelihood ratio of MRCP in detecting DS suggests that MRCP is a useful tool in the follow-up of PSC. However, diameter limits of DS should probably be less strict in MRCP than in ERCP.

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)

AbstractEndoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Does patient's position count during Endoscopic Retrograde Cholangio-pancreatography? Left lateral decubitus versus prone position.

To compare the efficacy and safety of left lateral decubitus versus prone position during endoscopic retrograde cholangio-pancreaticography (ERCP). This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January to June 2021. Patients requiring ERCP were subsequently allotted LL or PP group randomly (unequal randomization) except patients with recent abdominal surgery, in-dwelling catheters, raised intra-abdominal pressure, cervical spine abnormalities and limb contractures. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and student T or Mann Whitney U-test. A total of 114 patients were enrolled according to the inclusion criteria with 62(54%) males and majority of the patients (42%) belonging to the age group 31-45 years. The most common ERCP indication was choledocholithiasis (36%). Technical success was achieved in 109(96%) patients with no statistically significant difference between the two groups. The total time of procedure, time for deep cannulation, time for acquiring therapeutic goal and ERCP complexity level were all similar between the two groups. The rate of inadvertent PD cannulation and PEP were relatively higher for the PP group but were statistically non-significant through univariate and logistic regression analyses and the only outcome measure that showed significance was multiple cannulations in the PP group. The study concludes that LL is non-inferior to PP and both positions have comparable outcomes with non-significant differences in terms of technical success rate, complications (specifically PEP), total procedure time, time required for deep cannulation and attainment of goal, ERCP complexity level and inadvertent PD cannulation.

Technical Considerations and Complication of Percutaneous Transhepatic Biliary Drainage: A Single Center Retrospective Study

Introduction: With comparable outcomes, percutaneous transhepatic biliary drainage (PTBD) is the preferred method for relieving biliary obstruction when the gold standard endoscopic retrograde cholangiopancreaticography (ERCP) fails or is not practicable.&#x0D; Aims &amp; Objectives: To evaluate the technical success rate, clinical success rate, and complications of PTBD.&#x0D; Place and duration of study: This study was carried out in Radiology Department of Pakistan Kidney and Liver Institute and Research Center, Lahore, Pakistan from 29th February 2020 to 1st November 2021.&#x0D; Material &amp; Methods: In this study, consecutive PTBD procedures performed from 29th February 2020 to 1st November 2021 were retrospectively reviewed. We collected data including patients' age, gender, diagnosis, indications, prior ERCP performance, preoperative and post operative bilirubin, and complications. Technical success, clinical success, and complications were documented. SPSS Version 26 was used for data entry and analysis, P-value&lt;0.05 was taken as significant.&#x0D; Results: A total of 96 procedures were performed in 64 patients with the mean age of 52 years (range: 20 - 91 years). Out of 96, 66 (68.8%) procedures were performed in malignant obstruction with most common cause being cholangiocarcinoma (24%). Technical success was achieved in100% of the cases while clinical success rate was 90.6%. In total 96 procedures, 7 complications were reported. Major complication rate was 5.2%. These included 2 cases of post-procedure cholangitis (2.1%), 2 cases of acute pancreatitis (2.1%), and a case of bilio-venous fistula (1%). Minor complication rate (including 2 cases of pericatheter leakage) was 2.1%.&#x0D; Conclusion: PTBD is a reliable and effective procedure. In general, complication rate after PTBD is not high, and the patients having malignant disease were more prone to the complications.

Effect of the using a pupillometer on recovery and early cognitive functions in anesthesia management for endoscopic retrograde cholangiopancreaticography in geriatric patients

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure used for the diagnosis and treatment of pancreaticobiliary pathologies. Because it is an invasive procedure that is difficult to tolerate by the patient and takes a long time, it is preferable to use it under deep patient sedation and even under general anesthesia in some cases. This study aimed to evaluate the effects of using a pupillometer versus the Ramsey sedation scale (RSS) during anesthesia management for ERCP on recovery and return of cognitive functions in the geriatric patient population. Methods: A mini-mental test was applied to evaluate the pre-operative cognitive functions of the cases before the intervention. The included patients were divided into groups using the sealed-envelope method. Management of the depth of anesthesia was evaluated by Ramsey sedation scale; in group R and was evaluated by pupillometer in group P. The infusion dose of dexmedetomidine was changed to 0.1 µg/kg/h according to the results of the evaluation. Results: Sixty cases were included in the study. No difference between the groups in terms of age (P=0.246), gender (P=0.797), American Society of Anesthesiologists (ASA) score (P=0.197), comorbidity (P=0.748), anesthesia duration (P=0.397), midazolam doses (P=0.561), propofol doses (P=0.677), and intra-operative hemodynamic values (P=0.668) were found. Intra-operative dexmedetomidine dose was statistically significantly lower (P=0.004), and recovery was faster in group P (P&lt;0.001). While no differences between the groups in the pre-operative mini-mental test scores (P=0.140) were found, the post-operative scores were statistically significantly lower in group R (P=0.025). Conclusion: In this study, it was observed that the pupillometer led to a reduction in the use of dexmedetomidine and cognitive functions were better during the post-operative recovery period. As a result, depth of anesthesia can be monitored with a pupillometer. Although the use of pupillometer in endoscopic interventions in the geriatric patient group does not make a hemodynamic difference when compared with the RSS, the pupillometer leads to accelerated recovery from anesthesia, improvement in the return of cognitive functions, and reduction in drug consumption.

Digital single-operator cholangioscopy to guide selective cannulation of complex biliary strictures

BackgroundSelective cannulation and stenting of complex, tight, and/or angulated biliary strictures under endoscopic retrograde cholangiopancreaticography (ERCP) can be challenging. Digital single-operator cholangioscopy (SOC) may facilitate guidewire advancement through the stricture with endoscopic visual guidance. We aimed to describe a case series on clinical outcomes of this technique for selective cannulation, when used after failed conventional ERCP attempts.MethodsConsecutive patients who underwent therapeutic digital SOC for selective cannulation of biliary strictures after failed conventional ERCP were retrospectively included.ResultsTen patients with a malignant (n = 6) or benign (n = 4) biliary stricture were included. Digital SOC-assisted selective guidewire insertion and stent placement across the biliary stricture were technically successful in five (50%) patients. Bilirubin levels improved in all patients with technical success. One (10%) patient developed a post-ERCP pancreatitis.ConclusionsTechnically successful cannulation of biliary strictures with digital SOC was achieved in half of patients in whom cannulation with conventional ERCP failed, sparing them more invasive interventions. Stricture opacification during the failed ERCP was seen in all technically successful SOCs.

S1114 Protein-Calorie Malnutrition Is Associated With Worse Outcomes in Patients Admitted With Acute Cholangitis Undergoing Endoscopic Retrograde Cholangiopancreaticography

Introduction: Acute cholangitis, often caused by biliary obstruction, can lead to sepsis and death due to multiorgan failure. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended first line therapeutic modality in the management of acute cholangitis. ERCP can be associated with complications such as pancreatitis, perforation, and bleeding. Protein-calorie malnutrition (PCM) is associated with poor clinical outcomes in hospitalized patients. The aim of this study is to elucidate the relationship between PCM and patients undergoing ERCP for acute cholangitis. Methods: Data were extracted from the National Inpatient Sample (NIS) database in the period between 2016 to 2019. Using the International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes to obtain baseline demographic and clinical data, in-hospital mortality, hospital charges, and hospital length of stay (LOS). Statistical analysis was completed using t-test and Chi-squared analyses. Multivariate analysis for the mortality odds ratio (OR) was calculated after adjusting for potential confounders. Results: A total of 123,285 patients with ascending cholangitis underwent ERCP, and 11,135 (9%) of these patients had PCM. The mean age of the PCM group was 68.15 years which was not significantly different from the non-PMN group (p-value 0.86). Most patients in the PCM group were males (56%) and whites (62.6%). More patients in the PCM group were alcoholics, had diabetes mellitus, congestive heart failure (CHF), and cirrhosis compared to the non-PCM group. After controlling for potential confounders, PCM was associated with higher in-hospital mortality (OR 3.4, CI 2.85-4.04; p< 0.01). Moreover, patients with PCM had higher total hospital charges ($175,726 vs. $82,824; P< 0.01), and a longer LOS (12.7 vs 6.1 days; P< 0.01). In addition to malnutrition, age > 65 years, non-white race, cirrhosis, and CHF were independently associated with higher in-hospital mortality (Table). Conclusion: PCM is a strong predictor of poor clinical outcomes in patients with acute cholangitis admitted for ERCP. Systemic comorbidities such as cirrhosis and CHF are often associated with diminished nutritional states which may explain the higher prevalence of in-hospital mortality in the study group. Nutritional status is a modifiable risk factor and should be optimized to improve clinical outcomes in hospitalized patients with cholangitis. Table 1. - Univariate and multivariate analysis of factors affecting in-hospital mortality in patients with acute cholangitis undergoing ERCP Variable Univariate Multivariate OR (CI 95%) P-value OR (CI 95%) P-value Protein-calorie malnutrition 3.66 (3.08-4.34) < 0.01 3.4 (2.85-4.04) < 0.01 Age > 65 1.47 (1.25-1.73) < 0.01 1.38 (1.16-1.64) < 0.01 Female 1.06 (0.91-1.22) 0.41 1.06 (0.91-1.23) 0.436 Non-White 1.24 (1.06-1.44) < 0.01 1.25 (1.07-1.46) < 0.01 Alcoholism 1.4 (1.03-1.9) 0.02 1.32 (0.94-1.84) 0.1 Cirrhosis 2.18 (1.68-2.82) < 0.01 1.89 (1.82-2.6) < 0.01 Congestive heart failure 2.38 (2.02-2.82) < 0.01 2.17 (1.42-2.52) < 0.01 Smoking 0.57 (0.48-0.68) < 0.01 0.6 (0.5-0.71) < 0.01

High risk of complications and mortality in cirrhotic patients with acute pancreatitis

High risk of complications and mortality in cirrhotic patients with acute pancreatitis

A Year of Endoscopic Retrograde Cholangiopancreatography (ERCP) At a Glance. Indications, Interventions, Complications

Objective: To determine the demographics, indications and frequency of interventions and complications endoscopic retrograde cholangiopancreatography (ERCP).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2019.&#x0D; Methodology: The study included all the elective and emergency ERCP procedures from January 2019 to December 2019.&#x0D; Results: Out of 1030 patients who underwent endoscopic retrograde cholangio-pancreaticography, 903 were enrolled. Sixtyone percent of the participants were males. The mean age was 56 ± 16 years, with the majority of the patients lying in the age range of 41-65 years. The most common indication for ERCP in this study was choledocholithiasis (47%), the most common complication encountered was acute pancreatitis (2.1%), and a mortality rate of 0.2% was reported. The complication rate was statistically related to the intervention rather than the age and gender of the patients.&#x0D; Conclusion: The most common indication for ERCP remains choledocholithiasis, with the most common ERCP complication being acute pancreatitis followed by stent migration. Biliary fistulae, post-surgical biliary leaks and strictures, pancreatic pseudo cysts, acute cholangitis, choledocholithiasis and cholestasis secondary to as cariasis were found in a relatively younger group. The success rate was above 95% for high volume centres.

Endoscopic Retrograde Cholangio-pancreaticography versus Laparoscopic Common Bile Duct Exploration in Management of Choledocholithiasis: A Comparative Study

Endoscopic Retrograde Cholangio-pancreaticography versus Laparoscopic Common Bile Duct Exploration in Management of Choledocholithiasis: A Comparative Study

Endoscopic retrograde cholangiopancreaticography-related complications - Experience from tertiary care teaching centre over half a decade.

Endoscopic retrograde cholangiopancreaticography (ERCP) is an essential therapeutic procedure with a significant risk of complications. Data regarding the complications and predictors of adverse outcomes such as mortality are scarce, especially from India and Asia. We aimed to look at the incidence and outcome of complications in ERCP patients. This study is a retrospective analysis of prospectively collected data of all the patients who underwent ERCP and had a complication from January 2012 to December 2018. Data were recorded in predesigned pro forma. The data analysis was done by appropriate statistical tests. : A total of 17,163 ERCP were done. A total of 570 patients (3.3%) had complications; perforation (n = 275, 1.6%) was most common followed by pancreatitis (n = 177, 1.03%) and bleeding (n = 60, 0.35%). The majorities of perforations were managed conservatively (n = 205, 74.5%), and 53 (19%) required surgery. Overall, 69 (0.4%) patients died. Of these, 30 (10.9%) patients died with perforation. Age (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.005-1.07) and need of surgery (OR: 5.11, 95% CI: 1.66-15.77) were the predictors of mortality in patients with perforation. The majority pancreatitis were mild (n = 125, 70.6%) and overall mortality was 5.6% (n = 10). ERCP complications have been remained static over the years, with perforation and pancreatitis contributing the most. Most perforations can be managed conservatively with good clinical outcomes.

Mirizzi Syndrome: An Experience in Laparoscopic Era

Objective:To assess the presentation and surgical management of Mirrizi syndrome patients who underwent LaparoscopicCholecystectomy. Study Design and Setting:Retrospective Descriptive Study was conducted at Surgical Department Combined MilitaryHospital Rawalpindi and Combined Military Hospital Quetta from 1st Jan 2010 to 20th Jan 2016. Methodology:Patients undergoing laparoscopic cholecystectomy during this period were retrospectively reviewed. Allcases of Mirizzi Syndrome (MS) were identified and data analysed. Results:A total of 5500 patients underwent laparoscopic cholecystectomy during this period. Approximately 26(0.47%)cases were identified to be having MS. Out of these 26 cases only 8 (30%) were males while 18 (70%) were females. Ageranged from 25 to 80 years. Three patients (11%) had an endoscopic retrograde cholangiopancreaticography (ERCP) done.Type-I MS was found in 19 cases (73 %), Type-II in 3 cases (11%), Type-III and Type-IV in 2 cases each (7.69 %).Conversion to open surgery was carried out in 15 cases (57.6 %). All type-I MS had cholecystectomy except one casewhere partial cholecystectomy was done. T-tube closure of common bile duct was done in all Type-II MS. Similarly T-tube closure was possible in two cases of type-III while one hadRoux-en-Y hepaticojejunostomy. All cases of type-IV MS had Roux-en-Y hepaticojejunostomy. One patient out of 26 (3.8 %) had carcinoma gallbladder. There was no mortality. Conclusion:Type-I MS can be managed with laparoscopic cholecystectomy in selected patients.Type-II and type-III MS may need placement of T-tube while most of type-IV MS are managed with Roux-en-Y hepaticojejunostomy.

787 The Hidden and The Lost: A Case of a Rare Complication from A Long-Lost Surgical Technique

Abstract Background Various operative techniques have been developed for liver transplant since the 1960's. Waddell-Calne technique for biliary reconstruction in orthotopic liver transplant (OLT) was one of the rare and now relatively obsolete techniques. The aim of our presentation is to describe a long-term complication of this lost technique and how it posed multiple diagnosis and management challenges after 35 years post-liver transplant. Case presentation Our case is on a 50-year-old lady with a history of OLT for end-stage liver failure secondary to type-1 autoimmune hepatitis. Peri and postoperative period were completely unremarkable. 35 years later, she presented with symptoms of recurrent cholangitis. Magnetic resonance cholangio-pancreaticography demonstrated biliary tree dilatation with choledocholithiasis and possible cholecystitis. Removal of the distal stones together with pig-tail stent insertion was achieved via endoscopic retrograde cholangio-pancreaticography, however, her biliary colic persisted. The background of OLT and grossly distorted anatomy on imaging posed a challenge for further surgery. Extensive tracing of the history back from 1985 and multicentre multidisciplinary discussion revealed that the Waddell-Calne technique was carried out for her OLT where a gallbladder conduit was used for the hepaticojejunal-anastomosis. Finally, excision of the gallbladder conduit and hepaticojejunostomy with long Roux-en-Y was able to perform successfully. Conclusions Waddle-Calne technique is rarely seen globally nowadays but should be considered as a possible cause of recurrent cholangitis in patients with a history of OLT a long time ago. We demonstrated that the knowledge of such a rare procedure, together with the multidisciplinary approach could enormously benefit the management of the case.