Difficulty Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Diagnosis and management of type II endoscopic retrograde cholangiopancreatography-related perforations: a multicenter retrospective study

BackgroundThe management of type II endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is still controversial. This study aimed to compare the effects of covered self-expandable metallic stent (SEMS), surgery, and conservative treatment for type II perforation.MethodsFrom January 2010 to December 2021, this study collected relevant data from five large hospitals in China. The data of ERCP difficulty grading and ERCP-related perforation in 26,673 cases that underwent ERCP during 11 years were retrospectively analyzed. Of 55 patients with type II perforation, 41 patients were implanted with a biliary covered SEMS (stent group), 10 underwent surgery (surgery group), and 4 received conservative treatment (conservative group).ResultsAmong the 55 patients with type II perforation, ERCP and computed tomography diagnostic rates of type II perforation were 10.91% (6/55) and 89.09% (49/55), respectively. The incidence of type II perforation in grade 5 ERCP (0.43%, 11/2,537) was significantly higher than that in grade 1–3 ERCP (0.16%, 32/19,471). (P = 0.004) and grade 1–4 ERCP (0.26%,12/4,665) (P = 0.008), respectively. Among the 10 patients in the surgical group, primary repair was performed in only 7 patients in whom location of the perforation could be identified. The incidence of retroperitoneal abscess was significantly lower in the stent group than in the surgery group (P = 0.018) and the conservative group (P = 0.001), respectively. The average hospital stay in the stent group was shorter than that in the surgery group (P = 0.000) and conservative group (P = 0.001), respectively.ConclusionsThe incidence of type II perforation was dependent on the degree of difficulty of ERCP. The treatment of type II perforation with a covered SEMS can significantly reduce the incidence of retroperitoneal abscess and shorten the hospital stay, with better results than surgical and conservative treatments.

Management of borderline common bile duct stones: Retrospective comparative study

Background Borderline Size common bile duct stones (BLS-CBDS) are associated with hepato-pancreato-biliary morbidity and complications. Its optimum management is still controversial till now. Aim Is to compare conservative treatment versus endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of BLS-CBDS. Material and methods This retrospective study included patients with BLS-CBDS less than or equal to 10 mm who were treated conservatively or by ERCP endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). The primary outcome was successful common bile duct (CBD) clearance, and the secondary outcomes were complications, impact on laparoscopic cholecystectomy, and hospital stay. Results Out of 270 patients, 150 were treated by ERCP and 120 by the Conservative approach. There was complete clearance of CBDS in 75 (50%) patients out of 150 patients in the ERCP group and useless procedure in the remaining 75 (50%) patients. In the conservative group, there was complete clearance of CBDS in 99 (82.5%) cases, and useless in the remaining 21 (17.5%) patients. Post-ERCP pancreatitis occurred in 33 (22%) patients. Conclusion BLS-CBDS increases the technical difficulty of ERCP and the risk of post-ERCP pancreatitis. Conservative management of CBDS is effective in clearing CBDS, it should be considered to avoid unnecessary ERCP and its complications.

Ectopic Opening of Common Bile Duct to Duodenal Bulb: A Single Tertiary Center Experience.

The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients. This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020. The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP. Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

Effect of Disposable Elevator Cap Duodenoscopes on Persistent Microbial Contamination and Technical Performance of Endoscopic Retrograde Cholangiopancreatography

Infection transmission following endoscopic retrograde cholangiopancreatography (ERCP) can occur due to persistent contamination of duodenoscopes despite high-level disinfection to completely eliminate microorganisms on the instrument. To determine (1) contamination rates after high-level disinfection and (2) technical performance of duodenoscopes with disposable elevator caps compared with those with standard designs. In this parallel-arm multicenter randomized clinical trial at 2 tertiary ERCP centers in Canada, all patients 18 years and older and undergoing ERCP for any indication were eligible. The intervention was use of duodenoscopes with disposable elevator caps compared with duodenoscopes with a standard design. Coprimary outcomes were persistent microbial contamination of the duodenoscope elevator or channel, defined as growth of at least 10 colony-forming units of any organism or any growth of gram-negative bacteria following high-level disinfection (superiority outcome), and technical success of ERCP according to a priori criteria (noninferiority outcome with an a priori noninferiority margin of 7%), assessed by blinded reviewers. From December 2019 to February 2022, 518 patients were enrolled (259 disposable elevator cap duodenoscopes, 259 standard duodenoscopes). Patients had a mean (SD) age of 60.7 (17.0) years and 258 (49.8%) were female. No significant differences were observed between study groups, including in ERCP difficulty. Persistent microbial contamination was detected in 11.2% (24 of 214) of standard duodenoscopes and 3.8% (8 of 208) of disposable elevator cap duodenoscopes (P = .004), corresponding to a relative risk of 0.34 (95% CI, 0.16-0.75) and number needed to treat of 13.6 (95% CI, 8.1-42.7) to avoid persistent contamination. Technical success using the disposable cap scope was noninferior to that of the standard scope (94.6% vs 90.7%, P = .13). There were no differences between study groups in adverse events and other secondary outcomes. In this randomized clinical trial, disposable elevator cap duodenoscopes exhibited reduced contamination following high-level disinfection compared with standard scope designs, without affecting the technical performance and safety of ERCP. ClinicalTrials.gov Identifier: NCT04040504.

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.

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.

Multicenter database registry for endoscopic retrograde cholangiopancreatography: Japan endoscopic database project

Background and aim Few studies have reported on a national, population-based endoscopic retrograde cholangiopancreatography (ERCP) database. Hence, in 2015, we established a multicenter ERCP database registry, the Japan Endoscopic Database (JED) Project in preparation for a nationwide endoscopic database. The objective the present study was to evaluate this registry before the establishment of a nationwide endoscopic database. Methods From 1 January 2015 to 31 March 2017, we collected and analyzed the ERCP data of all patients who underwent ERCP in four participating centers in the JED Project based on the JED protocol. Results Four centers carried out 4104 ERCP on 2173 patients. Data entry of ERCP information (age, 100%; gender, 100%; American Society of Anesthesiologists Physical Status Classification System, 74.5%; scope, 92.7%; time to ERCP, 100%; antithrombotic drug information, 55.0%; primary selective common bile duct [CBD] cannulation methods, 73.0%; number of attempts at primary selective CBD cannulation, 67.6%; overall selective CBD cannulation methods, 68.9%; ERCP procedure time, 66.3%; fluoroscopy time, 65.1%; adverse events, 74.9%; serum amylase levels 1 day post-ERCP, 36.5%) was accurately extracted from the four centers. Success rate of CBD cannulation by level of ERCP difficulty was 98.5%, 99.0%, and 96.4% in grades 1, 2, and 3, respectively. Complication rate by overall selective CBD cannulation method was 5.6%, 7.6%, and 10.5% in the contrast-assisted technique, guidewire-assisted technique, and cross-over method, respectively. Conclusion Data from this evaluation of the JED Project, a multicenter ERCP database registry, suggest the feasibility of establishing a nationwide ERCP database and its challenges.

A Comparison of Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography (ERCP) by Different Fluoroscope Techniques

ABSTRACT Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively new endoscopic procedure combined with fluoroscopy that is performed for multiple diagnostic and therapeutic indications. It carries a known risk of radiation exposure to patients and staff. We aimed to examine radiation administration techniques and to measure the radiation dose delivered by these techniques. Methods This was a retrospective analysis of 437 ERCP procedures performed at a tertiary care hospital between April 2015 and April 2017. Results A total of 437 ERCP procedural charts were reviewed: fluoroscopy administration was endoscopist controlled (EC, n = 187, 42.79%) or technician controlled (TC, n = 250, 57.21%). The mean (and SD) fluoroscopy time (FT) was 2.107 ± 2.0 minutes. The mean (and SD) dose–area product (DAP) was 15,227.371 ± 16,784.738 Gy·cm2. The degree of ERCP difficulty was evaluated as recommended by the American Society for Gastrointestinal Endoscopy, and graded 1–4. Level I TC procedures had a mean FT and DAP of 1.600 minutes and 12,644.72 Gy·cm2, respectively. The FT and DAP values for level I EC procedures were 1.514 minutes and 12,966.71 Gy·cm2, respectively, as compared with level IV TC procedures (mean FT, 2.539 minutes; mean DAP, 19,469.94 Gy·cm2) and level IV EC procedures (mean FT, 4.890 minutes; mean DAP, 37,921.00 Gy·cm2). Conclusion DAP and FT are increased significantly in EC ERCP in American Society for Gastrointestinal Endoscopy 4 procedures. Comparison of the different degrees of difficulty indicated that there is a linear correlation between the degree of difficulty and both FT and DAP.

Morphology of the major papilla predicts ERCP procedural outcomes and adverse events.

The morphology of the major papilla affects the difficulty of endoscopic retrograde cholangiopancreatography (ERCP), but no associations with adverse events have previously been established. We aimed to assess whether papillary morphology predicts ERCP adverse events. A retrospective analysis was performed of a prospective registry of patients undergoing ERCP for biliary indications. The primary outcome was post-ERCP pancreatitis (PEP), with secondary outcomes including other adverse events and procedural outcomes such as inadvertent pancreatic duct cannulation, cannulation time, and attempts. Papillae were classified as normal (Type I), small or flat (Type II), bulging (Type IIIa), pendulous (Type IIIb), creased (Type IV), or peri-diverticular (Type D). Outcomes were ascertained prospectively at 30days from index procedures. A total of 637 patients with native papillae were included. Compared to Type I papillae, Type II and Type IIIb papillae were associated with PEP, with adjusted odds ratios (AOR) of 7.28 (95% confidence intervals, CI, 1.84-28.74) and 4.25 (95% CI 1.26-14.32), respectively. Type II and IIIb papillae were associated with significantly longer cannulation times by 5.37 (95% CI 2.39-8.35) and 4.01 (95% CI 1.72-6.30) minutes, respectively. Type IIIb papillae were associated with lower deep cannulation success (AOR 0.17, 95% CI 0.06-0.48). Papillary morphology is an important factor influencing both ERCP success and outcomes. Understanding this is key for managing intraprocedural approaches and minimizing adverse events. Clinicaltrials.gov identifier NCT04259580.

S0950 A Comparison of Radiation Exposure During ERCP by Different Fluoroscope Techniques

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure performed for multiple diagnostic and therapeutic indications. It carries benefits and risks like all other interventions. We focused on radiation exposure to patients and staff. In the literature review, we found that radiation dose is lower when radiation administration is physician-controlled, and as the physician becomes more experienced, they utilize less radiation. The aim was to compare different operation techniques of radiation administration during ERCP. METHODS: This was a retrospective study of all 437 ERCP procedures performed at a tertiary care hospital between April 2015 and April 2017. Data were collected from the hospital electronic system and included demographics, procedure indication, fluoroscopy time (FT), dose area product (DAP), degree of difficulty as per American Society of Gastrointestinal Endoscopy (ASGE) recommendations. Median and mean FT and DAP between endoscopist- controlled (EC) compared to technician-controlled (TC). RESULTS: Of the 437 cases analyzed 45.5%males, and the mean age was 56.7. EC was 187 cases, representing 42.79%. The mean fluoroscopy time (FT) was 2.107 ± 2.0 minutes. The mean dose–area product (DAP) was 15227.371 ± 16784.738 Gy·cm2 for all procedures. The degree of ERCP difficulty was graded from 1-4 as per ASGE. Level I TC procedures had a mean FT and DAP of 1.600 minutes and 12644.72 Gy·cm2, respectively; level I EC procedures were1.514 minutes and 12966.71 Gy·cm2, respectively. For level IV, TC procedures the mean FT, 2.539 minutes, and the mean DAP was 19469.94 Gy·cm2. For level IV EC procedures, the mean FT was 4.890 minutes; the mean DAP was 37921.00 Gy·cm2. CONCLUSION: This study did not show a significant difference in radiation dose between EC and TC except in ASGE level IV, where a significant increase noticed in the EC group. The results of multiple other fluoroscopic studies in urology and cardiology showed that when the procedure is physician-controlled, radiation administered is similar or lower than TC. This difference in comparison to the other studies could be attributed to the endoscopist attention divided into multiple fronts, including doing the procedure that predisposes them to push on the pedal for longer than intended while manipulating the scope and leading the team. Although these results are inconclusive, it does shed light on the importance of further studies on radiation administration techniques for patients and staff safety.

Multicenter database registry for endoscopic retrograde cholangiopancreatography: Japan Endoscopic Database Project

Few studies have reported on a national, population-based endoscopic retrograde cholangiopancreatography (ERCP) database. Hence, in 2015, we established a multicenter ERCP database registry, the Japan Endoscopic Database (JED) Project in preparation for a nationwide endoscopic database. The objective the present study was to evaluate this registry before the establishment of a nationwide endoscopic database. From 1 January 2015 to 31 March 2017, we collected and analyzed the ERCP data of all patients who underwent ERCP in four participating centers in the JED Project based on the JED protocol. Four centers carried out 4104 ERCP on 2173 patients. Data entry of ERCP information (age, 100%; gender, 100%; American Society of Anesthesiologists Physical Status Classification System, 74.5%; scope, 92.7%; time to ERCP, 100%; antithrombotic drug information, 55.0%; primary selective common bile duct [CBD] cannulation methods, 73.0%; number of attempts at primary selective CBD cannulation, 67.6%; overall selective CBD cannulation methods, 68.9%; ERCP procedure time, 66.3%; fluoroscopy time, 65.1%; adverse events, 74.9%; serum amylase levels 1day post-ERCP, 36.5%) was accurately extracted from the four centers. Success rate of CBD cannulation by level of ERCP difficulty was 98.5%, 99.0%, and 96.4% in grades 1, 2, and 3, respectively. Complication rate by overall selective CBD cannulation method was 5.6%, 7.6%, and 10.5% in the contrast-assisted technique, guidewire-assisted technique, and cross-over method, respectively. Data from this evaluation of the JED Project, a multicenter ERCP database registry, suggest the feasibility of establishing a nationwide ERCP database and its challenges.

Prospective evaluation of ERCP performance in an Italian regional database study

BackgroundProspective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare. AimTo assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice. MethodsProspective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered. Results38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed. ConclusionsThe procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting.

Safety and Efficacy of ERCP in Patients With Periampullary Diverticulum at a General Hospital in Singapore

Introduction: It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) in the presence of a periampullary diverticulum (PAD) may be associated with more difficulty, morbidity and complications. The safety and efficacy of ERCP in the setting of a periampullary diverticulum in Singapore is not known. The aim of the study is to investigate and compare the success rate, procedure difficulty (ERCP grade, cannulation difficulty, procedure time) and complication rate between patients with and without PAD undergoing ERCP at a single center in Singapore. Methods: This is a retrospective, single center cross-sectional study. A total of 548 ERCP procedures were performed at our endoscopy center from January 2015 to December 2016. Patients with previous ERCP intervention (i.e., sphincterotomy, stent insertion) or an abandoned procedure were excluded. Clinical and endoscopic data were collected from the electronic medical record. A total of 357 procedures in 351 patients were included in the analysis. Results: Of 357 procedures, 116 (32.5%) were found to have PAD. The ampulla was located within the diverticulum in 10 (8.9%), on the edge of the diverticulum in 44 (38.9%), and near the diverticulum in 59 (52.2%) cases. Patients with PAD were significantly older (69 vs. 60 years, p<0.001) and more likely to undergo ERCP for choledocholithiasis as the procedure indication (93.9% vs 83.8%, p<0.007). There was no statistically significant difference in the success and complication rates between the two patient groups. On multivariate logistic regression analysis, younger age was associated with higher cannulation success (p=0.023); older age and indication other than choledocholithiasis were associated with higher cannulation difficulty (p=0.01 and p=0.04 respectively). Patients with PAD were 3.3 times more likely to have common bile duct stones compared to patients without PAD (p=0.006). Conclusion: At a single ERCP center in Singapore, the frequency of PAD in patients undergoing ERCP is 33%. Choledocholithiasis is more prevalent in the PAD group of patients undergoing ERCP. Success and safety of ERCP in patients with and without PAD is comparable. In patients with PAD, older age and procedure indication other than choledocholithiasis are associated with higher ERCP difficulty.

Application of endoscopic retrograde cholangiopancreatography to common bile duct stones with periampullary diverticulum

Objective To explore the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones with periampullary diverticula (PAD). Methods Data of 2, 103 patients with common bile duct stones(CBD stones), who underwent therapeutic ERCP for the first time from April 2013 to March 2016, were prospectively analyzed. Patients were divided into two groups according to presence or absence of PAD (PAD group and non-PAD group). Success rate of ERCP, complete clearance rate of the CBD stones after the first attempt and difficult cannulation rate were compared between the two groups. Results The difficult CBD cannulation rate was 14.87%(117/787) in PAD group and 9.93% (123/1 239) in non-PAD group with significant difference (P=0.001). Successful CBD cannulation was achieved in 96.92% (787/812) patients in PAD group and 95.97% (1 239/1 291) in non-PAD group (P=0.156). The complete clearance rate of CBD stones after the first attempt was 85.39% (672/787) in PAD group and 87.09% (1 079/1 239)in non-PAD group (P=0.154). There was no significant difference between the two groups in the complication rate[26/812(3.20%) VS 33/1 291(2.56%), P=0.833]. Conclusion Although PAD increases the difficulty of ERCP, ERCP is an effective and safe method for patients of CBD stones with PAD. Key words: Cholangiopancreatography, endoscopic etrograde; Choledocholithiasis; Diverticulum

Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Gastrointestinal Anatomy: A Retrospective Study

Objective: The aim of this study was to evaluate the difficulty of endoscopic retrograde cholangiopancreatography (ERCP) procedures when performed in patients with different types of surgically altered gastrointestinal (GI) anatomies. Summary of background data: Clinical data of 102 consecutive patients with surgically altered GI anatomy who underwent ERCP using a double-balloon enteroscope or a regular gastroendoscope between January 2008 and March 2015 were retrospectively reviewed. Methods: The success rate of reaching the destination, the time until reaching the destination, the success rate of the procedures, and complications were assessed for each type of altered GI anatomy using a double-balloon enteroscope and a regular gastroendoscope. Results: A total of 180 ERCP procedures were performed. The total success rate of reaching the destination was 91% (164 of 180), and that of treatment was 88% (144 of 164). The success rate of reaching the destination in patients with Roux-en-Y hepaticojejunostomy (HJ + R-Y) was significantly lower than that of the other types of reconstruction. The time until reaching the destination was significantly longer in patients after R-Y reconstruction (gastrectomy or HJ) than that after Billroth-II gastrectomy or pancreatoduodenectomy. GI perforation occurred in 2 patients after R-Y reconstruction (1 patient after gastrectomy, and 1 patient after HJ). However, no other complications, such as severe pancreatitis, bleeding, or air embolism, were observed. Conclusions: ERCP for patients with surgically altered GI anatomy is feasible. Improvement of the success rate of reaching the destination in patients after HJ + R-Y and prevention of perforation in those with R-Y reconstruction are necessary.

First progress report on the Japan Endoscopy Database project.

The Japan Endoscopy Database (JED) Project was started to develop the world's largest endoscopic database, capture the actual performance of endoscopic practice, and standardize the terminology and fundamental items needed for a clinical and research registry. This paper presents a progress report on the first phase of this project undertaken at eight endoscopic centers in Japan. The list of data items to be collected was drafted by the MSED-J (Minimal Standard Endoscopic Database) subcommittee. These items were aggregated offline by integrating data from two endoscopic filing systems between July 2015 and December 2015. The study population included all patients who underwent esophagogastroduodenoscopy or colonoscopy at all eight centers, patients who underwent enteroscopy at five of the eight centers, and patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at four of the eight centers. Data collected in this phase included 61 070 endoscopic procedures, of which 40 475 were esophagogastroduodenoscopies, 215 were enteroscopies, 19 204 were colonoscopies, and 1176 were ERCPs. Frequencies of complications were 0.68% for esophagogastroduodenoscopy, 0% for enteroscopy, 0.43% for colonoscopy, and 13.34% for ERCP. In addition, we obtained various data including Helicobacter pylori infection status, past history of endoscopy in patients who underwent enteroscopy or colonoscopy, and degree of difficulty of ERCP, although the frequencies of reporting were sometimes low, with some items <20%. Results of the first phase suggest that the JED project can provide vast quantities of useful data about endoscopic procedures.

Assessment of the endoscopic retrograde cholangiopancreatography grading system: A prospective study from a tertiary care center

The American Society for Gastrointestinal Endoscopy (ASGE) endoscopic retrograde cholangiopancreatography (ERCP) grading system was proposed but has not been fully evaluated with prospective clinical studies. In this study, we aimed to evaluate the effectiveness of the ERCP difficulty grading system for predicting success and adverse event rates related to the procedure. A total of 1057 ERCP procedures performed on 752 patients were included in the present study. The complexity grades of the procedures were recorded according to the ASGE grading system. Specific complications of ERCP (pancreatitis, cholangitis, bleeding, and perforation) were also defined and graded. The procedure difficulty was determined as 1st degree in 153 patients (14.4%), 2nd degree in 498 patients (47.1%), 3rd degree in 271 (25.6%), and 4th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1st degree procedures was 99.3%, 97.2% for 2nd degree procedures, 86.7% for 3rd degree procedures, and 46.7% for 4th degree procedures (p<0.005). When the difficulty of the procedures increased from 1 to 4, the adverse event rates increased from 1.3% to 10.4%. The findings support the evidence that the difficulty degrees of ERCP procedures can help predict the success and complication rates of the procedure. Because of the increased rates of failure and complications in more difficult cases, the procedures should be performed by experienced endoscopists in advanced centers.

Major predictors for difficult common bile duct stone

Endoscopic retrograde cholangiopancreatography has become the standard treatment for common bile duct stones worldwide. However, there are only a few reports with small number of patients concerning the factors that contribute to the technical difficulty of endoscopic retrograde cholangiopancreatography in these patients. In this study we aimed to investigate these factors in a large group of patients. All patients with a naıïve papilla (n=1850) who underwent endoscopic retrograde cholangiopancreatography during a study period of 2 years were prospectively evaluated. Of these, 757 patients with common bile duct stones were included in the study. Following successful cannulation, patients who needed either more than one episode for stone extraction or mechanical lithotripsy, extracorporeal shock wave lithotripsy, or patients in whom stone extraction could not be achieved endoscopically and underwent surgery were regarded as having "difficult stones". Age, sex, laboratory parameters, endoscopic and cholangiographic findings were recorded in all patients. Predictive factors for difficult stones were investigated using univariate and multivariate analysis. The study group consisted of 432 women and 325 men with a mean age of 60±16 years (range, 4-96). Of the total 757 patients, 654 (86.4%) had easy and 103 (13.6%) had difficult stones. Endoscopic stone extraction was successful in 98.1% of patients. A stricture distal to the stone (OR: 8.248), smaller common bile duct/stone diameter ratio (OR: 0,348), stone diameter (OR: 1,187) stone impaction (OR: 1,117) and higher bilirubin levels (OR: 1,1) were found to be independent predictors of difficult stone extraction on multivariate analysis. Endoscopic retrograde cholangiopancreatography is a very effective method for the treatment of common bile duct stones. Presence of a stricture distal to the stone, smaller common bile duct/stone diameter ratio, stone diameter, impacted stone, and higher bilirubin levels are significant predictors of difficult stone.

What predicts failed cannulation and therapy at ERCP? Results of a large-scale multicenter analysis

STUDY BACKGROUND AND AIMS: Predicting outcome at endoscopic retrograde cholangiopancreatography (ERCP) remains difficult. Our aim was to identify the risk factors for failed ERCP. A prospective multicenter study of ERCP was performed in 66 hospitals across England. Data on 4561 patients were collected using a structured questionnaire completed at the time of ERCP. In total 3209 patients had not had an ERCP prior to the study period. Considering their first ever ERCP, 2683 (84 %) were successfully cannulated, 2241(70 %) had all intended therapy completed, 360 (11 %) had some intended therapy completed, and 608 (19 %) were considered to have had a failed procedure. For first ever ERCP, factors associated with incomplete procedure (odds ratio and 95 % confidence interval) were: Billroth surgery (9.2, 3.2 - 26.7), precutting (2.0, 1.6 - 2.7), common bile duct (CBD) stone size and number (3.2, 2.1 - 4.8 for multiple, large stones), interventions in the pancreatic duct (3.4, 1.6 - 7.0), and CBD stenting (2.8, 2.2 - 3.5). Analysis of the 1352 patients who had undergone an ERCP prior to the study period indicated previous failed ERCP was also predictive of incomplete therapy (1.5, 1.1 - 2.1). The modified Schutz score correlated with ERCP completion, as did the Morriston score, even when modified to include only variables measurable before the procedure. This study confirms that patient- and procedure-based variables are key predictors of technical success and validates current methods of rating ERCP difficulty. Of note, a correlation between outcome and institutional factors, such as unit and endoscopist caseload, was not demonstrated.

Outcome of endoscopic retrograde cholangiopancreatography during live endoscopy demonstrations

A number of factors may result in lower than expected success rates for endoscopic retrograde cholangiopancreatography (ERCP) performed by overseas experts during live demonstrations (LDs). Stratifying the degree of ERCP difficulty may help in the assessment of procedure outcomes, but no prior reports have done so. This study aimed to compare the success rate and complications of ERCP between procedures performed in live demonstrations and for matched control subjects. From 2004 to 2011, a total of 82 patients who underwent ERCP during live demonstrations at the Endoscopy Unit of King Chulalongkorn Memorial Hospital were reviewed. The control for each patient was a patient admitted to the same ERCP unit with matched indications at the time closest to the demonstration course who had matching gender and techniques in therapeutic interventions during ERCP. The success rates and complications between the two groups were compared based on the grading scale for the degree of difficulty according to Cotton and colleagues. For standard ERCP cases (levels 1-2), the success rate, complication rate, and duration of the procedure (DOP) did not differ significantly. In contrast, the success rate for complex ERCPs (levels 3-4) performed during LD was significantly lower (73% vs. 90%; P = 0.006). The complication rates and DOP were not significantly different (P = 0.31 and 0.23, respectively). The overall success rate was significantly lower for LD procedures than for control procedures (81% vs. 91%; P = 0.02). In this series, the standard ERCP performed during LD was associated with success and complication rates similar to those for the control subjects. Complex ERCP cases were, however, associated with lower success rates than those for the control subjects. A high proportion of complex ERCP cases during live demonstration can influence the overall success rate of ERCPs performed by overseas experts.