Endoscopic Retrograde Cholangiopancreatography Cases Research Articles

Risk factors for acute pancreatitis after endoscopic retrograde cholangiopancreatography: a retrospective single-center study

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure in the diagnosis and management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common and serious adverse event after ERCP. Purpose – to evaluate retrospectively PEP incidence and to identify independent risk factors of PEP. Materials and Methods. The analysis of 578 ERCP cases was done. A number of potential risk factors for PEP were taken into uni- and multivariate analisys: age, gender, common bile duct (CBD) size, bilirubin level, presence of cholangitis, Sphincter of Oddi dysfunction (SOD), malignant biliary obstruction, chronic pancreatitis, biliary obstruction, history of cholecystectomy, history of endoscopic papillosphincterotomy (EPST), initial ERCP success, therapeutic success, selective biliary cannulation, pancreatic cannulation/injection, Precut and EPST. Results. PEP was in 29 (5%) cases. Six factors with р < 0,05 by univariate analysis (CBD ≤ 10 mm, normal bilirubin level, SOD, history of cholecystectomy, pancreatic cannulation/injection, precut) were included into multivariate logistic regression model. The independent risk factor for PEP were CBD ≤ 10 mm (OR 2,416; 95% ДІ, 1,037–5,629; p = 0,041), SOD (OR 4,107; 95% ДІ, 1,726–9,771; p = 0,001) та pancreatic cannulation/injection (OR 3,447; 95% ДІ, 1,455–8,166; p = 0,005); and precut was an independent protective factor for PEP (OR 0,129; 95% ДІ, 0,047–0,354; p = 0,014). Conclusions. The incidence of PEP was 5%. Small CBD and SOD are independent PEP risk factors as well as pancreatic cannulation/injection. Early precut technique is an independent factor preventing PEP.

Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes.

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared with PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD. Using the National Readmission Database (NRD) 2016 to 2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by 3 weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. The primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis. A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs. 13.71% P<0.0001), 90 days (14.63% vs. 13.14%, P<0.0001) but lower rate at 6 months (8.50% vs. 9.67%, P=0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01d vs. 6.74d, P<0.0001), hospitalization cost ($106,947.97 vs. $97,602.25, P<0.0001), and overall mortality (6.86% vs. 4.35%, P<0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs. 6.88%, P=0.5382), 90 day (6.82% vs. 6.51%, P=0.5612), and 6 months (5.08% vs. 5.91%, P=0.1744). ERCP demonstrated superior results compared with PTBD for readmission rates, length of stay and overall mortality. For failed ERCP cases, emerging data for Endoscopic ultrasound guided-biliary drainage (EUS-BD) offers potential over PTBD and may provide additional options for the future in tertiary referral centers with experience.

Incidence of Post-ERCP Pancreatitis in Patients Receiving Rectal Indomethacin vs. Compounded Rectal Diclofenac Prophylaxis.

Endoscopic retrograde cholangiopancreatography (ERCP) carries a 3-15% risk of post-ERCP pancreatitis (PEP). Rectal indomethacin reduces the risk of PEP, but its cost has increased more than 20-fold over the past decade. Rectal diclofenac is also used to prevent PEP but is not commercially available in the United States. The aim of this study is to compare the incidence of PEP after administration of commercially available rectal indomethacin versus compounded rectal diclofenac and assess financial implications. ERCP cases at our institution with administration of 100mg rectal indomethacin or 100mg compounded rectal diclofenac between May 2018 and January 2022 were retrospectively reviewed. The incidence and severity of PEP was compared between the indomethacin (n = 728) and diclofenac (n = 304) groups. Risk factors (young age, female sex, history of pancreatitis or PEP, sphincterotomy during procedure, pancreatic indication, trainee involvement) and protective factors (prior sphincterotomy, pancreatic duct stenting) for PEP were compared between groups. 60 patients (8.2%) in the rectal indomethacin group and 25 patients (8.2%) in the compounded rectal diclofenac group developed PEP, resulting in moderate or severe PEP in 9 (15.0%) and 2 (8.0%) patients, respectively. The compounded rectal diclofenac group had more trainee involvement (46.1% vs. 32.8%, p = 0.0001) and more prior sphincterotomy cases (15.8% vs. 10.6%, p = 0.0193) compared to the rectal indomethacin group; no statistically significant differences were observed in all other risk and protective factors. Following switch to compounded rectal diclofenac, institutional annual cost savings amounted to $441,460.62 and patient charge decreased 45-fold. This retrospective single-center real-world analysis showed similar efficacy of rectal indomethacin and compounded rectal diclofenac in preventing PEP but demonstrates substantial cost savings after switching to compounded rectal diclofenac.

Preventive Antibiotic Use and Complications After Endoscopic Retrograde Cholangiopancreatography in Patients Hospitalized for Primary Sclerosing Cholangitis.

The American Society for Gastrointestinal Endoscopy recommends prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) in primary sclerosing cholangitis (PSC). We assessed the impact of this approach on the incidence of post-ERCP outcomes using nationwide data. Using 2015-2021 Nationwide Inpatient Sample data and relevant ICD-10 codes, we analyzed adult hospitalizations for PSC who underwent ERCP, with and without antibiotic prophylaxis. Hierarchical multivariate logistic regression analysis was used to assess the association between prophylactic antibiotic use andpost-ERCP complications including sepsis, acute cholangitis, and acute pancreatitis. We analyzed 32,972 hospitalizations for PSC involving ERCP, with 12,891 admissions (39.1%) receiving antibioticsbefore ERCP (cases) and 20,081 (60.9%) serving as controls. Cases were older than controls (mean age: 64.2 ± 8.6 vs. 61.3 ± 6.1 years; P = 0.020). Compared with controls, hospitalizations with antibiotic prophylaxis had a higher male population (7,541 (58.5%) vs. 11,265 (56.1%); P < 0.001) and higher comorbidity burden (Charlson comorbidity indexscore of ≥2: 5,867 (45.5%) of cases vs. 8,996 (44.8%) of controls; P = 0.01). Incidence of post-ERCP septicemia was 19.1% (6,275) with 2,935 incidences (22.8%) among cases compared with 3,340 (16.6%) among controls. Antibiotic prophylaxis did not significantly improve the odds of septicemia (aOR: 0.85; 95% CI: 0.77 - 1.09; P = 0.179). Approximately 2,271 (6.9%) cases of acute cholangitis and 5,625 (17.1%) cases of acute post-ERCP pancreatitis were recorded. After adjustments for multiple variables, no significant difference was observed in the odds of cholangitis (aOR: 0.87; 95% CI: 0.98 - 1.45; P = 0.08). However,antibiotic prophylaxis was correlated with a statistically significant reduction in the odds ratio of acute post-ERCP pancreatitis (aOR: 0.61; 95% CI: 0.57 - 0.66; P < 0.001). The use of antibioticprophylaxisin hospitalizations with PSC was correlated with a significant reduction in the odds of post-ERCP pancreatitis. Antibiotic prophylaxis did not improve the odds of post-ERCP sepsis or cholangitis. Prophylactic use of antibiotics should be individualized, considering both their anti-infective benefits and potential impact on the biochemical markers of liver disease.

Impact of the COVID-19 pandemic on the treatment of acute cholangitis caused by choledocholithiasis: A single-center retrospective study in Japan.

This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the treatment of acute cholangitis caused by choledocholithiasis. The Japanese government declared a state of emergency in April 2020 due to the COVID-19 pandemic. We retrospectively reviewed the medical records of 309 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis caused by choledocholithiasis between April 2017 and December 2022. Patients were categorized into a pregroup (n = 134) and a postgroup (n = 175), depending on whether they were diagnosed before or after the state of emergency declaration. The total number of ERCP cases and the number of ERCP cases with endoscopic stone removals increased after the state of emergency declaration. Compared with the pregroup, the numbers of patients with performance status of 0-1 and surgically altered anatomy increased, whereas the numbers of patients taking oral antiplatelets or anticoagulants and those with cerebrovascular disease decreased in the postgroup. The number of single-stage endoscopic stone removals increased and hospital stays were significantly shorter in the postgroup. No differences in adverse event rates were detected between the two groups. Although our hospital provides tertiary care, the number of patients with cholangitis in good general condition and no underlying disease increased after the state of emergency declaration. The COVID-19 pandemic resulted in an increase in the number of single-stage endoscopic treatments and shortened hospital stays for patients with acute cholangitis caused by choledocholithiasis. No safety issues with ERCP were detected, even during the pandemic.

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

Background and aimsAlthough quality improvement is crucial for endoscopic retrograde cholangiopancreatography (ERCP), a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. MethodsOur hospital performs approximately 200 ERCPs annually, with one expert performing approximately half of them and three nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases three years before and after the introduction of TPS. The primary endpoints of the study were the differences in two ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). ResultsA total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before: 87.4%, after: 92.3%, P=0.032), while the incidence of PEP decreased, but not significantly (before: 4.0%, after: 2.8%, P=0.402). All endoscopists benefited from utilizing TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before: 85.5%, after: 93.1%, P=0.019). ConclusionsTPS can effectively enhance the quality of ERCP irrespective of practice volume.

Risk factors for post-endoscopic retrograde pancreatography pancreatitis in malignant extrahepatic biliary obstruction: a retrospective single-center study

Background. Decompression interventions under the endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in malignant extrahepatic biliary obstruction (MEHBO). Acute pancreatitis is the most common complication of ERCP. Many studies have been performed to identify the risk factors for post-ERCP pancreatitis (PEP). However, these works in general include the analysis of ERCP in patients with various causes of biliary obstruction without subdividing patients with malignant obstruction.&#x0D; Purpose.The aim of this study was to determine the risk factors for PEP in patients with MEHBO.&#x0D; Materials and Methods. A retrospective analysis of 100 cases of ERCP in MEHBO was done. PEP was in 2 patients, and 14 patients had hyperamylasemia (HA). The following factors were analyzed: gender, age, level of MEHBO, obstruction of the main pancreatic duct (MPD), total bilirubin level, history of endoscopic papillosphincterotomy (EPST), periampullary diverticulum, successful ERCP, primary selective biliary cannulation, catheterization and/or contrast injection into MPD, Precut EPST, successful decompression.&#x0D; Results and discussion. Univariate analysis showed that PEP is associated with an obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.004) and with absence of MPD obstruction (p = 0.022); female gender (p = 0.012), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p &lt; 0.001), absence of MPD obstruction (p &lt; 0.001), catheterization and/or contrast injection into MPD (p = 0.040) are associated with PEP or hyperamylasemia (HA); female gender (p = 0.024), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p &lt; 0.001), absence of MPD obstruction (p=0.006), catheterization and/or contrast injection into MPD (p = 0.035), successful decompression (p = 0.004) are associated with HA. Multivariate regression analysis showed that, for PEP and for PEP or HA as well as for HA, the risk factors are obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.005; p &lt; 0.001; p &lt; 0.001, respectively) and absence of MPD obstruction (p = 0.022; p &lt; 0.001; p = 0.008, respectively). Female gender is a risk factor for PEP or HA and HA (p = 0.011; p = 0.028, respectively), and catheterization and/or contrast injection into MPD are risk factors for PEP or HA (p = 0.04). Conclusion. Development of PEP in MEHBO depends on the localization of a tumor and involvement of the pancreas. The risk factors for PEP in MEHBO are tumor localization at the level of the middle and proximal third of the hepaticocholedochus and absence of MPD obstruction.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum.

Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV. Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected. Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology-assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%. The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology-assisted rendezvous ERCP can be considered.

Rotatable sphincterotome as a rescue device for endoscopic retrograde cholangiopancreatography cannulation: a single-center experience.

Selective bile duct or pancreatic duct cannulation remains a significant initial hurdle in endoscopic retrograde cholangiopancreatography (ERCP) despite advances in endoscopy and accessories. This study evaluated our experience with a rotatable sphincterotome in cases of difficult cannulation. We retrospectively reviewed ERCP cases using TRUEtome, a rotatable sphincterotome, as a rescue device for cannulation at a cancer institute in Japan from October 2014 to December 2021. TRUEtome was used in 88 patients. Duodenoscopes were used for 51 patients, while single-balloon enteroscopes (SBE) were used for 37 patients. TRUEtome was used for biliary and pancreatic duct cannulation (84.1%), intrahepatic bile duct selection (12.5%), and strictures of the afferent limb (3.4%). Cannulation success rates were similar in the duodenoscope and SBE groups (86.3% vs. 75.7%, p=0.213). TRUEtome was more commonly used in cases with steep cannulation angles in the duodenoscope group and in cases requiring cannulation in different directions in the SBE group. There were no significant differences in adverse events between the two groups. The cannulation sphincterotome was useful for difficult cannulations in both unaltered and surgically altered anatomies. It may be an option to consider before high-risk procedures such as precut and endoscopic ultrasound-guided rendezvous techniques.

Comparison of Efficacy and Safety between Endoscopic Retrograde Cholangiopancreatography and Percutaneous Transhepatic Cholangial Drainage for the Treatment of Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis

Background: At present, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) are frequently used for reducing malignant obstructive jaundice (MOJ). However, it is controversial as to which method is superior in terms of efficacy and safety. Objectives: The aim of this study was to compare the safety, feasibility, and clinical benefits of ERCP and PTCD in matched cases of MOJ. Methods: The Web of Science, Cochrane, PubMed, and CNKI databases were searched systematically to identify studies published between January 2000 and December 2019, without language restrictions, that compared ERCP and PTCD in patients with MOJ. The primary outcome was the success rate for each procedure. The secondary outcomes were the technical success rate, serum total bilirubin level, length of hospital stay, hospital expense, complication rate, and survival. This meta-analysis was performed using Review Manager 5.3. Results: Sixteen studies met the inclusion criteria, including 1,143 cases of ERCP and 854 cases of PTCD. The analysis demonstrated that jaundice remission in PTCD was equal to that in ERCP (mean difference [MD], 1.19; 95% confidence interval [CI]: −0.56 to –2.93; p = 0.18). However, the length of hospital stay in the ERCP group was 3.03 days shorter than that in the PTCD group (MD, −2.41; 95% CI: −4.61 to −0.22; p = 0.03). ERCP had a lower rate of postoperative complications (odds ratio, 0.66; 95% CI: 0.42–1.05); however, the difference was not significant (p = 0.08). ERCP was also more cost-efficient (MD, −5.42; 95% CI: −5.52 to −5.32; p < 0.01). Further, we calculated the absolute mean of hospital stay (ERCP:PTCD = 8.73:12.95 days), hospital expenses (ERCP:PTCD = 5,104.13:5,866.75 RMB), and postoperative complications (ERCP:PTCD = 11.2%:9.1%) in both groups. Conclusion: For remission of MOJ, PTCD and ERCP had similar clinical efficacy. Each method has its own strengths and weaknesses. Considering that ERCP had a lower rate of postoperative complications, shorter hospital stay, and higher cost efficiency, ERCP may be a superior initial treatment choice for MOJ.

Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care.

Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC. We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC). We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l1 regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively. We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.

Diagnosis and Management of ERCP Complications: The Results of 15000 Cases from Two Centers

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a method of diagnosing and treating pancreaticobiliary diseases. ERCP differs from other endoscopic procedures with a greater risk of developing complications. The study aims to share experiences in diagnosing and managing complications in 15000 ERCP cases performed by two general surgeons in two separate general surgery ERCP units in 13 years and to determine appropriate diagnosis and treatment approaches in patients with complications. Materials and Methods: This study retrospectively evaluated the data of 15000 patients who underwent ERCP with various diagnoses between June 2009 and June 2022 in General Surgery Clinics in two different centers. Age, sex, ERCP indications, comorbidity, and clinical findings of the patients were recorded. Results: All patients who underwent ERCP were divided into two groups according to the incidence of complications. The patients who developed complications had higher ages, hospitalization days, and intensive care unit admission rates. Comorbidity increased the rate of complication development: amylasemia and acute pancreatitis were the most developed complications, respectively. Women developed more post-ERCP pancreatitis (PEP). Pre-incision, the number of ERCPs applied was not found to affect PEP development. Choledochal stone was the most important indication for ERCP in patients who developed PEP. Conclusion: ERCP is an invasive procedure, and complications such as acute pancreatitis, hemorrhage, perforation, cholangitis, and cholecystitis develop after this procedure. Determining these complications and related risk factors will be beneficial in terms of patient satisfaction and health expenditures.

S106 Management of Post-Cholecystectomy Bile Leaks: Predictors for Persistent Leak After Initial ERCP

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a 1st-line treatment for post-cholecystectomy bile leaks (PCBL). Despite appropriate initial ERCP interventions that optimize transpapillary bile flow, PCBL can persist. We aim to evaluate baseline clinical factors associated with persistent PCBL after initial ERCP. Methods: We created a retrospective database of patients with PCBL referred for ERCP at Indiana University Health (IUH) University Hospital. Data collected included endoscopic reports, fluoroscopic imaging, patient demographics, type of PCBL, ERCP timing and interventions, technical success, and treatment outcomes. A high-grade bile leak (HG-BL) was defined as visualization of contrast extravasation from the bile duct before filling of intrahepatic biliary branches with contrast. The PCBL was deemed to be persistent if > 1 interventional ERCP was required for the leak to resolve on cholangiogram. (Figure) Results: From 2011 to 2021, 369 cases of PCBL were referred for ERCP. After excluding cases with transected bile ducts (n=21) and patients lost to follow up (n=15), 333 cases were included in data analysis (Image 1). 21 patients received their initial ERCP at an outside hospital. All patients received biliary sphincterotomy with stenting unless there was coagulopathy or Roux-en-Y gastric bypass (n=12). Univariate logistic regression analysis identified male gender, steroids use at time of ERCP, presence of duodenal stricture, a HG-BL, Strasberg class D PCBL, presence of biloma, presence of abdominal drain, presence of biliary stricture, and initial ERCP performed at outside hospital to be significant variables for persistent PCBL (Table). On multivariate analysis, presence of a HG-BL (OR 7.08, CI 1.96 – 25.58, p = 0.003) and initial ERCP performed at an outside facility (OR 29.14, CI 3.35 – 253.63, p=0.002) remained significantly associated with persistent PCBL. Being a female gender (OR 0.30, CI 0.11 – 0.85, P = 0.022) remained significant for higher odds of PCBL resolution after initial ERCP. Conclusion: Our study suggests that a HG-BL in a male patient may justify more aggressive ERCP interventions or more prolonged stent indwell time. As a tertiary referral hospital, we had a significant referral bias in our cohort, which could have acted as a confounder causing statistical significance for lower initial ERCP success rates at outside medical facilities. The relatively high volume of ERCP cases at our center may also have contributed to better ERCP outcomes.Figure 1.: Flowchart of the Study Table 1. - Univariate analysis of clinical variables for persistent PCBL after initial ERCP treatment Variables Initial ERCP failure OR (95% CI) P value Patient Characteristics Female 25/204 (12.25%) 0.49 (0.27 – 0.86) 0.013 Age 55 years old or more 34/175 (19.43%) 1.60 (0.90-2.86) 0.112 Median BMI (IQR) 32.0 (26.0, 36.0) 1.00 (0.98 – 1.03) 0.874 On diabetic treatment 13/58 (22.41%) 1.81 (0.93 – 3.53) 0.083 On steroids 4/6 (66.67%) 10.18 (1.82 – 57.00) 0.008 Major papilla within duodenal diverticulum 11/57 (19.30%) 1.46 (0.73 – 2.93) 0.282 Duodenal stricture/stenosis 5/10 (50.00%) 5.17 (1.45 – 18.48) 0.011 Location and timing of ERCP Procedure ERCP performed > 3 days 48/273 (17.58%) 1.00 (0.47 – 2.12) 0.994 Initial ERCP performed at outside facility 17/21 (80.95%) 30.94 (9.96 -96.06) < 0.001 Bile leak characteristics Strasberg Class A bile leaks 44/302 (14.57%) 0.26 (0.12 – 0.54) < 0.001 Strasberg Class D bile leaks 10/31 (32.26%) 2.70 (1.19 – 6.12) 0.018 Bile leak from cystic duct* 34/192 (17.71%) 1.25 (0.70 – 2.24) 0.446 Bile leak from duct of Luschka 4/104 (3.85%) 0.21 (0.09 – 0.50) < 0.001 Bile leak from common bile duct/common hepatic duct 7/25 (28.00%) 2.66 (1.13 – 6.27) 0.025 High-grade bile leak 25/63 (39.68%) 4.80 (2.58 – 8.95) < 0.001 Concomitant biloma present 27/115 (23.48%) 2.06 (1.13 – 3.76) 0.018 Percutaneous abdominal drain present 42/204 (20.59%) 2.02 (1.07 – 3.82) 0.030 Presence of biliary stones 5/67 (7.46%) 0.34 (0.13 – 0.88) 0.026 Presence of biliary stricture 7/21 (33.33%) 2.63 (1.01 – 6.84) 0.048 ERCP interventions Biliary sphincterotomy performed 56/325 (17.23%) 1.04 (0.22 – 4.88) 0.960 Biliary sphincterotomy alone 2/6 (33.33%) 2.46 (0.44 – 13.73) 0.306 Biliary stenting alone 2/12 (16.67%) 0.96 (0.21 – 4.51) 0.960 Bridging biliary stents 20/134 (14.93%) 0.78 (0.43 – 1.43) 0.426 Multiple biliary plastic stents 6/55 (10.91%) 0.55 (0.22 – 1.36) 0.198 Self-expandable metal stent 2/11 (18.18%) 1.09 (0.23 – 5.21) 0.910 *Reference group. IQR, interquartile range; IUH, Indiana University Health.

Microbiology of bile aspirates obtained at ERCP in patients with suspected acute cholangitis.

Background The cornerstone of treatment for acute cholangitis is source control with biliary drainage and early antibiotics. The primary aim of this study was to describe the microbiology of bile aspirate pathogens obtained at the time of endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having acute cholangitis. Methods In this single-center retrospective study, patients were included if a bile aspirate was collected at ERCP for suspicion of acute cholangitis, from 1 January 2010 to 31 December 2016. Results There were 721 ERCP procedures for suspected acute cholangitis with bile culture results, with 662 positive bile cultures (91.8 %). Pathogens included: Enterococcus species (spp.) 448 (67.7 %); Klebsiella spp. 295 (44.6 %); Escherichia coli 269 (40.6 %); Pseudomonas spp. 52 (7.9 %); and anaerobes 64 (9.7 %). Susceptibility of Klebsiella pneumoniae and E.coli isolates to ciprofloxacin was 88 % and 64 %, respectively. Extended-spectrum beta-lactamases and carbapenem resistance were found in 7.9 % and 3.6 % of Enterobacteriaceae, respectively. There were 437 concurrent blood cultures, of which 174 were positive (39.8 % of cultures drawn). Prior biliary endoscopic sphincterotomy (ES) was evident in 459 ERCP cases (63.7 %), and was associated with increased frequency of Klebsiella spp., Pseudomonas aeruginosa , Enterobacter spp., and Enterococcus spp. Prior biliary ES significantly increased the probability of vancomycin-resistant Enterococcus (VRE). Conclusions The vast majority of bile cultures (91.8 %) were positive. The susceptibilities of E.coli and K.pneumoniae to ciprofloxacin are lower than historically noted. A notable portion of cultures contained pathogenic drug-resistant organisms. Prior biliary ES is associated with a higher frequency of certain organisms and higher frequency of VRE.

A102 INDICATION FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATION WITH HEMORRHAGE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Hemorrhage is a complication associated with up to 2% of cases of Endoscopic Retrograde Cholangiopancreatography (ERCP), most commonly following sphincterotomy. Studies investigating risk factors associated with hemorrhage, such as ERCP indication, have been conflicting. Aims We performed a systematic review and meta-analysis to determine the association between the indication for ERCP and ERCP-associated hemorrhage. Methods A systematic search of MEDLINE, EMBASE, and CENTRAL was done from inception until September 2021 for studies reporting on factors associated with ERCP-associated hemorrhage (both immediate and delayed) in adults. Exclusion criteria included: pediatric patients, no outcome of interest, did not investigate hemorrhage risk factors, inappropriate study design (basic science, reviews, and case reports/series), or if no English text was available. A DerSimonian and Laird random-effects meta-analysis was performed to generate pooled Odds Ratios (OR) with 95% Confidence Intervals (CIs) for each procedural indication in relation to hemorrhage. Results 952 records were identified of which 17 were included in our quantitative analysis. Common indications included acute cholangitis, choledocholithiasis, Sphincter of Oddi dysfunction (SOD), acute pancreatitis, chronic pancreatitis, and malignancy-associated duct obstruction. Rates of hemorrhage varied in the included studies (median 2.2%; IQR 1.7–6.9). Sphincterotomy rates also differed in the included studies (median 100%; IQR 71.1–100). Five studies did not report on antiplatelet or anticoagulant use with the remaining reporting varying rates of antiplatelet (median 8.3%; IQR 0–26.5) and anticoagulant (median 0.8%; IQR 0–2.25) use. Hemorrhage was significantly associated with acute cholangitis (OR 2.48; 95% CI 1.62–3.78) and choledocholithiasis (OR 1.76; 95% CI 1.06–2.94) but not SOD (OR 1.38; 95% CI 0.74–2.58), malignancy (OR 0.68; 95% CI 0.29–1.59), acute pancreatitis (OR 1.08; 95% CI 0.30–3.82), or chronic pancreatitis (OR 0.56; 95% CI 0.16–1.99). Conclusions Acute cholangitis and choledocholithiasis were associated with increased hemorrhage, whereas SOD, malignancy, acute pancreatitis, and chronic pancreatitis were not. Providers should consider procedural indication when counselling patients on hemorrhage risk in ERCP. Funding Agencies None

Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

Background/AimsCholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. MethodsOne hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: “Trainees,” “Consultants group 1” (performed >75 ERCPs per year), and “Consultants group 2” (performed >100 ERCPs per year). ResultsTrainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77–0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74–0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69–0.95). ConclusionsThis investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

Is Immediate Laparoscopic Cholecystectomy after ERCP a Safe Treatment for Gallstone Complications?

Background: Laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) is a standard treatment for patients with complicated cholelithiasis. Currently, there is no conclusion about the optimal interval between LC and ERCP, especially in the case of emergent ERCP. Objective: The purpose of this study is to compare the outcome of patients treated with immediate, early, and delayed LC after ERCP. Materials and Methods: A total of 198 patients who received LC and ERCP between July 2017 and June 2019 were retrospectively reviewed. Patients were divided into 3 groups: immediate (single-staged LC with ERCP &ndash; 109 patients), early (LC &lt;72 hr after ERCP &ndash; 20 patients) and delayed (LC &gt;72 hr after ERCP &ndash; 69 patients). Patient demographics and primary endpoints (conversion rate to open cholecystectomy (OC), blood loss, operative time, complications, mortality and length of hospital stay) were recorded. The secondary endpoint was to analyze factors that influence the conversion to OC. Results: There were no statistical differences in the conversion rate (p=0.921) and major complications (p=0.548) between all three groups. However, the immediate group demonstrated shorter length of post-ERCP hospital stay than other groups (p=0.0001). The analysis of emergent ERCP cases showed no difference in the conversion rate and major complications (p=0.999 and 0.329). Patients with a history of previous ERCP tend to convert to OC but the difference was not statistically significant in the multivariate analysis (p=0.106). Conclusion: Performing LC immediately after ERCP is safe, does not increase the conversion rate, and results in shorter hospital stays even in emergent ERCP cases. Keywords: Laparoscopic cholecystectomy; Endoscopic retrograde cholangiopancreatography; LC; ERCP; Minimally invasive surgery

Management of our endoscopic retrograde cholangio pancreatography cases during the pandemic process.

Endoscopic retrograde cholangio pancreatography (ERCP) is a technique in which endoscope and radiological imaging are used in combination in the diagnosis and treatment of diseases related to the pancreaticobiliary system. Our aim in this study is to discuss all aspects of approach strategies to ERCP patients whose operation is mandatory during the pandemic period, to draw the future perspective and to summarize the measures that the surgical team should take in terms of their own health and public health. During the pandemic period between 14 March and 31 December 2020, we accepted 270 patients to our ERCP unit. We made our analysis regarding the management of these cases under COVID-19 pandemic conditions. We presented our patients' form of application, application complaints, COVID- 19 contact stories, pre-procedure preparations, and our prevention methods to prevent COVID-19 transmission of the patient and healthcare team during the procedure, and post-procedure patient follow-up methods, and the management of our COVID-19-positive patients before the procedure. ERCP was applied to 270 patients. The COVID-19 test of 13 patients was positive before the procedure and they were taken to our COVID-19 isolated service. There was no problem in the anesthesia of patients who had positive COVID-19 PCR test and subsequently underwent ERCP. There was no difference in the discharge time after the ERCP procedure. COVID-19 pandemic has significantly affected the management and safety of ERCP units. ERCP procedures should be performed by determining the urgency of patients so that their treatment needs are not delayed. Postponing cases without planning can develop an increased workload in centers offering ERCP, and this situation can lead to further delays or negative consequences.

ID: 3524384 IMPACT OF AN ERCP RADIATION SAFETY INITIATIVE ON STAFF DOSE EXPOSURES: A QUALITY IMPROVEMENT INITIATIVE

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is crucial for the management of hepatobiliary disease. Use of fluoroscopy during ERCP results in radiation exposure to the interventional endoscopy care providers. Prevention of radiation induced injuries such as cataracts, cancer, skin injuries and vascular aging from long term exposure is of vital importance. Current guidelines recommend monitored radiation exposure to be “as low as reasonably achievable” (ALARA) with institution dependent numerical limits. Prompted by a pregnancy among one of our providers who chose to continue performing ERCP, we initated a radiation safety initiative and evaluated the impact of this initiative on mean fluoroscopy times and radiation dose exposure to our staff. Methods: All ERCP cases performed from June 2018 to February 2020 were reviewed (data collection halted in March 2020 due to the COVID19 pandemic). Cases performed from June 2018 to June 2019 were categorized as “pre initiative”. Cases from July 2019 to February 2020 were categorized as “post initiative”. The safety initiative included use of a new fluoroscopy bed with a lead skirt, c-arm receiver unit lead shield, mindful fluoroscopy use by the attending physician only, appropriate usage of dosimeter badges and evaluation of personal protective equipment (PPE) (lead aprons, thyroid shield, lead glasses) to ensure quality. The following data was collected: mean fluoroscopy time per procedure, individual provider (physicians, nurses and technicians), the monthly deep dose equivalent (DDE) representing body, gonads and blood making organs, the monthly shallow dose equivalent (SDE) representing skin and extremities and monthly lens of eye dose equivalent (LDE) were collected. Results: A total of 198 ERCPs were performed in the pre-initiative group (14 cases per month). Mean fluoroscopy time per case was 12.1 minutes. A total of 110 ERCPs were performed in the post-initiation group (also 14 cases per month) with a mean fluoroscopy time per case of 6.3 minutes (48% reduction). For all providers, the average monthly DDE went from 47.6 mrem to 9.23 (81% reduction), the average monthly SDE went from 102.49 mrem to 31.35 (69.5% reduction) and the average monthly LDE went from 100.25 mrem to 30.18 (70% reduction). The fetal dosimeter badge worn by the pregnant provider detected an undetectable reading every month. Discussion: Quality initiatives coupled with adequate personal protective equipment to improve the radiation dose exposure of advanced endoscopy staff performing ERCP can result in significant improvement. Performing ERCP during pregnancy is a feasible option if proper techniques and policy are implanted to protect the fetus. Improvement of the safety profile of ERCP for women of child-bearing age is an important step in increasing the number of women in the field of advanced endoscopy.

What Would Be the Appropriate Number of Clinical ERCP Cases for Trainees to Acquire Basic Competence? A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is technically demanding and carries significant risks. It is performed by gastrointestinal and surgical endoscopists. There is no consensus on the minimum number of ERCPs required during training. This study was conducted to analyze the minimum number of clinical ERCPs that a trainee needs to perform to achieve competency. PubMed, Ovid-Embase, and the Cochrane library were searched systematically for prospective and retrospective studies reporting on trainees' ERCP performance. Mete-analysis was conducted to analyze the success rate of cannulation, other basic techniques, and adverse event rate, using the random-effect model with Review Manager 5.3. Thirteen studies met the inclusion criteria, with 149 trainees performing a total of 18 794 ERCP procedures. The pooled cannulation success rate was 85.7% (95% CI: 78.1%-91.0%) at completion of training. The cannulation success rate was 76.5% (95% CI: 69.2%-82.5%) when the trainees had completed 180 ERCPs, which increased to 81.8% (95% CI: 69.8%-90.6%) after 200 ERCP procedures. Adverse events and post-ERCP pancreatitis rates were 4.7% (95% CI: 2.9%-9.1%) and 2.0% (0.9%-3.9%), respectively. Achieving a cannulation success rate of >90% was considered a quality indicator for ERCP training by most societal guidelines. However, our retrospective analysis indicated that trainees only attained a pooled cannulation success rate of only 81.8% after 200 procedures. Therefore, the minimum number of ERCPs required to achieve competency during training may need to be redefined to meet the basic requirement.