Endoscopic Retrograde Cholangiopancreatography Procedures Research Articles

Risks of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Liver Transplantation.

Biliary complications are common after liver transplantation (LT). Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method to treat biliary complications. Nevertheless, ERCP is not without complications and may have a greater complication rate in the LT population. Knowledge of the prevalence, severity, and possible risk factors for post-ERCP pancreatitis (PEP) in LT recipients is limited. Therefore, this study aims to determine the incidence and severity of PEP and identify potential risk factors in LT recipients. This retrospective cohort included patients ≥18 years who underwent ≥1 ERCP procedures after LT between January 2010 and October 2021. Two hundred thirty-two patients were included, who underwent 260 LTs and 1125 ERCPs. PEP occurred after 23 ERCP procedures (2%) with subsequent mortality in three (13%). Multivariate logistic regression identified wire cannulation of the pancreatic duct as a significant risk factor for PEP (OR, 3.21). The complication rate of PEP after LT in this study was shown to be low and is lower compared to patients without a history of LT. Nevertheless, the mortality rate of this group of patients was notably higher.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi.

Endoscopic retrograde cholangiopancreatography (ERCP), with its clinical ad-vantages of less trauma and faster recovery, has become the primary treatment for choledocholithiasis. To investigate the effects of different ERCP procedures on the sphincter of Oddi. The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively. The patients were divided into endoscopic sphincterotomy (EST, n = 24) and endoscopic papillary balloon dilation (EPBD, n = 67) groups. The duration of operation, pancreatic development, pancreatic sphincterotomy, intubation difficulties, stone recurrence, and incidence of reflux cholangitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction in the EST and EPBD groups. Differences in hypertension, diabetes, increased bilirubin, small diameter of the common bile duct, or ampullary diverticulum between the two groups were not significant. Statistically significant differences were observed between the two groups concerning sex and age (< 60 years). Patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group. The number of cases of pancreatic development, pancreatic duct sphincterotomy, and difficult intubation were higher in the EST group than in the EPBD group. The number of Oddi's sphincter manometries, ERCP surgical outcomes, and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group. The numbers of stone recurrences, reflux cholangitis, and cholecystitis were higher in the EST group than in the EPBD group. In summary, common bile duct stones, pancreatitis history, and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD. Based on this evidence, this study can provide actionable insights for clinicians and researchers.

Charting Unexplored Territories: ERCP Indications and Complications in Pediatric Patients; A Cross-Sectional Study from 2022 to 2023

Background: There are ongoing concerns about the safety of endoscopic retrograde cholangiopancreatography (ERCP) in children, as recorded cases have shown complications. Objectives: The objective of this study is to investigate the indications, complications, and outcomes of ERCP in pediatric patients. Methods: This cross-sectional study was conducted at Namazi and Abu Ali Sina Hospitals between September 2022 and December 2023. The study focused on pediatric patients aged 1 month to 18 years undergoing ERCP. The demographics, indications for ERCP, pre-procedural imaging findings, and complications within 72 hours and up to 6 months after ERCP were extracted from medical records. Results: During the study period, a total of 100 ERCP procedures were performed on 56 pediatric patients. The mean age of the patients was 10.22 ± 4.80 years, with females accounting for 53.6% of the group. The main indications for performing ERCP were the presence of a stricture after orthotopic liver transplantation (22%) and the presence of a common bile duct stone (19%). The incidence of complications was notable for acute pancreatitis (3%) and bleeding (2%), while the failure rate for ERCP operations was determined to be 4%. Conclusions: The infrequent occurrence of failures and complications highlights the substantial benefit of ERCP in treating biliary and pancreatic illnesses in children.

Clinical Approach Strategy in Managing Complex Biliary Cases: Lesson learnt from a tertiary referral private hospital

Introduction: In the era of laparoscopic procedure, there are innovations on non-surgical management approaches for managing biliary tract disorders, such as therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and interventional endoscopic ultrasound (EUS). There is still no clear consensus yet in step-approach for managing difficult biliary disorders. Method: A retrospective endoscopy database study was conducted. Complex biliary cases which included in this study, where multi-management approach is needed, biliary obstruction accompanied with cholangitis or biliary sepsis, difficult CBD stone, recurrent CBD stone, or advanced progressive malignant biliary obstruction. Results: Sixty-one subjects in this retrospective database study were considered as complex biliary cases. In this study, 16.4% of the subjects underwent combination of therapeutic ERCP and EUS in one session based on the complexity of the case; and 8.2% of the subjects underwent therapeutic ERCP with additional single operator cholangioscopy procedure. One subject underwent rendezvous ERCP procedure through percutaneous approach. Around 4.9% of the subjects underwent EUS-guided biliary drainage procedure. Conclusion: Complex biliary cases require a good clinical approach algorithm to decide which procedure comes first based on comprehensive evaluation consists of patient’s factor, expertise, cost, and the risk of complications. Keywords: biliary tract; endoscopic retrograde cholangiography; endoscopic ultrasound; laparoscopic procedure

In-depth exploration of the radiation exposure to staff performing endoscopic retrograde cholangiopancreatography procedures (ERCP) through RANDO phantom and TLDs.

This study provides a comprehensive evaluation of the occupational radiation exposure faced by healthcare professionals during Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures. Utilizing an anthropomorphic RANDO phantom equipped with Thermoluminescent Dosimeters (TLDs), we replicated ERCP scenarios to measure radiation doses received by medical staff. The study meticulously assessed radiation exposure in various corresponding body regions typically occupied by medical staff during ERCP, with a focus on eyes, thyroid, hands, and reproductive corresponding organ regions. The findings revealed significant variations in radiation doses across different body parts, highlighting areas of higher exposure and underscoring the need for improved protective measures and procedural adjustments. The effective radiation doses were calculated using standard protocols, considering the varying levels of protection offered by lead aprons and thyroid shields. The results demonstrate the substantial radiation exposure experienced by healthcare staff, particularly in regions not adequately shielded. This study emphasizes the necessity for enhanced radiation safety protocols in clinical settings, advocating for advanced protective equipment, training in radiation safety, and the exploration of alternative imaging modalities. The findings have crucial implications for both patient and staff safety, ensuring the continued efficacy and safety of ERCP and similar interventional procedures. This research contributes significantly to the field of occupational health and safety in interventional radiology, providing vital data for the development of safer medical practices.

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis after sleeve gastrectomy and Roux-en-Y.

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis after sleeve gastrectomy and Roux-en-Y.

Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones.

Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.

Radiation exposure in therapeutic endoscopic retrograde cholangiopancreatography with two types of fluoroscopy systems

AbstractFluoroscopy is necessary for endoscopic retrograde cholangiopancreatography (ERCP). Occupational radiation exposure of staff (endoscopists, nurses, or assistants) is inevitable. Fluoroscopes with a tube over‐couch (OC) rather than under‐couch (UC) may have more radiation reflection dosage on the staff's upper body theoretically, where the most vital organs are. In the study, we assessed the radiation exposure on staff by two different types of fluoroscopes in real‐world practice. Using a radiation dosimeter to measure the radiation dosage on endoscopists and assistants in each ERCP procedure under two different fluoroscopic systems (UC vs. OC). Forty‐one ERCP procedures were enrolled. Dosimeters were used NanoDots for the measurement of personal radiation exposure. Those dosimeters were attached to the left forearm and chest of the endoscopist and only the chest of two assistants, the wall of the ERCP room, and the controlling room in every procedure. Nine‐teen ERCPs were performed under the OC unit, and the other 22 ERCPs were UC method. Fluoroscopic time and output of radiation dose showed no significant difference between the two groups. Radiation exposure in endoscopist were 0.0911[0.1041–0.3974] mGy (OC) versus 0.0276 [0.0080–0.2924] mGy (UC), p &lt; .01 for the forearm; and 0.0318 [0.0070–0.2628] mGy (OC) versus 0.0182 [0.0088–0.1628] mGy (UC), p = .04 for the endoscopist's body. There was no difference in radiation exposure from assistants in both groups. For all the ERCP procedures, the measurement of radiation exposure from high to low is endoscopist's hand, endoscopist's body, assistant 1, assistant 2, and ERCP room (p &lt; .01). Radiation detection from ERCP room is slightly higher but close to controlling room (p = .06). For the safety of occupational radiation protection, tube of fluoroscope UC is better than OC for the endoscopists more than assistants. Besides, the assistant 1 took higher radiation exposure than assistant 2 for each ERCP procedure.

Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP

BackgroundProper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients.MethodsThe medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50–64 years, n = 202), elderly (65–79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups.ResultsThe three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423).ConclusionThe results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.

Timing of Endoscopic Retrograde Cholangiopancreatography in Postcholecystectomy Patients and Its Effect on Post-ERCP Complications.

Background: Due to the increasing use of laparoscopy for symptomatic cholelithiasis and other gallbladder disorders, as well as the ongoing issue of associated biliary tree injuries, endoscopic retrograde cholangiopancreatography (ERCP) still holds a significant position in the diagnosis and treatment of postcholecystectomy disorders. In our study, we aimed to examine the relationship between the time elapsed between cholecystectomy and ERCP with the post-ERCP complications. Methods: Ninety-six patients with a history of cholecystectomy who underwent ERCP between January 2016 and January 2021 at the General Surgery Clinic of the University of Health Sciences Bakırköy Dr. Sadi Konuk Health Application and Research Center were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate analyses. Results: In the matter of post-ERCP complication status, differences observed in terms of age, body mass index (BMI) values, gender, comorbidities, number of ERCP procedures, and the time elapsed between cholecystectomy and ERCP among cases were not statistically significant. Discussion: Our study demonstrates that age, BMI values, gender, comorbidities, ERCP count, and the time between procedures are not significant risk factors for post-ERCP complications. Regardless of the time between surgery and ERCP, the presence of post-ERCP complications is comparable.

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Endoscopic Removal of Common Bile Duct Stones: An Update in Chinese Patients with Choledocholithiasis

Aim: Endoscopic Retrograde Cholangiopancreatography (ERCP) has been widely used in endoscopic surgery for many biliary and pancreatic diseases. Post-ERCP Pancreatitis (PEP) is the most common complication that occurs, even with expert surgeons. However, few reports have addressed the risk of PEP by focusing on the removal of Common Bile Duct Stones (CBDS). Methods: To detect potential risk factors for PEP after endoscopic removal of CBDS, the medical records of CBDS patients who received ERCP procedures at the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2023 were retrospectively analyzed. Patient- and procedure-related data were collected, and PEP was reevaluated. Single- and multiplevariable analyses were conducted to identify potential risk factors. Results: A total of 1,251 procedures were performed in 1,173 patients and PEP occurred in 84 cases (6.71%). Univariate and multivariate logistic regression analyses showed that female sex (P= 0.049, 95% Confidence Interval [CI]: 1.002-2.521), cerebral infarction (P=0.011, 95% CI: 1.197-3.964), acute pancreatitis history (P=0.001, 95% CI: 2.436-7.249), fatty liver disease (P=0.021, 95% CI: 1.140 -4.843), common bile duct diameter &lt;10 mm (P=0.005, 95% CI: 1.299-4.313), and Endoscopic Papillary Balloon Dilatation (EBD) (P=0.01, 95% CI: 0.321-0.855) were independent risk factors for PEP in CBDS patients. Conclusion: Female sex, a history of Fatty Liver Disease (FLD), previous acute pancreatitis, and common bile duct stenosis are risk factors for PEP, whereas EPBD is a protective factor for PEP in patients with CBDS, which should be considered by clinicians.

Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis.

Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables. Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation. Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003. We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.

Assessing Patient Radiation Exposure in Endoscopic Retrograde Cholangiopancreatography: A Multicenter Retrospective Analysis of Procedural Complexity and Clinical Factors.

Endoscopic retrograde cholangiopancreatography (ERCP) procedures can result in significant patient radiation exposure. This retrospective multicenter study aimed to assess the influence of procedural complexity and other clinical factors on radiation exposure in ERCP. Data on kerma-area product (KAP), air-kerma at the reference point (Ka,r), fluoroscopy time, and the number of exposures, and relevant patient, procedure, and operator factors were collected from 2641 ERCP procedures performed at four university hospitals. The influence of procedural complexity, assessed using the American Society for Gastrointestinal Endoscopy (ASGE) and HOUSE complexity grading scales, on radiation exposure quantities was analyzed within each center. The procedures were categorized into two groups based on ERCP indications: primary sclerosing cholangitis (PSC) and other ERCPs. Both the ASGE and HOUSE complexity grading scales had a significant impact on radiation exposure quantities. Remarkably, there was up to a 50-fold difference in dose quantities observed across the participating centers. For non-PSC ERCP procedures, the median KAP ranged from 0.9 to 64.4 Gy·cm2 among the centers. The individual endoscopist also had a substantial influence on radiation dose. Procedural complexity grading in ERCP significantly affects radiation exposure. Higher procedural complexity is typically associated with increased patient radiation dose. The ASGE complexity grading scale demonstrated greater sensitivity to changes in radiation exposure compared to the HOUSE grading scale. Additionally, significant variations in dose indices, fluoroscopy times, and number of exposures were observed across the participating centers.

ERCP-induced perforation: review and revisit after half a century.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure. We aimed to investigate ERCP-induced perforations at our institution and conduct a comprehensive review of literature on ERCP-induced perforations (EIP) since the introduction of this procedure as a therapeutic intervention. This was a case-control study, in which charts of all patients diagnosed with ERCP-induced duodenal perforation were reviewed and compared to a control group without perforation. Patient's sociodemographic and clinical data, including ERCP procedure-related data, were gathered. A total of 996 ERCP procedures were performed; only 13 patients proved to have EIP. Obstructive jaundice was the most common indication for ERCP. The main predisposing factor was difficult cannulation (P = 0.003). In total, five patients required surgical treatment; the majority of them had type I perforation, whereas type IV was the most common in patients who were treated conservatively. The overall mortality rate was 15%, the surgical group had a slightly higher mortality rate. Fifty years after the introduction of ERCP for therapy, it remains an invasive procedure that carries significant morbidity and mortality, even in skilled hands or at high- volume units. Conservative management of perforation yields favorable outcomes in selected patients.

Comparative study between biliary covered self-expandable metal stent and conventional endoscopic bile drainage treatment in endoscopic retrograde cholangiopancreatography-related Stapfer type II retroperitoneal perforations.

Perforation is one of the most serious complications of endoscopic retrograde cholangiopancreatography (ERCP). Conventional nonsurgical endoscopic treatments including intravenous antibiotic administration and plastic endoscopic biliary drainage are generally approved for the treatment of ERCP-related Stapfer type II perforation (perivaterian type). Biliary covered metal stent placement has recently been reported to have favorable outcomes in ERCP-related Stapfer type II perforations. We aimed to compare the outcomes of conventional endoscopic bile drainage and biliary covered self-expandable metal stent (SEMS) insertion in patients with Stapfer type II perforation. Medical records of patients who underwent ERCP at Kyungpook National University Hospital in Daegu from 2011 to 2022 were retrospectively reviewed. A total of 8,402 ERCP procedures were performed in our hospital. Sixty-six ERCP-related perforations (0.78%) were identified. Among them, 37 patients (56.1%) who had Stapfer type II perforations were enrolled. Thirteen and twenty-four patients received biliary covered SEMS insertion and conventional endoscopic bile drainage treatments, respectively. No significant differences were observed in the clinical success rate (92.3% vs. 91.7%, p = 1.000), hospital stay (9.46 ± 5.97 vs. 13.9 ± 13.2 days, p = 0.258), and post-ERCP-related fasting time (5.4 ± 3.4 vs 4.3 ± 3.0 days, p = 0.305). Complications including bleeding, post-ERCP pancreatitis, fever, and death were not significantly different between the two groups. The conventional endoscopic bile drainage group took less time for ERCP than the SEMS group (11.5 ± 5.2 vs. 18.5 ± 11.2 min, p = 0.013). Compared with the conventional endoscopic bile drainage treatment method, biliary covered SEMS did not improve patient outcomes in ERCP-related Stapfer type II perforations.

A nomogram for prediction of ERCP success in patients with bile duct leaks: a multicenter study.

Bile duct leaks (BDLs) are serious complications that occurs after hepatobiliary surgery and trauma, leading to rapid clinical deterioration. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for BDLs, but it is not clear which patients will respond to this therapy and which patients will require additional surgical intervention. The aim of our study was to explore the predictors of successful ERCP for BDLs. A retrospective analysis was conducted using data from six centers' databases. All consecutive patients who were clinically confirmed as BDLs were included in the study. Collected data were demographics, disease severity, and ERCP procedure characteristics. Univariate and multivariate analysis were used to select independent predictive factors that affect the outcome of ERCP for BDLs, and a nomogram was established. Calibration and ROC curves were used to evaluate the models. Four hundred and forty-eight consecutive patients were clinically confirmed as BDLs and 347 were excluded. In the 101 patients included patients, clinical success was achieved in 78 patients (77.2%). In logistic multivariable regression, two independent factors were negatively associated with the success of ERCP: SIRS (OR, 0.183; 95% CI 0.039-0.864; P = 0.032) and high-grade leak (OR 0.073; 95% CI 0.010-0.539; P = 0.010). Two independent factors were positively associated with the success of ERCP: leak-bridging drainage (OR 4.792; 95% CI 1.08-21.21; P = 0.039) and cystic duct leak (OR 6.193; 95% CI 1.03-37.17; P = 0.046). The prediction model with these four factors was evaluated using a receiver-operating characteristic (ROC) curve, which demonstrated an area under the curve of 0.9351. The calibration curve showed that the model had good predictive accuracy. Leak-bridging drainage and cystic duct leak are positive predictors for the success of ERCP, while SIRS and high-grade leak are negative predictors. This prediction model with nomogram has good predictive ability and practical clinical value, and may be helpful in clinical decision-making and prognostication.

The Course of Endoscopic Treatment Success in Biliary Complications After Living Donor Liver Transplantation.

Our aim was to present the results of endoscopic retrograde cholangiopancreatography (ERCP) after living donor liver transplantation (LDLT) between February 2015 and June 2021. Clinical data included LDLT indications, time to perform ERCP after LDLT, number of ERCP procedures, indications for ERCP, and all treatment outcomes, including ERCP, percutaneous, and surgical interventions. We compared the obtained data with our previous study published by our team in 2018, which included 446 patients who underwent ERCP for biliary complications after LDLT between 2005 and 2015. We performed ERCP in 283 of 1506 patients with LDLT who underwent duct-to-duct anastomosis during transplantation and then developed biliary complications. Our endoscopic success rates were 60.9% and 71.0% in the previous and present studies, respectively. Our findings suggest that the success rate of endoscopic treatment of biliary complications in patients with LDLT increases in correlation with the increasing experience of clinicians treating these patients.

Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation

Background and aimsNeedle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear.Patients and methodsThis retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events.ResultsHaraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69).ConclusionsNKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Validity of Predictive Markers for Post ERCP Pancreatitis Patients: A Single Centre Study

Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is a proprietary procedure, endoscopic modality, and specialized procedure used to diagnose and treat disorders of the pancreatic and biliary systems. The incidence of reported post-ERCP complications varied among several studies including post ERCP pancreatitis (PEP), duodenal perforation, and cholangitis. In this study, the author would like to show certain intra procedural factors related to PEP incidence. This was a retrospective study of secondary data of patients undergoing ERCP procedures from 2017-2022 at Prof. Dr. R. D. Kandou Hospital, Manado. Length of procedure, cannulation on pancreatic duct, pancreatogram, double wire technique, and the use of certain common bile duct (CBD) stone retrieval techniques such as endoscopic papillary balloon dilatation (EPBD) were recorded and analyzed. The results showed that based on the analyzed data, the percentage of pancreas cannulation was 8%, pancreatogram 5%, double-wire technique 3%, and EPBD procedure 10%, Incidence rate of PEP in all ERCP procedures was 19%. Increased amylase/lipase enzymes were found in 13 of 24 patients (54%) who underwent cannulation; 8 of 16 patients (50%) who underwent pancreatogram; 4 of 9 patients (44%) who underwent double wire procedure; and 10 of 30 patients (33%) who underwent EPBD. This PEP could be caused by several risk factors during ERCP including cannulation, pancreatogram, double wire, and EPBD. Number of cannulation attempt could result in trauma to the ampulla. Pancreatogram could result in hydrostatic, chemical, and allergic injury. Any manipulation of the pancreas that caused trauma could trigger the incidence of PEP. Assessment of the occurrence of PEP was based on increases in lipase and amylase enzyme values by four times the normal value and tested 6 hours after procedure. We could reduce the incidence of PEP by providing prophylactic therapy before ERCP. In conclusion, PEP is the most common complication in ERCP procedures and can be risky in patients with high risk factors. In this study, factors that affecting the incidence of PEP are cannulation, pancreatogram, double wire and EPBD. Keywords: endoscopic retrograde cholangiopancreatography; pancreatitis; complications

Risk Factors for Post-Endoscopic Retrograde Cholangio-Pancreatography Pancreatitis in Children With Chronic Pancreatitis and Its Prediction Using 4-Hour Postprocedure Serum Amylase and Lipase Levels.

Post-endoscopic retrograde cholangio-pancreatography pancreatitis (PEP) is seen in 3% to 16% of children undergoing therapeutic endoscopic retrograde cholangio-pancreatography (ERCP). We evaluated the risk factors of PEP and utility of 4-hour post-ERCP amylase and lipase for early prediction of PEP in children with chronic pancreatitis (CP). Thirty children with CP (boys 20, 14.3 [interquartile range, 9.3-16] years) who underwent 62 ERCP procedures were studied. Clinical and procedural details with outcome were noted. Serum amylase and lipase were measured before, 4 hours, and 24 hours after ERCP. Multivariate analysis was done to identify risk factors for PEP. Cutoff scores of 4-hour amylase and lipase were identified. PEP occurred in 14.5% (9/62) of ERCP procedures (mild, 8; moderate, 1) with no mortality. On univariate analysis, endoscopic sphincterotomy ( P = 0.04), difficult cannulation ( P = 0.004), and prior PEP ( P = 0.036) were risk factors, while prior ERCP ( P = 0.04) was protective. Difficult cannulation (odds ratio, 5.83; 95% confidence interval, 1.329-25.592) was the independent risk factor on multivariate analysis overall and for first ERCP session alone. Amylase >3.3 times upper limit of normal (ULN) and lipase of >5 times ULN at 4 hours had best sensitivity and specificity for diagnosis of PEP. All cases with PEP were symptomatic by 6 hours and none had amylase/lipase <3 ULN at 4 hours. Amylase/lipase of <3 ULN at 4 hours could exclude PEP with good sensitivity (100%) and specificity (76% and 81%, respectively). PEP occurred in 14.5% of procedures in children with CP, with difficult cannulation being the independent risk factor. Asymptomatic patients with 4-hour amylase/lipase <3 times ULN can be safely discharged.