Endoscopic Retrograde Cholangiopancreatography Related Complications Research Articles

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Predictive Factors for Therapeutic Endoscopic Retrograde Cholangiopancreatography-Related Complications in the Treatment of Choledocholithiasis

Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of our study is to evaluate the complication rate of ERCP in the treatment of choledocholithiasis and to assess the factors related to their occurrence. Methods: This is a retrospective descriptive and analytical study including 1048 patients who underwent ERCP for choledocholithiasis between January 2007 and August 2021. The factors associated with the occurrence of post-ERCP complications were studied by logistic regression analysis. Results: Among the patients studied, 60.5% had a simple lithiasis, 27.6% had multiple choledochal stones and 11.9% had large stones (> 15mm). Clinically, 18.7% of the patients presented with cholangitis and 9.4% with acute pancreatitis. A periampullary diverticulum was found in 9.4% of cases. A common bile duct stenosis was present in 6.5% of cases. The primary vacuity rate was 77.3%. However, additional manoeuvres were used in 20.5% of cases. Complications were reported in 5.8% of cases, including hemorrhage in 4.5%, pancreatitis in 0.8%, cholangitis in 0.2%, perforation in 0.1% and dormia impaction in 0.2%. No death was reported due to our procedures. In a multivariate analysis following adjustment of confounding factors, only the presence of a large stone (OR= 5.9, CI (1.460- 23.875), p=0.013) and female gender (OR= 1.867, CI (1.012-3.444), p=0.046) increased the risk of complications during ERCP. Conclusion: Our study suggests that female gender and the presence of à large gallstone are associated with a high risk of post-ERCP complications.

Endoscopic retrograde cholangiopancreatography-related complications for bile duct stones in asymptomatic and symptomatic patients.

Background and AimCurrent guidelines recommend the removal of common bile duct (CBD) stones by endoscopic retrograde cholangiopancreatography (ERCP) for both asymptomatic and symptomatic patients. We conducted this study because of the limited research comparing the risks of ERCP‐related complications between these two groups.MethodsThis retrospective study involved 1491 patients with native major duodenal papilla diagnosed with choledocholithiasis at three institutions in Japan. The rates of ERCP‐related complications, including post‐ERCP pancreatitis (PEP), cholangitis, bleeding, and perforation, were compared using one‐to‐one propensity score matching between the asymptomatic and symptomatic patients.ResultsComplications were observed in 112 (7.5%) of the 1491 patients (asymptomatic group: 31/172 [18.0%] vs symptomatic group: 81/1319 [6.1%], P < 0.001). The rate of severe complications was higher in the asymptomatic group than that in the symptomatic group (asymptomatic group: 5/31 [16.1%] vs symptomatic group: 3/81 [3.7%], P = 0.036). In the propensity‐matched asymptomatic and symptomatic patients, the incidences of PEP, cholangitis, bleeding, and perforation were 18/143 (12.6%) vs 4/143 (2.8%) (P = 0.003); 4/107 (3.7%) vs 6/107 (5.6%) (P = 0.75); 1/140 (0.7%) vs 3/140 (2.1%) (P = 0.62); and 2/140 (1.4%) vs 2/140 (1.4%) (P = 1.0).ConclusionsERCP for asymptomatic patients with CBD stones is associated with a higher risk of overall and severe complications than that for symptomatic patients with CBD stones; the overall rate is influenced by the high incidence of PEP in the asymptomatic group. Endoscopists should explain the risk of ERCP‐related complications for asymptomatic patients before performing the procedure.

The Incidence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review.

BackgroundExisting literature on post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with liver transplant remains scarce and largely inconsistent. We therefore aimed to systematically review and analyze the literature on complication rates associated with ERCP in patients with liver transplant.MethodsWe performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through March 2020 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.ResultsFourteen studies with a total of 1,787 patients were analyzed. In total, 3,192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% confidence interval (CI): 0.035 - 0.075). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025 - 0.047), bleeding 1.1% (95% CI: 0.006 - 0.020), infections 0.2% (95% CI: 0.025 - 0.047), and cholangitis 0.8% (95% CI: 0.004 - 0.020). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455 - 3.653, P = 0.633, I2 = 72.88%).ConclusionPost-ERCP complication rates in liver transplant patients are comparable to the general population and hence, peri-procedural evaluation and management may follow the current standards of care in this patient population.

S0916 Analysis of Clinical Outcomes and Length of Stay Among Patients With Systemic Lupus Erythematosus Undergoing Endoscopic Retrograde Cholangiopancreatography: A Nationwide Inpatient Sample Analysis

INTRODUCTION: Systemic Lupus Erythematosus (SLE) is a chronic disease that is characterized by a high inflammatory state and is associated with biliary and pancreatic disease. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard of care for diagnosing and treating biliary or pancreatic ductal complications. The literature is deficient on the associations of ERCP related outcomes and complications in SLE patients. This study aims to evaluate the effects of SLE on clinical outcomes and in-patient mortality in patients undergoing ERCP. METHODS: The NIS database was used to identify hospitalized patients who had an ERCP study from 2012 to 2014 using ICD-9 codes. Patients were divided into 2 groups, those with and without SLE. Primary outcomes: mortality, hospital charges, and length of stay (LOS). Secondary outcomes: ERCP related complications (perforation, pancreatitis, gastrointestinal (GI) bleed, fistula/abscess formation, and sepsis). Chi squared tests for categorical data and independent T test for continuous data were used to compare the outcomes between the 2 groups. Multivariate analysis was done to assess the primary outcomes after adjusting for confounding variables. RESULTS: There was 83,900 ERCP related hospitalizations from 2012 to 2014, of which 420 patients had SLE. In patients with SLE who had an ERCP procedure, 390 (92.9%) were female and the average age was 53.1. The average LOS was 7.7 days, mortality rate was 2.4% (10 patients), and total hospital charges was $71,758. There was no statistical significance in the primary outcomes of LOS, mortality, or hospital cost in SLE patients. There was no statistical significance in the rate of pancreatitis, GI bleed, perforation, abscess formation, or sepsis. In SLE patients, there were statistically significant less strictures (20.2% vs 24.9%, OR 0.87, 95% CI 0.68–1.11) and higher fistula formation rates (1.2% vs 0.2%, OR 7.60, 95% CI 3.05–18.9). CONCLUSION: With SLE patients being in a high inflammatory state, it was hypothesized that SLE would be associated with higher rates of complications after ERCP procedures leading to prolonged hospitalization and worse outcomes. However, in this study, the primary outcomes were not found to be statistically significant, but an increased risk of fistula formation was significant. It is possible that many SLE patients do not present with an acute flare and are likely immunosuppressed which can have a protective effect on the results. Further studies are needed to elucidate such associations.Table 1.: Table demonstrating demographics and resource utilization of patients with and without Lupus who had an endoscopic retrograde cholangiopancreatography procedureTable 2.: Table demonstrating clinical outcomes in patients with and without Lupus, who underwent endoscopic retrograde cholangiopancreatography procedures during their hospitalization

Prevalence of Endoscopic Retrograde Cholangiopancreatography Complications and Amylase Sensitivity for Predicting Pancreatitis in ERCP Patients.

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure that is widely used for diagnosis and treatment of biliary and pancreatic diseases. With respect to its growing application, the present study aims to evaluate ERCP outcomes and complications. This cross-sectional study was performed using the data from 824 patients who underwent ERCP during 2014-2017 in Qom Shahid Beheshti hospital. Data were collected by a checklist and analyzed using SPSS V22. Among 824 patients, 397 (48.18%) were male and 427 (51.82%) were female with a mean age of 47 ± 6 years. The most common indications for ERCP were choledocholithiasis (78.28%) and cholestasis (20.27%), respectively. Total prevalence of complications was 15.66% and mortality rate was 0.72%. The most common complications were pancreatitis (9.59%) and bleeding (3.28%), respectively. A serum amylase level of greater than 160 could predict pancreatitis with sensitivity of 93.3% and specificity of 90.3%. Endoscopic retrograde cholangiopancreatography-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high-risk patients may increase the mortality of the procedure.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review.

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

107 The Prevalence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review

INTRODUCTION: Biliary complications following liver transplantation are usually managed with endoscopic retrograde cholangiopancreatography (ERCP); however, the literature on post-ERCP complications remains poorly reported and largely inconsistent in this patient population. Hereby we aimed to systematically review and analyze the literature on complication rates associated with the performance of ERCP in patients with liver transplant. METHODS: We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and prevalence were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. RESULTS: Fourteen studies with a total of 1787 patients were included in this analysis. In total, 3192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% CI: 0.035–0.075) (Figure 1). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025–0.047), bleeding 1.1% (95% CI: 0.006–0.020), infections 0.2% (95% CI: 0.025–0.047), and cholangitis 0.8% (95% CI 0.004–0.020) (Figure 2a–d). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455–3.653, P = 0.633, I2 = 72.88%) (Figure 3). CONCLUSION: The risk of post-ERCP complications has been a major concern for many endoscopists in patients with liver transplantation. This might be related to theoretical concerns of distorted anatomy and difficult cannulation, combined with a general lack of evidence on the true prevalence of these complications. Our study confirms that post-ERCP complication rates are comparable to the general population undergoing ERCP and hence, peri-procedural evaluation and management should be continued as per the standard of care in this patient population.

Clinical Outcomes and Efficacy of a New Endoscopic Ultrasound Program in a Community Hospital

Introduction: Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic pancreaticobiliary imaging in various benign and malignant conditions. Studies have shown the accuracy of EUS to be comparable and even superior to ERCP for diagnosing pancreaticobiliary diseases but with fewer side effects. The main side effect of ERCP is post-ERCP pancreatitis which can be avoided in certain conditions where therapeutic intervention is not necessary. Both procedures can be combined into a single EUS-ERCP session for management of obstructive jaundice. In this study, we investigated the clinical outcomes and efficacy of starting a new EUS program, as well as the impact of combining EUS with ERCP in a single endoscopic session. Methods: In a retrospective study, EUS and combined EUS-ERCP procedures performed over a period of three years were selected. Data was collected regarding indications, outcomes, interventions, and complications. Clinical indications, outcomes, and complications were analyzed with two-way ANOVA test and Fisher's exact test. Results: A total of 766 EUS performed over a 3-year period between 2013 and 2015 were included in the study, out of which 130(16.9%) were combined EUS-ERCP in a single endoscopic session. There was a 39.6% relative increase in the number of EUS performed with a p-value of <0.0001. The success rate for EUS and EUS-ERCP was 99.8% and 97% respectively. There were 33(25.3%) patients with malignancyrelated obstructive jaundice who underwent combined EUS-ERCP for diagnosis and relieving obstruction in a single session. Fine needle aspiration was performed in 313(49.2%) cases in EUS and 53(40.7%) in EUS-ERCP. Complications were noted to be acute pancreatitis [3(0.47%) vs 11(8.4%)] and abdominal pain [8(1.2%) vs 10(7.6%)]. A total of 70[(11%) confidence interval (CI) ± 2] ERCP procedures were saved by doing EUS, resulting in prevention of acute pancreatitis (0.7%, CI: 0.4). Conclusion: We are reporting our experience of the introduction of EUS as a new service in a community hospital showing high success and low complication rate and is associated with avoiding unnecessary ERCP procedures thus protecting against ERCP related complications. Combining EUS-ERCP procedures resulted in significant impact on patients with obstructive jaundice by diagnosing and relieving obstruction in one endoscopic session.777_A Figure 1. Graph representing an increase in the volume of EUS over the course of 3 years (39.6% relative increase; p <0.0001). FNA was performed in 313(49.2%) cases which also shows relative increase.777_B Figure 2. Analysis of EUS and combined EUS-ERCP

Endoscopic Retrograde Cholangiopancreatography-Related Complications From the Nationwide Inpatient Sample: An Analysis of Racial Distribution, Length of Stay, and Mortality

Endoscopic Retrograde Cholangiopancreatography-Related Complications From the Nationwide Inpatient Sample: An Analysis of Racial Distribution, Length of Stay, and Mortality

Managing endoscopic retrograde cholangiopancreatography-related complications in patients referred to the surgical emergency unit.

The goal of this study was to present our experience in the management of endoscopic retrograde cholangiopancreatography-related complications in patients referred to our surgical emergency unit by various endoscopy centers. A retrospective investigation was conducted on the records of the 54 patients who were referred to our surgical emergency unit between October 2005 and January 2014 due to endoscopic retrograde cholangiopancreatography-related complications. There were 25 and 29 female and male patients, respectively. Pancreatitis was the most common complication (38.8%). Perforation (27.7%), infection (20.3%), and bleeding (12.9%) were the other complications. In 22.2% of cases, patients were died. The mortality rate was the highest in patients with perforation (40%). The mean age of the patients who were died due to complications was 75.9 years (range, 47-94 years). In total, 41.6% of the patients were died within the first week and 33.3% were died within the second week following ERCP. Nearly half of these patients had a cancerous disease (one had metastatic breast cancer, one had a gallbladder cancer, one had a duodenal cancer, and the other three had periampullary cancers) and 50% of the patients who died also had cardiopulmonary and/or cerebrovascular disorders. Comprehending and managing the main risk factors can minimize complications; however, they would not be eliminated. Moderate and severe complications may increase the mortality rates, particularly in high-risk patients.

Non-trauma Emergency Pancreatoduodenectomies: A Single-Center Retrospective Analysis.

To retrospectively assess the frequency and indications for emergency pancreatoduodenctomies in a tertiary referral center. Pancreatoduodenectomies between January 2005 and January 2014 were retrospectively assessed for emergency indications defined as surgery following unplanned hospital admission in less than 24h. Data on indications and on the intraoperative as well as the post-operative course were collected. Out of 583 pancreatoduodenectomies during the interval, a total of 10 (1.7%) were performed as an emergency surgery. Indications included uncontrollable bleeding, duodenal and proximal jejunal perforations, and endoscopic retrograde cholangiopancreatography-related complications. Three of the 10 (30.0%) patients died during the hospital course. In one patient, an intraoperative mass transfusion was necessary. No intraoperative death occurred. All but one patient were American Society of Anesthesiologists class three or higher. In two cases, the pancreatic remnant was left without anastomosis for second-stage pancreatojejunostomy. Median operation time was 326.5min (SD 100.3min). Hospital stay of the surviving patients was prolonged (median 43.0days; SD 24.0days). Emergency pancreatoduodenectomies are non-frequent, have a diverse range of indications and serve as an ultima ratio to cope with severe injuries and complications around the pancreatic head area.

Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis.

To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach. Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials (RCT) studies which met our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCP-related bleeding, perforation and cannulation success rates. Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group (OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis (PEP) was not different between the two groups (3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation (6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41). This meta-analysis suggests that pre-cut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.

Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases.

Endoscopic biliary drainage is an established mode of biliary decompression in patients with acute cholangitis as a result of biliary obstruction secondary to stones and benign strictures. However, there are no reports on endoscopic management of severe acute cholangitis caused by malignant conditions. We prospectively compared the efficacy of the endoscopic drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. Forty-three patients with severe acute cholangitis requiring urgent biliary drainage were included. Sixteen patients (mean age 58.2 +/- 9.3 years; seven men, nine women) had biliary obstruction as a result of malignant diseases and 27 had benign biliary diseases (mean age 41.6 +/- 14.3 years; nine men, 18 women). Indications for urgent drainage included any one of the following: temperature >38 degrees C (n = 21), septic shock with systolic blood pressure <100 mmHg (n = 9), localized peritonism (n = 21), impaired consciousness (n = 6) and failure to improve within 72 h of conservative management (n = 13). After successful bile duct cannul degrees ation, patients received either a nasobiliary catheter (n = 38) or an in-dwelling stent (n = 5) with or without sphincterotomy for biliary drainage. Outcome measures included complications and clinical response. Endoscopic drainage was established successfully in all the patients in both the groups. Clinical improvement after biliary drainage occurred in 94% patients (15/16) in the malignant group compared with 96% patients (26/27) in the benign group (P = not significant [NS]). Fever subsided at a median of 2.2 days in the malignant group and at 1 day in the benign group (P = NS). Normalization of leukocyte count was seen at a median of 6 days (range 1-17) and 2 days (range 1-5) days in the malignant group and the the benign group, respectively (P = NS). There were no endoscopic retrograde cholangiopancreatography-related complications. The mortality rate as a result of cholangitis was 4.6%, that is two of 43 patients (6.2% of the malignant group vs 3.7% of the benign group; P = NS). Endoscopic biliary drainage is equally effective in patients with severe acute cholangitis caused by either malignant or benign biliary diseases.

Endoscopic retrograde cholangiopancreatographic evaluation of patients with obstructive jaundice.

To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. A retrospective, observational study. The study was carried out at Valley Clinic, Rawalpindi, from January 1999 to January 2002. Two-hundred and twenty-six patients, who underwent ERCP for evaluation of obstructive jaundice were included. ERCP in each case was performed with standard technique and the findings were recorded. Therapeutic procedures like sphincterotomy, Dormia extraction for stone, and stent placements were performed whenever indicated. Of the 226 patients, 117 (51.8%) were males, and 109 (48.2%) females, their mean age being 51.8+/-16.6 years. Common bile and pancreatic ducts were visualized in 81.8% and 68.1% patients respectively. Growth/masses and stones were commonest causes of obstructive jaundice. Choledocholithias was common in males, while biliary channel related growth/masses were common in females (p-value=0.03). Common bile duct stone clearance rate was 88%, stenting was highly successful in patients with growth and strictures. ERCP related complications were noted in 11 (4.8%) patients. ERCP is an important diagnostic and therapeutic modality for evaluation of patients with obstructive jaundice. Growth/masses and stones are common causes of obstructive jaundice which can be diagnosed and treated with ERCP.