Endoscopic Retrograde Cholangiopancreatography Treatment Research Articles

Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis.

IntroductionPost-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is associated with increased morbidity and mortality in patients ERCP. The aim of the present study was to analyze the predictors of PEC and to formulate a predictive model for early diagnosis and management.Materials and methodsIt was a cross-sectional study that was carried out at the Sindh Institute of Urology and Transplantation from September 2019 to June 2021. All patients aged between 18 and 75 years and undergoing ERCP due to obstructive jaundice were included. Patients with altered biliary anatomy, history of hepatobiliary surgery, and concurrent sepsis were excluded. Endoscopic retrograde cholangiopancreatography intervention was performed by an expert gastroenterologist. Laboratory parameters (total leukocyte count, total bilirubin, alanine transaminase) and patient temperature were checked on admission, at 12 hours, 24 hours, and 36 hours after ERCP to document PEC.ResultsA total of 349 patients were included in the study. Among them, 176 (50.4%) patients were males. Common bile duct (CBD) stricture was the most common indication of ERCP seen in 148 (42.4%) patients followed by CBD stone and cholangiocarcinoma in 108 (30.9%) and 48 (13.8%) patients, respectively. The most common presenting complaint was jaundice noted in 300 (86%) patients followed by right hypochondrial pain in 280 (80.2%) and weight loss in 194 (55.6%) patients, respectively. Post-ERCP cholangitis developed in 251 (71.9%) patients. On univariate analysis, age >50 years, female gender, right hypochondrial pain, fever, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, TLC of >10,000 cells/L at 12 hours, 24 hours, and 36 hours post-ERCP and rise in ALT >50 IU 24 and 48 hours post-ERCP were significantly associated with PEC. While on multivariate analysis, female gender, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, post-ERCP fever, and rise in TLC of >10000 cells/L at 24 hours post-ERCP were independently associated with PEC. HinCh score was formulated and was found to be significantly associated with the presence of cholangitis. Area under the receiver operating characteristics (AUROC) of HinCh score was 0.74 and at cutoff of ≥4, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HinCh were 81.67%, 59.18%, 83.67%, and 55.71%, respectively with a diagnostic accuracy of 75.36%.ConclusionThe performance of HinCh score in predicting PEC was accurate in 86% of the patients. However, further studies are needed to validate the score.How to cite this articleIsmail H, Yaseen RT, Danish M, et al. Role of “HinCh Score” as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis. Euroasian J Hepato-Gastroenterol 2022;12(1):19–23.

Long-Term Outcomes of Endoscopic Intervention in the Treatment of Symptomatic Pancreas Divisum.

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of patients with symptomatic pancreas divisum (PD) and to discuss the possible risk factors of endoscopic reintervention for symptomatic PD. A total of 50 patients with symptomatic PD who underwent ERCP from January 2010 to December 2019 were finally brought into study. All patients were divided into the nonage and the adult group according to their ages. Meanwhile, all patients were also divided into the intervention and the reintervention group according to times of ERCP. The long-term outcome of each patient was collected during the follow-up by phone call. The total success rate of ERCP was 94.7% (89/93), and the effective rate of first ERCP was 58% (29/50). There were no statistical differences on the outcomes of ERCP treatment between the adult and nonage group. There were 17 patients with complete pancreas divisum and 19 patients with chronic pancreatitis in the reintervention group, which were more than 6 patients and 8 patients in the intervention group (P < 0.05). In bivariate regression analysis, chronic pancreatitis and complete pancreas divisum might be significant risk factors for endoscopic reintervention for patients with symptomatic PD (OR, 8.010, 95% CI, 1.483–43.276, P=0.016; OR, 8.869, 95% CI, 1.450–54.254, P=0.018, respectively). ERCP in treating adult and nonage patients with symptomatic PD are effective and safe. But, many patients may need endoscopic reintervention. Complete pancreas divisum and chronic pancreatitis may be risk factors of ERCP reintervention for patients with symptomatic PD.

Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto.

BACKGROUNDMost of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.AIMTo compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.METHODSPatients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.RESULTSA total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.CONCLUSIONMany clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

Efficacy and safety of endoscopic retrograde cholangiopancreatography for the treatment of acute biliary pancreatitis with or without cholangitis

Objective: To evaluate the result of endoscopic retrograde cholangiopancreatography (ERCP) for treatment of acute biliary pancreatitis (ABP) with or without cholangitis. Subject and method: A retrospective cohort study, 30 patients of ABP at Institute of Gastroenterology and Hepatology, 108 Military Central Hospital, from January 2019 to November 2021. Result: We divided the patients into 2 groups: 19 patients ABP with cholangitis, 11 patients without cholangitis. Mean age: 60.7 ± 17.9 (26 - 92), male/female (1.5). The technical success rates were 94.7% and 100%, the clinical success rates were 100% and 90.9% of the two groups with and without cholangitis, respectively. The concomitant cholangitis was not associated with the timing of ERCP (p=0.192), technical success rate (p=0.439), and clinical success rate (p=0.367). And the total length of hospital stay was not different between the two groups (7.7 ± 3 vs. 7.7 ± 4.1 days, p=0.974). No significant differences were found in the duration of hospital after ERCP or procedural-related complications, in patients with acute biliary pancreatitis, according to the concomitant disease (with vs without cholangitis). Conclusion: These findings support ERCP could be performed effectively and safely in acute biliary pancreatitis with or without cholangitis.

S999 Impact of Trainee Involvement on the Total Procedural and Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography (ERCP)

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) training guidelines are evolving to be more competency-based in the absence of a standardized curriculum. We aimed to determine the effect of trainee involvement and center volume influences the ERCP scope time (ST), total procedural time (TPT), and fluoroscopy time (FT). Methods: Patients from Clinical Outcome Research Initiative National Endoscopic Database CORI-NED (2009-2014) who underwent ERCP were stratified based on the trainee participation (trainee participated vs. not participated), center volume (ERCPs performed >200/year-high volume (HV), 100-200/ year- intermediate volume (IV), < 100 per year-low volume (LV)). ST was defined as the time interval between ERCP scope insertion and withdrawal, TPT as the time interval requiring ERCP intervention, and FT as the time interval fluoroscopy activated. The time variables were compared against trainee involvement and ERCP center volume using the Kruskal-Wallis test and significance level defined for a p-value < 0.05 (Table 1). Results: A total of 13,855 ERCPs, comprising trainee participation (n= 6488) and non-participation (n=7367) were performed at HV (n=2220), IV (n=5062) and LV (n=6573) centers respectively. Trainee participation vs. non-participation significantly increased ST [31(20-40) versus 23.5(16-38.5), p< 0.014, Fig 1a], TPT [28 (24-48) vs. 24 (17.75-41.25), p< 0.00, Fig 1b]. However, FT was unaffected by trainee participation or non-participation (Fig 1c). HV vs. LV ERCP centers were significantly associated with prolonged ST [36(22.5-58) versus 24(16-39), p< 0.001)], TPT [36(25.5-61) vs. 28(18-42), p< 0.001)] and FT [6(3.5-9) vs. 2(1-2), p< 0.001)], respectively. HV vs. IV ERCP centers were significantly associated with prolonged ST [36(22.5-58) versus 31(16.5-46), p< 0.001)]. HV vs. IV centers were not associated with prolonged TPT [36(25.5-61) vs. 35(28-58.5), p=NS)] and FT was only marginally prolonged to statistical significance [6(3.5-9) vs. 5(2.5-11), p=0.03)], (Fig 1 d,e,f). Conclusion: Trainee involvement in ERCP interventions is associated with significantly longer scope time, total procedural time, and fluoroscopy time. Differences were similar for scope time and fluoroscopy time comparing HV centers with IV centers, but no difference was noted for total procedure time. It is anticipated that these findings will have a profound impact on structuring ERCP training and resource utilization.Table 1.: Pair-wise comparisons of scope time, total procedure time, and fluoroscopy time (minutes) across independent variables (trainee participation and center volume). DF#- degrees of freedom, IQR*-interquartile range, H (c2 chi-square statistic) for Kruskal Wallis test, NS-not significant.Figure 1.: Comparison of the various intraprocedural time intervals during ERCP with trainee participation and procedure volume.

Value of endoscopic retrograde cholangiopancreatography in treatment of patients with biliary and pancreatic diseases with digestive tract stricture

Value of endoscopic retrograde cholangiopancreatography in treatment of patients with biliary and pancreatic diseases with digestive tract stricture

The correlation between postoperative complications of ERCP and quality of life after discharge in patients with choledocholithiasis.

The treatment of choledocholithiasis by endoscopic retrograde cholangiopancreatography (ERCP) is a difficult endoscopic procedure involving a complicated surgical process. During and after ERCP, surgery-related complications may occur, and serious complications can threaten the life of the patient. This study aims to evaluate the correlation between the possible complications of ERCP treatment of choledocholithiasis and the quality of life of patients, and to provide a basis for formulating corresponding intervention measures. Using the Gastrointestinal Quality of Life Index (GIQLI) and the MOS item short from health survey (SF-36), we conducted random telephone follow-ups of 194 patients admitted to The Second Affiliated Hospital of Soochow University who underwent ERCP for the treatment of choledocholithiasis from October 2017 to December 2020. The patients' complications symptoms and quality of life were recorded, and a comparative analysis was performed. During the hospitalization of the included 194 patients, complications occurred in 38 cases (19.6%), including 18 cases (9.3%) of hyperamylase, 11 cases (5.7%) of acute pancreatitis, and 5 cases (2.6%) of cholecystitis. There were 4 cases (2.1%) of gastrointestinal bleeding. The SF-36 scores in the complication group were significantly lower than those in the non-complication group across various dimensions, including bodily pain (BP), general health (GH), vitality (VT), social functioning (SE), and mental health (MH). Furthermore, the GIQLI scores in the complication group were lower than those in the non-complication group across various dimensions, including symptoms, subjective symptoms, physical function status, social activity status, as well as mental and psychological status. Multiple regression analysis showed that dimensions such as PF, BP, and subjective symptoms were more likely to be affected by hyperamylaseemia, acute pancreatitis, and cholecystitis, and the difference was statistically significant (P<0.05). Complications after ERCP result in a poor quality of life after discharge in choledocholithiasis patients, suggesting that nurses need to take effective measures to prevent and actively treat hyperamylase, acute pancreatitis, and acute pancreatitis during the hospitalization of holedocholithiasis patients after ERCP. Common complications, such as cholecystitis, promote the recovery of patients and reduce the impact of the disease on quality of life.

Increased Risk of Pyogenic Liver Abscess after Endoscopic Sphincterotomy for Treatment of Choledocholithiasis.

Background and AimEndoscopic sphincterotomy (ES) abolished the barrier between the hepatobiliary system and duodenum and might be at risk of pyogenic liver abscess (PLA). We aimed to identify the association factors of PLA in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures for treatment of choledocholithiasis.MethodsThis study was based on the Chung Gung Research Database (CGRD) between January 1, 2001 and December 31, 2018. Those who had an International Classification of Diseases, Ninth and Tenth Revision (ICD9 and ICD10) codes of choledocholithiasis and received ERCP were enrolled. After strict exclusions, 11,697 patients were further divided into the endoscopic sphincterotomy (ES) group (n=7,111) and other ERCP group (n=4,586) for analysis.ResultsPatients receiving ES had significantly higher rates of PLA than those of the other ERCP group (5-year cumulative incidence 2.4% versus 1.7%; 10-year cumulative incidence 3.9% versus 3.2%, log-rank p=0.0177). Aging, male gender, surgery for hepato-pancreato-biliary system and hepatobiliary malignancy were significant association factors of PLA. On multivariate analysis, the ES increased the risk of PLA (adjusted hazard ratio [aHR]=1.49; 95% CI=1.12–1.98; p=0.0058) but decreased the risks for acute pancreatitis (aHR=0.72; 95% CI=0.60–0.85; p=0.0002) and cholangitis (aHR= 0.91; 95% CI=0.84–0.99; p=0.0259). There was no significant difference about recurrent choledocholithiasis between groups.ConclusionThis study demonstrated a significant risk of PLA after patients receiving ES compared with the other ERCP group. We should also carefully monitor the association factors of PLA after ERCP treatment of choledocholithiasis including aging, male gender, surgery for the hepato-pancreato-biliary system and hepatobiliary malignancy.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones.

Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the gold standard for diagnosis and interventions in biliopancreatic diseases. However, ERCP in patients with surgically altered anatomy (SAA) appears to be more difficult compared to cases with normal anatomy. Since the production of a balloon enteroscope (BE) for small intestine disorders, BE had also been used for biliopancreatic diseases in patients with SAA. Since the development of BE-assisted ERCP, the outcomes of procedures, such as stone extraction or drainage, have been reported as favorable. Recently, an interventional endoscopic ultrasound (EUS), such as EUS-guided biliary drainage (EUS-BD), has been developed and is available mainly for patients with difficult cases of ERCP. It is a good option for patients with SAA. The effectiveness of interventional EUS for patients with SAA has been reported. Both BE-assisted ERCP and interventional EUS have advantages and disadvantages. The choice of procedure should be individualized to the patient’s condition or the expertise of the endoscopists. The aim of this review article is to discuss recent advances in interventional ERCP and EUS for patients with SAA.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) can safely and effectively manage postsurgical or traumatic bile duct leaks (BDLs). Standardized guidelines are lacking regarding effective management of BDLs. Our aim was to evaluate the efficacy, clinical outcomes, and complications of different ERCP techniques and intervention timing using a nationwide database. Patients and methods We performed a retrospective analysis of the IBM Explorys database (1999–2019), a pooled, national, de-identified clinical database of over 64 million unique patients across the United States. ERCP timing after BDL was classified as emergent (< 1 day), urgent (1–3 days) or expectant (> 3 days). ERCP technique was classified into sphincterotomy, stent or combination therapy. ERCP complications were defined as pancreatitis, duodenal perforation, duodenal hemorrhage, and ascending cholangitis within 7 days of the procedure. Results Expectant ERCP had a decreased risk of adverse events (AEs) compared to emergent and urgent ERCP ( P = 0.004). Rehospitalization rates also were lower in expectant ERCP ( P < 0.001). Patients with COPD were more likely to have an AE if the ERCP was performed emergently compared to expectantly ( P = 0.002). Combination therapy had a lower rate of ERCP failure compared to placement of a biliary stent ( P = 0.02). There was no statistically significant difference in rates of ERCP failure between biliary stent and sphincterotomy ( P = 0.06) or sphincterotomy and combination therapy ( P = 0.74). Conclusion Our study suggests that ERCP does not need to be performed emergently or urgently for management of BDLs. Combination therapy is superior to stenting but not sphincterotomy; however, future prospective studies are needed to validate these findings.

Clinical Outcomes Following Therapeutic Endoscopic Retrograde Cholangiopancreatography in Children With Pancreas Divisum.

Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD. We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy. Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy. The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.

The Emergency Endoscopic Treatment in Acute Cholangitis.

Background: Acute cholangitis is a systemic disease caused by acute inflammation and infection of the biliary tree and carries significant morbidity and mortality rates. The most common cause of acute cholangitis is choledocholithiasis, which can lead to an increased death rate in severe forms and in the absence of appropriate treatment. The clinical Charcot's triad is outdated due to low sensitivity and has been replaced with the criteria established by the Tokyo guidelines. The criteria of diagnosis are based on the presence of systemic inflammation, cholestasis and/or jaundice and biliary obstruction documented by imaging studies. Depending on the severity of the disease, treatment varies from antibiotic therapy to emergency endoscopic biliary drainage. In severe cases the first-line treatment is achieved by endoscopic retrograde cholangiopancreatography (ERCP). Method: To evaluate the effectiveness of urgent ERCP treatment in patients with acute cholangitis, a retrospective data analysis was performed of 185 patients that underwent endoscopic interventions between 2018 and September 2020, 74 patients of which have been identified with different grades of acute cholangitis. Results: The studied group consisted of 42 women (56.7%) and 32 men (43.3%), with a mean age of 62.2 (38-93) years. Obstructive choledocholithiasis was as the main cause of cholangitis (44 patients, 59.5%), with varying degrees of severity - grade I (41, 55.4%), grade II (22 patients, 29.7%) and grade III (11 patients, 14.8%). For cases with grade II and III of severity (33 patients, 44.5%), the endoscopic intervention took place in the first 12-24 hours after admission. Patients that had endoscopic dezobstruction in the first 12-24 hours had normal blood tests in 4.7 days (mean) and 5.8 days (mean) of hospital stay while patients that had dezobstruction more than 24 hours after admission had normal blood tests in 6.3 days (mean) and 7.6 days of hospital stay. Mortality was 5.4%, all 4 patients having grade III severity cholangitis. Conclusion: Patients that benefited from endoscopic biliary drainage in the first 24 hours after admission had a faster recovery, decreased duration of antibiotic therapy, decreased duration of hospital stay, lower morbidity and mortality rate compared to those that suffered the intervention more than 24 hours after admission.

A rare case of duodenal diaphragm in an adult during ERCP treatment for choledocholithiasis

BackgroundDuodenal Diaphragm in adults is very uncommon, caused by congenital and acquired changes. It is reported that acquired duodenal diaphragm is related to the long-term use of nonsteroidal anti-inflammatory drugs.Case summaryWe report an adult presentation of duodenal diaphragm in a 77-year-old woman, suffered from acute cholangitis and choledocholithiasis. She was performed endoscopic retrograde cholangiopancreatography (ERCP) procedure to remove the stone in common bile duct (CBD). After the stenosis ring dilated by endoscopic balloon dilatation, ERCP procedure was applied, and the CBD stone was removed successfully.ConclusionDuodenal diaphragm is difficult to diagnose in clinic. Although the patient in this case had relatively mild symptoms of incomplete upper hemi-abdominal obstruction, these symptoms could be obscured by the emergency acute upper abdominal pain with fever as clinical manifestations of acute cholangitis.

Endoscopic retrograde cholangiopancreatography in the treatment of pancreaticopleural fistula in children.

BACKGROUNDPancreaticopleural fistula (PPF) is a rare disease, especially in children. Conservative treatment and surgery are traditional therapies, but surgery is invasive. The emergence of endoscopic retrograde cholangiopancreatography (ERCP) has provided a new noninvasive treatment for PPF and may become the first choice for children with PPF.AIMTo explore the treatment response to ERCP for PPF in children.METHODSSeven children with PPF were hospitalized in the Gastroenterology Department of Beijing Children’s Hospital from December 2007 to May 2019. Data on these seven patients’ clinical characteristics, diagnosis, treatments, and outcomes were analyzed, and their treatment responses following surgery and ERCP were compared. The correlation between the length of hospital stay and conservative treatment was analyzed. Peer-reviewed articles written in English and Chinese published from January 2009 to December 2019 were obtained from various open data sources and reviewed.RESULTSThe seven patients comprised three boys and four girls with a mean age of 6.57 ± 3.26 years. The main symptoms were chest tightness and pain (n = 4), intermittent fever (n = 3), dyspnea (n = 3), and abdominal pain (n = 1), and all patients had bloody pleural effusion. All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography, and all were initially treated conservatively for a mean of 34.67 ± 22.03 d with a poor response. Among five patients who underwent ERCP, one required surgery because of intubation failure; thus, the success rate of ERCP was 80%. Two patients were successfully treated with surgery (100%). The postoperative hospital stay of the two patients treated by surgery was 20 and 30 d, respectively (mean of 25 d), and that of the four patients treated by ERCP ranged from 12 to 30 d (mean of 19.25 ± 8.85 d). The recovery time after ERCP was short [time to oral feeding, 4-6 d (mean, 5.33 ± 1.15 d); duration of closed thoracic drainage, 2-22 d (mean, 13.3 d)]. Analysis of previous cases of PPF published worldwide during the past decade showed that the treatment success rate of ERCP is not lower than that of surgery. There was no significant difference in the postoperative hospital stay between surgery (16 ± 10.95 d) and ERCP (18.7 ± 6.88 d, P > 0.05). A positive linear correlation was found between the overall hospital stay and ERCP intervention time (R2 = 0.9992).CONCLUSIONERCP is recommended as the first-choice treatment for PPF in children. ERCP should be performed as early as possible if conditions permit.

The influence of periampullary diverticula on ERCP for treatment of common bile duct stones

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

Tu1029 POST BARIATRIC ANATOMY AS A RISK FACTOR FOR POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS: A NATIONWIDE, MATCHED, CASE-CONTROL ANALYSIS

Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis (PEP) is a common complication occurring at a rate of 1-15%. Predictors of PEP include the type of intervention, age, and hospital setting. Performing ERCP in patients with altered anatomy, such as those with roux-en-Y gastric bypass (RYGB), is becoming increasingly common. However, data is limited on the risk of PEP in this patient population. The aim of this study is to evaluate post bariatric anatomy as a risk factor for PEP. The study population was extracted from the Nationwide Inpatient Sample (NIS) for the years 2000-2014. Adult patients, who were admitted with biliary obstruction without acute pancreatitis as their primary diagnosis and had an inpatient ERCP were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. PEP was defined as having a diagnosis of acute pancreatitis after index ERCP. Patients with bariatric anatomy were identified by the code V45.86 and the above timeframe was chosen in an effort to capture the RYGB population while minimizing the more recent sleeve gastrectomy procedure which does not require an altered approach to ERCP. Cases were matched in a 4:1 fashion to controls by age, gender, race, geographic region, hospital teaching status, and ERCP intervention (diagnostic, biliary without pancreatic and biliary with pancreatic cannulation or intervention). Rates of PEP were calculated based on the bariatric surgery status and by ERCP intervention type and were compared using Chi square and regression analyses. A total of 3,890 patients with bariatric anatomy who were admitted with biliary obstruction and had inpatient ERCP were identified. Mean age was 51 years, 81% were female and 69% were of white ethnicity. These patients were matched to 12,784 patients without bariatric anatomy (Table 1). Overall rate of PEP was 6.3%. Patients with bariatric anatomy had a PEP rate of 8.1% as compared to 5.8% for those without bariatric anatomy (p<0.001). After matching for intervention and the above-mentioned demographics, odds ratio of PEP was 1.4 (CI 1.2-1.6, p <0.001). The rate varied significantly based on the ERCP intervention as below (Figure 1). In this nationwide analysis, bariatric surgical anatomy was associated with a significant increase in the post ERCP pancreatitis rate even after controlling for classic procedural and patient risk factors. Since most of these procedures were being performed with forward viewing deep enteroscopy, the increased risk could be attributed to the technical difficulty of cannulation. This might be ameliorated with the use of newer techniques that involve access to the excluded stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk factors for 30-day readmission and indication for ERCP following laparoscopic cholecystectomy: a retrospective NSQIP cohort study.

Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP. We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operativecharacteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention. Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001). Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Predictors of postendoscopic retrograde cholangiopancreatography pancreatitis, analysis of more than half a million procedures performed nationwide over the last 15 years.

Background and AimPost‐ERCP pancreatitis (PEP) is the most common complication following endoscopic retrograde cholangiopancreatography (ERCP). It is still controversial whether the presence of a trainee would increase the risk of PEP. Additionally, the effects of demographic factors and comorbidities on the risk and severity of PEP are not fully understood. Our aim was to evaluate these factors using national database.MethodsNationwide Inpatient Sample 2000–2014 was used to identify adult patients admitted with biliary obstruction without acute pancreatitis and had an inpatient ERCP. PEP was defined as having a subsequent diagnosis of acute pancreatitis. The presence of major organs failure marked moderate–severe PEP. Demographic information, hospital characteristics, and ERCP intervention types were collected.ResultsWe included 654 394 patients. Overall PEP rate was 5.4%. The PEP rate was lower in teaching (4.8%) compared with nonteaching (6.2%, P < 0.001) hospitals. The highest PEP rate was observed among patients undergoing Sphincter of Oddi Manometry (15.1%, odds ratio [OR] = 2.5, P < 0.001) as compared to diagnostic cholangiography (4.4%). Asians and Hispanics had higher rate of PEP (10% and 7.9%, respectively) compared with Caucasians and African Americans (4.9% and 5%, respectively, P < 0.001). Multivariate analysis showed that after controlling for the ERCP intervention types, Asians and Hispanics continued to have higher odds of PEP (OR = 1.3, P < 0.001). Seventeen percent of patients were classified as moderate–severe PEP. Older patients (OR = 3.2, P < 0.001), males (OR = 1.4, P < 0.001), and high comorbidities (1.3, P < 0.001) were major predictors of moderate–severe PEP.ConclusionNo evidence of higher PEP rates in teaching hospitals. Asians and Hispanics had higher PEP rates. Although ERCP intervention type is the major PEP predictor, its severity is dependent on patient characteristics.

Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial.

Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events. This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis. 21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %; P = 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %; P > 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %, P = 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event. Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.