Endoscopic Retrograde Cholangiopancreatography Treatment Research Articles

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients.

BACKGROUNDHepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates.AIMTo examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures.METHODSWe performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease (MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques (single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates.RESULTS77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding (7.8%), infection (6.5%), and bile leak (2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events (β = 0.55, P < 0.01). MELD-Na scores also significantly predicted adverse events (β = 0.037, P < 0.01). Presence of advanced techniques was not associated with higher adverse events (P > 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events (P < 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases.CONCLUSIONIncreasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study.

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in pediatric patients with cholangiopancreatic diseases. To evaluate the efficacy, safety, and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction (PBM). A multicenter, retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019. They were divided into four PBM groups based on the fluoroscopy in ERCP. Their clinical characteristics, specific ERCP procedures, adverse events, and long-term follow-up results were retrospectively reviewed. Totally, 112 ERCPs were performed on the 75 children with symptomatic PBM. Clinical manifestations included abdominal pain (62/75, 82.7%), vomiting (35/75, 46.7%), acholic stool (4/75, 5.3%), fever (3/75, 4.0%), acute pancreatitis (47/75, 62.7%), hyperbilirubinemia (13/75, 17.3%), and elevated liver enzymes (22/75, 29.3%). ERCP interventions included endoscopic sphincterotomy, endoscopic retrograde biliary or pancreatic drainage, stone extraction, etc. Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis (9/75, 12.0%), gastrointestinal bleeding (1/75, 1.3%), and infection (2/75, 2.7%). During a mean follow-up period of 46 mo (range: 2 to 134 mo), ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis. The overall effective rate of ERCP therapy was 82.4%; seven patients (9.3%) were lost to follow-up, eight (11.8%) re-experienced pancreatitis, and eleven (16.2%) underwent radical surgery, known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy. ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM, with the characteristics of minor trauma, fewer complications, and repeatability.

The role of seed implantation in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using ERCP

PurposeThe purpose of the study was to investigate the role of iodine-125 seed implantation, guided by endoscopic ultrasound (EUS) and/or percutanous ultrasound, in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using endoscopic retrograde cholangiopancreatography (ERCP). Methods and MaterialsA total of 101 patients with obstructive jaundice due to unresectable pancreatic carcinoma were enrolled between January 2010 and December 2017 in this retrospective study. Of these patients, 50 underwent implantation of iodine-125 seeds under EUS and/or percutaneous ultrasound guidance after receiving a stent via ERCP (treatment group), and 51 received a stent via ERCP without undergoing seed implantation (control group). The clinical data and therapeutic outcomes of these patients were analyzed. ResultsCompared with the control group, the treatment group obtained significant relief of abdominal pain at the 1-week, 1-month, and 3-month followup (p < 0.05), with a significantly lower visual analog scale pain score (p < 0.05). The treatment group obtained a longer median survival (8.8 vs. 6.5 months, p = 0.02), longer median duration of stent patency (10.8 ± 1.4 vs. 6.9 ± 0.8 months, p = 0.02), and prolonged average time to gastric outlet obstruction (6.8 ± 1.6 vs. 5.3 ± 1.3 months, p = 0.02). Differences between liver function and appetite for the two groups were not significant (p > 0.05 and p = 0.59, respectively). ConclusionsIodine-125 seed implantation after relief of obstructive jaundice via ERCP prolongs survival, biliary stent patency, and time to gastric outlet obstruction and improves patient quality of life by relieving pancreatic pain in patients with unresectable pancreatic carcinoma.

Comparative study of biliary stent placement by percutaneous transhepatic cholangial drainage and endoscopic retrograde cholangiopancreatography in treatment of malignant biliary obstruction

Comparative study of biliary stent placement by percutaneous transhepatic cholangial drainage and endoscopic retrograde cholangiopancreatography in treatment of malignant biliary obstruction

Application of multimedia health education in patients with endoscopic retrograde cholangio-pancreatography minimally invasive treatment

Objective To evaluate the effect of mobile nursing workstation multimedia module applied to preoperative health education of patients with minimally invasive endoscopic retrograde cholangiopancreatography (ERCP) . Methods By convenience sampling, 100 patients who met the inclusion criteria in-hospitalized in Department of Digestive Medicine, Beijing Chao-Yang Hospital, Capital Medical University from January to June of 2018 were selected and divided into the observation group (n=44) and control group (n=44) according to the random number table. Conventional education approach of oral teaching and distribution of teaching materials was adopted in the control group, besides of that the observation group received the intensive teaching approach through mobile nursing platform multimedia and open communication. The knowledge mastering status, satisfactory degree and anxiety scores were compared between the two groups after health education. Results In the observation group, the score of knowledge mastering status was (33.00±9.41) , satisfactory degree was (23.45±1.18) , both higher than the control group [ (28.82±7.48) , (17.61±1.95) ] with statistical difference (P<0.05) ; the observation group achieved lower score in anxiety than the control group with statistical difference (P<0.01) . Conclusion The use of mobile nursing platform multimedia teaching method can improve the quality of health education for patients with minimally invasive ERCP treatment and patient satisfaction, alleviate the anxiety of patients. Key words: Health education; Endoscopic retrograde cholangiopancreatography; Minimally invasive treatment; Multimedia

Analysis of operation timing and clinical efficacy of endoscopic retrograde cholangiopancreatography in the treatment of acute biliary pancreatitis

Objective To discuss the operation timing, clinical efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of acute biliary pancreatitis. Methods Retrospective analyzed the clinical data of 65 acute biliary pancreatitis patients in First People′s Hospital of Jiangxia District, Wuhan city form October 2015 to July 2017, there were 45 males and 30 females, the age was (46.35±8.95) years (range, 25-72 years). All patients were treated with ERCP, and divided into 24-72 h group (the time from onset to ERCP treatment 24-72 h) 16 cases, 72-120 h group (the time from onset to ERCP treatment 72-120 h) 25 cases and ≥120 h group(the time from onset to ERCP treatment ≥120 h) 34 cases, recorded and compared the clinical indexes during and after operation, laboratory indexes before and after treatment, incidence of surgical complications, recurrence rate and mortality.The measurement data with normal distribution were expressed as mean±standard deviation (Mean±SD), the F test was used for comparison among the three groups, and the t test was used for comparison between the two groups, the count data were compared by χ2 test, and the rank sum test was used to compare the incidence of surgical complications. Results The abdominal pain relief time, amylase recovery time, length of stay and hospitalization expenses of the 24-72 h group were (4.48±1.29) d, (3.59±1.22) d, (7.24±1.55) d and (1.55±0.31) ten thousand yuan respectively, the 72-120 h group were (7.35±1.76) d, (4.91±1.37) d, (13.61±2.13) d, (2.02±0.37) ten thousand yuan respectively, the ≥120 h group were (11.21±2.02) d, (8.86±1.95) d, (21.58±2.86) d, (2.49±0.52) ten thousand yuan respectively, with significant differences between any two groups(P 0.05). Conclusion In the treatment of acute biliary pancreatitis within 24-72 h and 72-120 h are safe and effective, but the improvement of laboratory indexes within 24-72 h ERCP treatment is more obvious, the length of stay is shorter, the hospitalization expenses is more provincial, and with more clinical advantage. Key words: Cholangiopancreatography, endoscopic retrograde; Pancreatitis; Postoperative complications; Safety

No need for surgery: endoscopic management of posttransplant biliary strictures in the modern era

Background: Biliary strictures are a common source of morbidity following orthotopic liver transplantation (OLT). While traditional management has been biliary reconstruction with Roux-en-Y hepaticojejunostomy (RYHJ), advances in endoscopic and percutaneous therapies have made these non-operative interventions commonplace in the management of both early and late posttransplant strictures. We set out to evaluate our center’s experience with the management of biliary stricture following OLT. Methods: All OLTs from January 2013 to June 2018 at a single institution were reviewed from a prospectively-maintained database. Patients with biliary bypass prior to or at time of transplantation were excluded. All biliary anastomoses were performed as a choledochocholedochostomy without the use of stents or T-tubes. Patients with biliary strictures were identified, and patient demographics, donor and operative details, and postoperative outcomes were collected. Descriptive statistics are reported as medians and interquartile range (IQR). Groups were compared using Wilcoxon rank-sum test, and p-values <0.05 were considered statistically significant. Results: A total of 462 grafts were transplanted into 449 patients during the study period. Among the 462 transplants that occurred, the biliary stricture rate was 15.6% (n = 72), with 95.8% (n = 69) being anastomotic strictures and 22.2% (n = 16) associated with a concurrent biliary leak. All patients underwent initial attempt at endoscopic treatment. 57 patients (79.2%) achieved stricture resolution with endoscopy alone. Among this group, the median time to first endoscopic retrograde cholangiopancreatography (ERCP) was 28 days (13–80 days) and treatment included a median of 3 (2–4) ERCP interventions over a median 186 days (142–273 days). The interventions utilized during ERCP included sphincterotomy, balloon dilation, and stent placement (TABLE). Patients who underwent balloon dilation at the time of first ERCP were further out from transplantation compared to those who had balloon dilation deferred until subsequent ERCP (40 vs 16 days, p < 0.01), reflecting our practice of avoiding dilation on a new ductal anastomosis. However, balloon dilation at initial ERCP was not associated with quicker stricture resolution (186 days vs 174 days, p = 0.58). Overall, only 3 patients (4.2%) required additional “step up” intervention beyond ERCP – two patients were managed with percutaneous transhepatic cholangiography (PTC) catheter placement and only one patient underwent RYHJ over the entire experience for a refractory biliary stricture. Conclusion: In our experience with liver transplantation over 5.5 years, endoscopic management of posttransplant biliary strictures resulted in successful stricture resolution. While repeat endoscopies are required for treatment, a strategy of watchful waiting in collaboration with an experienced endoscopist may avert the need for surgical reconstruction.

Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients.

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. Device-assisted enteroscopy and laparoscopic-assisted methods suffer from high failure rates and/or post-procedural complications. A novel endoscopic technique termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE) has recently emerged, demonstrating excellent technical and therapeutic success. The technique involves endoscopic ultrasound-guided deployment of a lumen-apposing metal stent (LAMS) to gain access into the remnant stomach to facilitate standard ERCP. In this case series, we describe our center's experience and unique approach with the GATE procedure and discuss several key strategies and differences. Patients underwent the GATE procedure via a novel algorithmic approach. Key information on procedural details, technical and clinical success, follow-up, and adverse events was prospectively collected and retrospectively reviewed. 10 patients underwent the GATE procedure from May 2017 to March 2018. Technical and clinical success were both 100%. Gastric and jejunal access points for LAMS deployment were 30% and 70%, respectively. Total procedure time per patient, including LAMS deployment, ERCP, and all follow-up procedures, averaged 2.37 ± 0.63h. 2 out of 10 patients (20%) had adverse events that were resolved either intra-procedurally or after repeat endoscopy with no long-term complications and none requiring surgery. For patients with complete follow-up (n = 7), access tract closure rate was 100% with the aid of a temporary plastic double pigtail stent to facilitate closure. GATE appears to be a safe and effective procedure and may be considered the preferred approach to ERCP in patients with RYGB anatomy at centers with LAMS experience. The procedure offers more definitive and higher range of ERCP interventions compared to traditional methods and is associated with fewer adverse events. Improvements in strategies and methods with the GATE technique may reduce risks and improve outcomes.

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

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

Endoscopic ultrasonography combined with endoscopic retrograde cholangiopancreatography in treatment of biliary and pancreatic diseases

Endoscopic retrograde cholangiopancreatography ( ERCP) , as the main means of digestive endoscopy, plays an important role in the minimally invasive treatment of some pancreaticobiliary diseases, such as biliary drainage, external drainage, and pancreatic duct stenting for the decompression treatment of biliary stricture and pancreatic duct stricture and the treatment of pancreatic fistula. In recent years, with the progress in interventional endoscopic ultrasonography ( EUS) , EUS-guided puncture and stent implantation can be used to complete decompression of the bile duct and pancreatic duct when ERCP intubation is not successful or ERCP is unable to complete decompression of the bile duct and pancreatic duct due to postoperative anatomical changes, which provides a new choice of treatment for biliary and pancreatic diseases and reflects the complementary role of EUS and ERCP in the treatment of biliary and pancreatic diseases.

3:00 PM Abstract No. 160 Obstructive cholangiocarcinoma: hilar location as an indication for initial percutaneous management

The best initial therapy for hilar biliary obstruction is unclear: endoscopic retrograde cholangio-pancreatography (ERCP) is utilized by many clinicians, despite evidence suggesting that percutaneous transhepatic biliary drainage (PTBD) may be more appropriate in this setting [1]. The purpose of this study is to identify the influence of cholangiocarcinoma location on therapy outcomes. Records of 122 patients with newly diagnosed cholangiocarcinoma requiring biliary decompression from 2007 to 2016 were retrospectively reviewed. Preprocedural MRI was used to classify tumor location for 84% of patients. When this was not available, fluoroscopic procedural images were used. Hilar cholangiocarcinoma (Klatskin tumor) was present in 74 patients, and 41 had tumor involving the common hepatic and/or common bile ducts but not the hilum. PTBD was the initial therapy for 57 patients, and 65 were initially treated by ERCP. Therapeutic success was defined as resolution of hyperbilirubinemia to below 2.5 mg/dL, a level at which systemic chemotherapy can be safely administered. Of the group receiving initial ERCP treatment, 18/33 (55%) patients with hilar cholangiocarcinoma required conversion to PTBD within 30 days, compared to 4/28 (14%) with cholangiocarcinoma of the common hepatic or common bile ducts. Patients with hilar tumors are therefore over three times more likely to fail endoscopic management (p = 0.001). Immediately apparent technical failure of ERCP stent placement occurred in 9/33 (27%) patients with hilar tumors. The ERCP and PTBD treatment groups had average pretreatment serum total bilirubin concentrations of 17.5 and 17.4 mg/dl, respectively. In both treatment groups, half of the patients reached therapeutic success within the period of available follow-up data. The PTBD group had a shorter mean time to therapeutic success of 33 days vs. 41 days for the ERCP group. Hilar location of cholangiocarcinoma is a strong predictor of failure of endoscopic management. PTBD as the first-line therapy for these patients could minimize the number of procedures performed and the associated complication risks. MRI is useful to determine which treatment best suits a patient.

Clinical effect of biliary metal stent implantation via endoscopic retrograde cholangiopancreatography in treatment of unresectable malignant extrahepatic biliary obstruction

Clinical effect of biliary metal stent implantation via endoscopic retrograde cholangiopancreatography in treatment of unresectable malignant extrahepatic biliary obstruction

Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data? A retrospective cohort study

ObjectiveTo develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation.Study designRetrospective...

Non-Operative Management of Type 2 ERCP-Related Retroperitoneal Duodenal Perforations: A 9-Year Experience From a Single Center.

BackgroundNo consensus exists on treatment of endoscopic retrograde cholangiopancreatography (ERCP) -related, retroperitoneal duodenal perforations. The aim of this study is to determine the incidence of post-ERCP retroperitoneal periampullary (type 2) duodenal perforations and the clinical outcome of non-surgical management.MethodsPatients who underwent ERCP in our institution during the period from January 1, 2009 to December 31, 2017 were included. Any cases of retroperitoneal periampullary duodenal (type 2) perforation were identified. Relevant data (patient characteristics, indications, radiographic findings, time to diagnosis and surgery, surgical procedures, hospital stay and outcome) were retrospectively collected and reviewed. Results were compared to those from the existing literature.ResultsThere were 24 patients with retroperitoneal type 2 duodenal perforation following 4,196 ERCPs were identified (24/4196, 0.57%) over the 9-year period. ERCP indications were: choledocholithiasis, obstructive jaundice and ampullectomy (ampullary adenoma). Diagnosis (aided by CT scan) was established within the first 12 h in the majority of patients (21/24, 87.5%) and intraprocedural in 3/24, (12.5%). Twelve patients (50%) with deteriorating clinical course were managed with CT-guided percutaneous drainage. Surgical intervention was required in two (8.3%). Overall mortality was 4.2%, 1/24 (one patient died after surgery).ConclusionsRetroperitoneal duodenal perforation is a rare and severe ERCP complication. However, conservative management is feasible in the majority of cases.

Hemodynamic stability of ketamine/propofol admixture ketofol in patients undergoing endoscopic retrograde cholangiopancreatography

Background and aim Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure for diagnosis of many gastrointestinal tract disorders. Propofol is a commonly used agent, but we decrease its adverse effects by adding ketamine. We aimed in this study to compare propofol versus propofol–ketamine regarding hemodynamic stability, recovery, and complications in ERCP. Patients and methods A total of 90 American Society of Anesthesiology status II–III patients aged 18–60 years who underwent ERCP were randomly allocated by sealed envelope assignment into two groups of 45 patients each: group P received intravenous 2 mg/kg propofol and group KF received intravenous propofol–ketamine 3:1 mixture (%1 15 ml propofol + 1 ml 50 mg/ml ketamine + 4 ml saline in a 20 ml syringe, which resulted in 0.25 mg/ml ketamine and 0.75 mg/ml propofol) until Ramsay sedation scale increased to 3–4. For each patient, the following data were collected: heart rate, mean arterial blood pressure, oxygen saturation, procedure time, total drug dosage, recovery score, and patients' and the doctor's satisfaction score (clinical trial NCT02618668). Results The total dosage of propofol consumed was significantly higher in group P compared with group KF (283.78 ± 144.23 and 110.94 ± 51.75 mg, respectively). Recovery time was slightly longer in group P compared with group KF (20.67 ± 5.29 and 19.44 ± 4.16 min, respectively). There was a significance difference in patient satisfaction scores between group KF (1.16 ± 0.64) and group P (1.82 ± 0.83). There was a significance difference in surgeon satisfaction scores between group KF (1.11 ± 0.49) and group P (2.13 ± 0.97). Conclusion Propofol ketamine combination (ketofol) is associated with greater satisfaction scores and a shorter recovery than propofol and without important adverse effects in ERCP interventions.

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014

endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

Application value of biliary stent in endoscopic retrograde cholangio pancreatography for treatment of benign biliary stricture after liver transplantation

Objective To explore the application value of plastic biliary stent and fully covered self-expandable metallic stent (FCSEMS) in endoscopic retrograde cholangio pancreatography (ERCP) for treatment of benign biliary stricture after liver transplantation. Methods The retrospective cross-sectional study was conducted. The clinical data of 54 patients with benign biliary stricture after liver transplantation undergoing ERCP treatment who were admitted to the First Affiliated Hospital of Xi′an Jiaotong University between January 2010 and August 2016 were collected. Among 54 patients, 44 had simple anastomotic stricture and 10 had non-anastomotic stricture. All the patients underwent stent implantation by ERCP. Patients with stricture within 1 month postoperatively initially selected single plastic stent or endoscopic nasobiliary drainage (ENBD), and then changed into multiple plastic stents at the second stent replacement. Patients with stricture after 1 month postoperatively selected multiple plastic stents, multiple plastic stents after balloon dilation or FCSEMS. Observation indicators: ERCP situations, stent implantation, time of stent indwelling, postoperative complications, stent dislocation, treatment outcome and follow-up situations. Patients were followed up by outpatient examination and telephone interview up to November 2016. Clinical symptoms of patients were observed within 1 month postoperatively and liver function and abdominal ultrasound were retested. Liver function and remission degree of biliary stricture were monitored regularly once every 3 months. Measurement data were described as average (range). Results All the patients underwent successful ERCP, of which 53 completed the process of ERCP and 1 rejected treatment due to economic problems. All the 54 patients received 140 times ERCPs with an average of 2.59 times per person, 21 times ENBDs, 11 times FCSEMSs and 108 times plastic stent implantations (including 35 times single stent implantations, 46 times double stents implantations, 23 times 3-stents implantations and 4 times 4-stents implantations). All the 54 patients were followed up for 3-143 months, with an average time of 73 months. Of 44 with anastomotic stricture, 34 received plastic stent implantation and 98 times ERCPs, with an average number of stent implantation of 2 (range, 1-4) and an average time of stent indwelling of 10.7 months (range, 9.0-13.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 4 persons every time, 7 persons every time, 10 persons every time and 3 persons every time, respectively; 26 patients were cured and 5 were improved, with an effective rate of 91.2% (31/34); 3 patients with noneffective treatment continued to undergo ERCP and 3 patients had recurrence of anastomotic stricture. Among 10 patients with initial FCSEMS implantation, 12 times ERCPs were performed, with an average time of stent indwelling of 7.6 months (range, 6.0-12.0 months); postoperative biliary infection, hyperamylasemia and stent dislocation were detected in 1 person every time, 1 person every time and 1 person every time, respectively; 8 patients were cured, with an effective rate of 8/10; of 2 patients with persistent stricture, 1 patient received contrast examination after stent removal, showing a comparative stricture in level 1 branch of intrahepatic duct and considering combined ischaemia, and then underwent the second implantation using multiple plastic stents; the other patient had elevated level of jaundice at 3 months after stents removal and received ERCP, showing anastomotic inflammatory polyp, and then underwent FCSEMS implantation again. Ten patients with non-anastomotic stricture received plastic stent implantation and 30 times ERCPs, with an average number of stent implantation of 3 (range, 2-4) and an average time of stent indwelling of 11.3 months (range, 10.0-14.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 2 persons every time, 5 persons every time, 2 persons every time and 1 person every time, respectively; 3 patients were cured and 3 were improved, with an effective rate of 6/10; of 4 patients with noneffective treatment, 2 died of gradually deteriorating liver function and 2 underwent the second liver transplantation. Conclusions Stent implantation in ERCP is safe and effective for treatment of benign biliary stricture after liver transplantation, single plastic stent should be used in the early period (within 1 month) and multiple plastic stents should be used in the later period. Although FCSEMS has a higher displacement rate, it should be recommended due to a better clinical effect, lower incidence of complications and simple operation. For patients with non-anastomotic stricture, plastic stent should be used for extrahepatic biliary stricture, with a good clinical effect, and there is worse effect in stent implantation through ERCP for multiple intrahepatic biliary strictures. Key words: Benign bile duct stricture; Liver transplantation; Plastic bile duct stent; Fully covered self-expandable metallic stent

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

How to Improve Cannulation Rates During Endoscopic Retrograde Cholangiopancreatography

Risk Factors of Hyperglycemia in Patients After a First Episode of Acute Pancreatitis: A Retrospective Cohort.

The aim of this study was to evaluate the risk factors for hyperglycemia development after a first episode of acute pancreatitis (AP). Three hundred and ten patients treated for AP were retrospectively evaluated. Hyperglycemia was determined by fasting blood glucose. All data were collected from the medical records room database and a follow-up telephone call. The incidence rate of hyperglycemia was obviously increased 5 years after the event. Hazard ratios (HRs) of developing hyperglycemia in patients with hyperlipidemia, fatty liver, and hypertension were 2.52 (P < 0.001), 1.87 (P = 0.01), and 1.78 (P = 0.017), respectively. Patients of biliary origin that underwent endoscopic retrograde cholangiopancreatography presented a 4.62-fold greater risk than those managed conservatively. Other risk factors were random blood glucose greater than 8.33 mmol/L (HR, 4.19; P < 0.001), lactate dehydrogenase greater than 350 U/L (HR, 1.99; P = 0.017), calcium less than 1.75 mmol/L (HR, 3.86; P = 0.004), and elevated creatine kinase (HR, 2.74; P = 0.001). Patients with AB blood type showed 2.92-fold greater risk compared with those with O blood type. Among them, hyperlipidemia and hyperglycemia on admission were the only independent risk factors (both P < 0.05). Hyperlipidemia, fatty liver, hypertension, endoscopic retrograde cholangiopancreatography treatment, acute hyperglycemia, elevated lactate dehydrogenase and creatine kinase, decreased calcium, and AB blood type were risk factors for hyperglycemia development after AP.

Application of endoscopic retrograde cholangiopancreatography in treatment of extrahepatic biliary adenoma

Application of endoscopic retrograde cholangiopancreatography in treatment of extrahepatic biliary adenoma