ERCP Experience Research Articles

Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study.

Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures. A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis. Of survey respondents (N= 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P≤ .001), practice at a teaching program (P≤ .001),<10 years in practice (P= .005), higher procedure volume (P≤ .001), and higher proportion of pancreatic cases (P≤ .001). Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.

Single-use duodenoscope for ERCP performed by endoscopists with a range of experience in procedures of variable complexity

Expert endoscopists previously reported ERCP outcomes for the first commercialized single-use duodenoscope. We aimed to document usability of this device by endoscopists with different levels of ERCP experience. Fourteen "expert" (>2000 lifetime ERCPs) and 5 "less-expert" endoscopists performed consecutive ERCPs in patients without altered pancreaticobiliary anatomy. Outcomes included ERCP completion for the intended indication, rate of crossover to another endoscope, device performance ratings, and serious adverse events. Two hundred ERCPs including 81 (40.5%) with high complexity (American Society for Gastrointestinal Endoscopy grades 3-4) were performed. Crossover rate (11.3% vs 2.5%, P= .131), ERCP completion rate (regardless of crossovers) (96.3% vs 97.5%, P= .999), median ERCP completion time (25.0 vs 28.5 minutes, P= .130), mean cannulation attempts (2.8 vs 2.8, P= .954), and median overall satisfaction with the single-use duodenoscope (8.0 vs 8.0 [range, 1.0-10.0], P= .840) were similar for expert versus less-expert endoscopists, respectively. The same metrics were similar by procedural complexity except for shorter median completion time for grades 1 to 2 versus grades 3 to 4 (P< .001). Serious adverse events were reported in 13 patients (6.5%). In consecutive ERCPs including high complexity procedures, endoscopists with varying ERCP experience had good procedural success and reported high device performance ratings. (Clinical trial registration number: NCT04223830.).

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees. Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases. The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

Paediatric pancreaticobiliary endoscopy: a 21-year experience from a tertiary hepatobiliary centre and systematic literature review

BackgroundIn adults ERCP and endoscopic ultrasound (EUS) are standard methods of evaluating and treating many hepatopancreaticobiliary (HPB) conditions. HPB disease is being diagnosed with increasing frequency in children but information about role of ERCP and EUS and their outcomes in this population remain limited. Therefore the aims of this study were to describe the paediatric ERCP and EUS experience from a large tertiary referral HPB centre, and to systematically compare outcomes with those of other published series.MethodsAll patients <18 years undergoing an ERCP or EUS between January 1992–December 2014 were included. Indications for the procedure, rates of technical success, procedural adverse events and reinterventions were recorded in all cases.ResultsNinety children underwent 111 procedures (87 ERCPs and 24 EUS). 53% (48) were female with a median age of 14 years (range: 3 months - 17 years). Procedures were performed under general anaesthesia (n = 48) or conscious sedation (n = 63). Common indications for ERCP included chronic or recurrent pancreatitis and biliary obstruction. Patients frequently had multiple comorbidities, with a median ASA grade of 2 (range 1–4). Therapeutic procedures performed included biliary or pancreatic sphincterotomy, common bile duct or pancreatic duct stone removal, biliary or pancreatic stent insertion, EUS-guided fine needle aspiration and endoscopic transmural drainage of pancreatic fluid collections. No adverse events were reported following ERCP but there was one complication requiring surgery following EUS guided cystenterostomy.ConclusionERCP and EUS in children and adolescents have high technical success rates and low rates of adverse events when performed in high volume HPB centres.

PWE-016 Is there an increasing role for general anaesthetic during ercp?: Abstract PWE-016 Table 1

Introduction ERCP remains an important diagnostic and therapeutic tool for the management of biliary and pancreatic diseases. In the UK this is mainly performed using conscious sedation but there appears to be an increasing need for deeper sedation and general anaesthesia. Since 2009 there has been a regular fortnightly list for provision of general anaesthetic to assist ERCP particularly for complex interventions in our unit. We report our experience of ERCP performed under general anaesthetic (GAERCP). Method Retrospective analysis of all patients who underwent ERCP in our centre was performed using the Unisoft reporting tool over the period June 2008 to December 2014. Patient demographics, indication for ERCP, indication for GA, complication rate and Cotton complexity scores were recorded. Trends in numbers of patients undergoing ERCP under GA, complications rates and complexity scores were calculated and comparison made to patients undergoing ERCP under sedation. Results Over the study period 2797 patients (1165 males, median age 69 years) under went ERCP of which 159 (5.7%) were under general anaesthetic. Those undergoing GAERCP were significantly younger than those having sedation (mean age 54.9 vs. 65.7 years, p Conclusion There is an increasing need for ERCP under general anaesthetic particularly to cater for more complex and higher risk interventions. This can be achieved with a high completion rate but with a higher, but acceptable rate of post procedural pancreatitis. Disclosure of interest None Declared.

PWE-425 Does the presence of a trainee compromise biliary cannulation rates at ercp :results from a prospective audit

Introduction A trainee endoscopist on the ERCP list prolongs procedure time and may increase risk of technical failure or procedural complications. 1,2 Recent BSG guidance has identified a biliary cannulation rate of 90% as an ERCP performance indicator which may conflict with the need to train juniors. This prospective audit assessed the impact of an endoscopy trainee on the overall biliary cannulation rates. Method We prospectively audited sequential ERCPs done on a “virgin” ampulla (no previous ERCP). Procedures were supervised by 2 experienced trainers; trainees were present when possible (trainees were senior SpRs with limited ERCP experience). A short-wire system was used for biliary cannulation and standard techniques used. 1 The trainee would have 6 min to achieve biliary cannulation, failing which the trainer would take over. Predicted ERCP difficulty was graded using accepted criteria. 3 The primary outcome was the biliary cannulation rate. Results One hundred and eight sequential ERCPs were prospectively audited over a period of 6 months [July 2014–Dec 2014]. Difficulty was graded as 1 (n = 69] or 2 [n = 39]. One of two trainee endoscopists was present during 61[56%] ERCP cases; remaining cases were done by a consultant alone [n = 47, 44%]. Deep biliary cannulation was successful in 99 cases [91%]. The cannulation rate was 93% [57/61] with a trainee and 89% [42/47] without[p = 0.7229 Fishers exact test] Median cannulation time was 6.6 min (range 1–25). There was no significant difference in cannulation times when a trainee was present[T test, p = 0.890]. Where a trainee was involved, 20/61[32%] cannulations were achieved independently by the trainee. There were no major complications recorded in cases where a trainee was involved. Conclusion This audit suggested that acceptable biliary cannulation rates can be achieved on ERCP training lists, with involvement of experienced trainers and defined training parameters. Disclosure of interest None Declared. References Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al . Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18 Shekhar, Shetty, Fisher BSG 2014 (abstract) SchutzSM, AbbottRM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc. 2000;51(5):535–9

OC-037 The Increasing Role Of Enhanced Sedation Assisted Ercp: Important Lessons For Service Provision

IntroductionERCP in the UK has historically been performed under conscious sedation (SED). However, given the increasing complexity of cases the role of enhanced sedation assisted ERCP (ENS ERCP) is increasing....

Mission Impossible: Predicting ERCP Procedure Times to Facilitate Quality Improvement

Purpose: ERCP procedure length remains quite variable, ranging from minutes to hours, given the heterogeneity of procedural indications and inherent technical difficulty. ERCPs are typically scheduled in block time without taking into consideration indication, patient anatomy, or other clinical factors. At times, the procedure may be longer or shorter than the allotted time. We aimed to retrospectively evaluate the utility of a priori prediction of ERCP procedural length with an overall goal to improve the scheduling efficiency and capacity of our therapeutic endoscopy unit. Methods: Our endoscopy database was utilized to identify patients who underwent ERCP procedures from January 1, 2012 to February 1, 2012 at a tertiary care medical center. Clinical and procedural data were reviewed. A brief summary was generated by a medical resident for each patient, which outlined recent clinical history and ERCP indication. Additional procedural information was provided regarding GI fellow assistance, sphincterotomy status, failure or success of previous ERCPs, and presence of surgically-altered anatomy or stents. A 2nd-year GI fellow and a staff therapeutic endoscopist with >20 years of ERCP experience attempted to retrospectively predict procedural length (0-30 min, 31-60 min, 61-90 min, >90 min) in each case blinded to other details about the case. Predictions were then compared to actual procedural length using the kappa statistic. Results: ONe consecutive ERCP procedures (51 men; mean age 62±15 years) were included. Indications for ERCP included a biliary etiology in 83 cases. The remaining cases were divided equally between pancreatic (N=10) and various other indications (N=7). Fellows participated in 70 procedures. Median ERCP time was 43 minutes (IQR 28-63). ERCP times were classified by blocks of time (min): 0-30 (n=28), 31-60 (n=44), 61-90 (n=16), >90 (n=12). Time blocks were accurately predicted in 40% cases by the 2nd year GI fellow and in (31%) cases by the staff endoscopist. When compared to actual ERCP times, both the fellow's and staff endoscopist predicted times had poor kappa agreement (κ=0.15 and κ=0.02, respectively). The kappa between fellow and staff was also poor (κ=0.08) with an overall agreement of 35%. Neither fellow nor consultant predicted correctly in 41% cases with both overestimating in 23/41 (56%), both underestimating in 13/41 (32%), and one overestimating/one underestimating in 5/41 (12%). Conclusion: Accurate prediction of ERCP procedure length appears to be very challenging. Inaccurate prediction is likely multifactorial with the inherent technical difficulty and unpredictability of ERCP being major limiting factors. Prospective studies with a priori prediction of ERCP length are needed to confirm our findings.

ERCP in the management of pancreatic diseases in children

ERCP experience in pancreatic disorders in children is limited. This study evaluated the utility and efficacy of ERCP in children with pancreatic diseases at a tertiary care referral center. Consecutive patients 18 years of age and younger who underwent ERCP for pancreatic diseases from January 2010 to June 2011 were identified. Indications, findings, interventions, adverse events, and outcomes were recorded. A total of 221 ERCPs were performed in 172 children (102 boys, mean ± standard deviation age 13.8 ± 3.2 years, 157 therapeutic). A total of 143 children (83.1%) had chronic pancreatitis (CP), 19 (11%) had recurrent acute pancreatitis (RAP), and 10 (5.8%) had acute pancreatitis (AP). Indications included pain (153, 89.4%), pancreatic fistula (11, 6.3%), symptomatic pseudocyst (4, 2.3%), and jaundice (3, 1.7%). In chronic pancreatitis patients, findings included a dilated and irregular main pancreatic duct (92, 64.3%), pancreatic duct (PD) calculi (76, 53%), dominant PD stricture (23, 16%), PD leak (7, 4.9%), pancreas divisum (35, 24.5%), and common bile duct (CBD) stricture (3, 2%). Therapeutic procedures included major papilla sphincterotomy (93, 65%), minor papilla sphincterotomy (32, 22.3%), PD stenting (77, 53.8%), and CBD stenting (3, 2.2%). PD stones larger than 5 mm were retrieved endoscopically after 57 extracorporeal shock wave lithotripsy sessions in 50 patients (34.9%). In patients with RAP, 6 (31.5%) had complete and 1 partial pancreas divisum. All underwent minor papillotomy. In patients with AP, 4 (40%) had stenting for PD leak, 2 (20%) underwent CBD clearance for biliary pancreatitis, and 4 (40%) had transpapillary pseudocyst drainage. During 13 ± 4.7 months (range 6-22 months) of follow-up, improvement of symptoms was seen in 143 of 172 (83%) patients. Procedure-related adverse events were seen in 8 (4.7%) patients. Retrospective study. ERCP is a safe therapeutic option for pancreatic disorders in children.

Evaluation of Repeat ERCP: Analysis of a Four-Year Experience

In this trial, a total of 1010 ERCP procedures performed in 410 patients at the endoscopy department of our hospital between 2006 and 2010, were retrospectively evaluated. The age, gender, complaints, pre-procedure diagnosis, the radiologic and clinical results, number of procedure repetitions and the final diagnosis were assessed. The local Ethics Committee approved this retrospective study protocol. All of the procedures were performed by the same team of endoscopists with compatible levels of ERCP experience (Mean 5 years). At our department, pethidine HCl (0.3-0.5 mg/kg), midazolam (0.03-0.07 mg/kg) and hyoscine-N-butylbromide (0.3-0.6 mg/kg) are used in the ERCP procedures for premedication and additionally, cefazolin 1 gram intravenous is routinely administered for prophyllaxis one hour before the examination. During the procedure, oxygen saturation and heart rate are monitored by pulse-oximeter. The patients were those admitted to our hospital or referred from other healthcare centers. Statistical assessment was performed by evaluating the first ERCP procedures and the repeat procedure records. Chi-square test was used to statistically analyze the results. The level of significance was set at p<0.05.

788e: A Multi-Center, U.S. Experience of Single Balloon, Double Balloon, and Rotational Overtube Enteroscopy-Assisted ERCP in Long Limb Surgical Bypass Patients

Evaluate ERCP success in pts with long limb surgical bypass (LLSB) using single (SBE) or double (DBE) balloon, or rotational overtube (RoE) enteroscopy.

Radiation Doses to ERCP Patients Are Significantly Lower with Experienced Endoscopists

Purpose: Patients undergoing ERCP receive a significant dose of radiation which may increase their risk of developing future cancers, especially in young patients. Mean effective doses are comparable to the radiation received from an abdominal/pelvic CT. Radiation doses to patients during ERCP correlate most closely with fluoroscopy time (FT). We hypothesized that FT is lower with experienced ERCPists. Methods: We analyzed the prospectively collected ERCP Quality Database to determine if the number of years of ERCP experience and number of ERCP's performed in the last year correlated with FT, adjusting for clustering of complexity of cases and fellow involvement. Multivariate mixed linear regression models of log-transformed FT were used for the analysis to determine adjusted percentage differences in FT. Results: 8,399 ERCPs by 68 providers from 6 countries had complete data. ERCP experience ranged from 1 to 36 years and 10 to 940 ERCPs performed in the last year. Median FT was 3.0 minutes (min), (range: 0.1-60.0 minutes). Cases associated with greater FT included hilar stent placement, stricture dilation, biliary brushing, extraction of biliary stone >10 mm, pancreatic stone extraction, and need for pre-cut sphincterotomy (difficult cases median=4.9 min, less difficult cases=2.5 min). There was significant interaction between annual volume of ERCPs and case difficulty for FT (p<0.0001). Adjusting for clustering within endoscopists and fellow involvement in the case, ERCPist experience was inversely associated with FT in the less difficult cases. ERCPists who performed less than 100 ERCPs per year had 104% increase in FT (p<0.0001), and those who performed 100-200 ERCPs per year had 27% increase (p<0.0001) compared to those performing greater than 200 ERCPs. Additionally, for every 10 years of additional ERCP experience, FT was associated with a 21% decrease in FT (p<0.0001). For difficult cases, ERCP experience was also inversely associated with FT (<100 ERCPs: 59% increase, p<0.0001; 100-200 ERCPs: 11%, p=0.005; every 10 years of ERCP: 20% decrease, p<0.0001). For both difficult and less difficult cases, fellow involvement was associated with greater FT (involvement ≤50% of difficult case: 83% increase, p<0.0001; ≤50% of less difficult case: 112% increase, p<0.0001). If the case was performed entirely by the fellow, the differences were marginal (9 or 14% increase). Conclusion: Fluoroscopy time is lower when ERCP is performed by experienced endoscopists, adjusting for clustering by case difficulty and fellow involvement. Both years performing ERCP and annual volume of ERCP contribute independent effects. These findings may have important ramifications for radiation-induced cancer risk.

ERCP Mechanical Simulator (EMS) Practice Enhances Traineesʼ Success with Common Bile Duct (CBD) Cannulation

Purpose: Background: EMS practice in the early stage of clinical ERCP training has been reported to be beneficial (GIE 2009; 69:AB141). Its role in augmenting performance of trainees with some clinical ERCP experience is unknown. Hypothesis: EMS practice is a predictor of success in CBD cannulation when introduced to EMS naive trainees after 6 months of usual clinical training.Table 1: Success with deep CBD cannulationTable 2: Factors associated with success of selective CBD cannulation by trainees (GEE analysis)Methods: Design: A randomized controlled cross-over study. 8 trainees attended didactic lectures on ERCP. Randomization was stratified based on site (n=2). Study group (SG) trainees participated in a one day handson simulator practice of selective bile duct cannulation supervised by JWL. Control group (CG) trainees did not participate in EMS practice. Subsequent clinical ERCP performance of all trainees was documented objectively. Primary outcome was successful deep CBD cannulation (0=fail, 1=success). After 6 months, CG trainees were crossed over to participate in one session of EMS practice. Performance of all trainees was tracked for another 6 months. The primary outcome was correlated to EMS practice status (with or without), overall clinical ERCP experience (days entered into ERCP training) and level of difficulty (normal papilla, diverticula, prior papillotomy or stenting) for CBD cannulation. Statistical analysis was performed using generalized estimation equations (GEEs) to fit the parameters of a generalized linear model where unknown correlations are present. The equations allow for correlation without explicitly defining a model for the origin of the dependency and are most suitable when the random effects and their variances are not of direct interest. The average response over the population (“population-averaged” effects) is estimated rather than the regression parameters that would enable prediction of the effect of changing one or more components of an unknown factor on a given individual. Results: Deep CBD cannulation was attempted in 153 of 224 and 142 of 225 cases in each of the two consecutive 6 months period, respectively. The table summarizes the odds ratio of trainee success in deep CBD cannulation taking all pre and post crossover data into consideration. EMS practice is a significant factor in predicting success while difficult papilla predicts cannulation failure. Conclusion: A single session of EMS practice enhances the success rate of CBD cannulation regardless of when it is introduced - at the beginning or after 6 months of usual clinical training. The results provide evidence to support the use of mechanical simulator practice, offered at the beginning or midway through clinical ERCP training, to augment the ERCP training experience. Disclosure: Cook Endoscopy - educational grant and equipment support Olympus America - educational grant and equipment support Dr Joseph Leung is supported by Cook Asia (speakers honorarium) during his sabbatical leave to conduct the research study in Taiwan. Partial research funding support from ACG Research Grant. This research was supported by an industry grant from Cook Endoscopy and Olympus Tokyo provided equipment support for simulator practice. The ERCP mechanical simulator is not commercially available and is used for teaching and research purposes.

Evaluation of Computer and Mechanical ERCP Simulators By Endoscopists with Different ERCP Experience - An Update

Background: We previously reported preliminary data of 7 GI trainees' evaluation of computer (CS) and mechanical (MS) ERCP simulators. Aim: To compare trainees' and trainers' evaluations after practice with MS and CS. Setting: Hands-on ERCP training workshops. Subjects: 15 GI trainees with varying ERCP experience and 3 trainers. Interventions: Participants perform scope insertion, selective bile duct cannulation, guide-wire negotiation of a bile duct stricture, biliary papillotomy and insertion of single biliary stent. Main outcome measurements: Evaluations of each simulator by participants based on modified published criteria (GIE 2003; 57: 886-90). Results: Overall practice with the MS resulted in significantly greater change in understanding [max=20] (4.29±0.93 vs. 2.12±0.80), confidence [max=20] (5.41±1.01 vs. 2.53±0.80) and credibility [max=50] (6.65±1.78 vs. 0.18±2.14) scores after the practice, respectively (p< 0.05). The scores were significantly higher for the MS in realism [max=80] (58.33±2.18 vs. 42.28±2.70, p<0.05) and usefulness as instructional tool/general applicability in ERCP training [max=60] (49.5±1.23 vs. 37.17±2.05, p<0.05). When the results were stratified according to the level of ERCP experience (<100 versus > 100), the difference in pre and post understanding, confidence, and credibility scores were significantly higher for the less experienced endoscopists than that for the experienced endoscopists regardless of the type of simulator (Table). The scores for realism, usefulness as an instructional tool, and applicability were higher among the less experienced endoscopists for both types of simulators, but were only statistically significant for the CS when compared to the experienced. There was no statistical difference in the scores for the MS between the two groups. Conclusion: Endoscopists at varying levels of experience evaluated the MS as superior to CS for ERCP practice, which was more significant among less experienced endoscopists. TableDifference in scores based on ERCP experience Computer simulator Mechanical simulator Survey question <100 ERCP experience >100 ERCP experience <100 ERCP experience >100 ERCP experience Understanding(difference between pre and post) 3.07 ± 0.84† -0.75 ± 0.75† 5.23 ± 0.99 1.25±1.70 Confidence(difference between pre and post) 3.07 ± 0.90 0.75 ± 0.75 6.15 ± 1.12 3.0 ± 2.12 Credibility(difference between pre and post) 1.71 ± 1.92 -6.0 ± 5.73 7.54 ± 2.17 3.75 ± 2.59 Realism compared to human ERCP 45.29 ± 2.04† 31.75 ± 8.64† 59.57 ± 2.29 54.0 ± 5.80 Usefulness as an instructional tool & applicability 39.79 ± 1.59† 28.0 ± 5.67† 50.5 ± 1.26 46.0 ± 3.11 Data expressed as mean ± SEM (standard error of mean). For endoscopists with <100 ERCP experience, N=14 except for mechanical understanding/confidence/credibility scores where N=13. For endoscopists with >100 ERCP experience, N=4 for computer and mechanical. † p value significant. Open table in a new tab Data expressed as mean ± SEM (standard error of mean). For endoscopists with <100 ERCP experience, N=14 except for mechanical understanding/confidence/credibility scores where N=13. For endoscopists with >100 ERCP experience, N=4 for computer and mechanical. † p value significant.

Usefulness of Double Balloon Enteroscopy for Diagnostic and Therapeutic ERCP in Postoperatively Altered Anatomy - A Retrospective Analysis

Objectives: Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient, such as BII-situation and biliodigestive anastomosis, by conventional ERCP are difficult and in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients. Methods: Double balloon enteroscopy was introduced in the Department of Medicine B in November 2004. From November 2004 until the end of March 2008 1080 double balloon enteroscopies and 2050 ERCP's have been performed.

Assessment of Safety and Success Rate of Precut Fistulotomy: A Single Endoscopist's Experience

Aims: This study were done to evaluate the safety and success rate of precut fistulotomy performed by a single endoscopist and to assess change in success rate of precut fistulotomy over time. Patients and Methods: From January 2004 to August 2008, all patients who had undergone precut fistulotomy by single endoscopist with 8 years of prior ERCP experience were included. Data were collected by retrospective review of medical records. Main outcome measures were overall success and complications of precut fistulotomy.

Comparison of accessory performance using a novel ERCP mechanical simulator

There is a paucity of in vitro methods for evaluating ERCP accessories. We hypothesize that the time taken to perform a simulated single stent or multiple stents placement is different for stenting systems with or without the capability of intraductal ductal release (IDR) of the guide wire. We conducted an un-blinded in vitro comparison of ERCP accessories using a mechanical simulator during hands-on ERCP practice workshops. A total of 21 U.S. participants and 20 Chinese participants with various level of ERCP experience took part in the different practice workshops. Accessories with and without the capability of intraductal release of guide wire were compared. Total time required for completing a simulated stenting procedure with single or multiple stents and the respective simulated fluoroscopy time were recorded. There was no significant difference in the time taken for placement of a single stent using either stenting systems. Stenting system capable of intraductal release of the guide wire required significantly shorter time to complete placement of three stents. Using time required to complete a specific task, i. e. biliary stenting, the mechanical simulator permits the performance of different accessories by the same group of operators to be evaluated objectively.

Multiple Biliary Stenting – An In Vitro Comparison Using a Novel ERCP Mechanical Simulator

Purpose: There is a paucity of methods for objective evaluation of ERCP accessories. In this study, we tested the hypothesis that practice on a mechanical simulator allows comparison of performance of different ERCP accessories. Methods: Endoscopists at various level of ERCP experience participated in Hands-on ERCP practice workshops using a mechanical simulator. Accessories for biliary stenting with (Fusion OASIS, Cook Endoscopy) and without (RX, Boston Scientific) the capability of intraductal release (IDR) of the guide wire were compared. Total time taken to insert single or multiple stents across an artificial bile duct stricture using the ERCP simulator and simulated fluoroscopy time were recorded. Results: There was no significant difference in the time required for placement of single stent (Table 1). The accessories that permitted IDR and exchange of guide wire required significantly shorter time to complete placement of three stents (Table 2), most likely because of the absence of need for re-cannulation. Conclusion: Objective comparison of the function of different ERCP accessories is made possible by referencing the time taken to complete a specific task, e.g. single or multiple stenting. The mechanical simulator permits performance of different accessories by the same group of operators to be objectively evaluated. How the results of in vitro practice and comparison using the mechanical simulator will translate in clinical settings remain to be established.Table: Comparison of Single Stenting with 2 Short Wire SystemsTime in minutes (mean ± SEM), IDR = intraductal release, SFT = Simulated fluoroscopy time, *versus Fusion OASIS, P < 0.05, unpaired t testTable: Comparison of Time Taken for Triple Stenting

Development of a novel ERCP mechanical simulator

There is a paucity of objective methods for evaluating trainee performance and comparing ERCP accessories. Use of a mechanical ERCP simulator to evaluate trainee performance and to compare ERCP accessories via procedure time. Pilot study using a mechanical simulator. Hands-on ERCP practice workshops. Endoscopists at various levels of ERCP experience. Validation studies are described to show that the simulator permits participants with varying ERCP experience to demonstrate their skill levels and offers novel training applications in ERCP courses. The time required for completing a simulated stent placement procedure, simulated fluoroscopy time, and participant expectations were recorded in different settings. Participants' expectations were compared before and after training to determine whether the simulator was a credible adjunct to ERCP training. Significantly shorter procedure times were recorded for the same accessories used by participants with more ERCP experience than those with less experience and for the same group of participants when using accessories with 1 design compared with another. The mean total credibility score showed a significant increase after simulator practice. In vitro practice by using a mechanical simulator; results may not translate directly to the clinical setting. How the objective procedure times measured during practice can complement assessment of trainee competence or define usefulness of different accessories is unknown but deserves to be explored in future studies. The procedure times can categorize participants according to their ERCP experience and separate accessories according to their ease of use. An increase in credibility score validates participants' endorsement of such practice as a credible adjunct to ERCP training.

An Algorithm for the Management of Bile Leak Following Laparoscopic Cholecystectomy

The management of bile leaks following laparoscopic cholecystectomy has evolved with increased experience of ERCP and laparoscopy. The purpose of this study was to determine the impact of a minimally invasive management protocol. Twenty-four patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 1993 and 2003. Between 1993-1998, 10 patients were managed on a case-by-case basis. Between 1998-2003, 14 patients were managed according to a minimally invasive protocol utilising ERC/biliary stenting and re-laparoscopy if indicated. Bile leaks presented as bile in a drain left in situ post laparoscopic cholecystectomy (8/10 versus 10/14) or biliary peritonitis (2/10 versus 4/14). Prior to 1998, neither ERC nor laparoscopy were utilised routinely. During this period, 4/10 patients recovered with conservative management and 6/10 (60%) underwent laparotomy. There was one postoperative death and median hospital stay post laparoscopic cholecystectomy was 10 days (range, 5-30 days). In the protocol era, ERC +/- stenting was performed in 11/14 (P = 0.01 versus pre-protocol) with the main indication being a persistent bile leak. Re-laparoscopy was necessary in 5/14 (P = 0.05 versus preprotocol). No laparotomies were performed (P < 0.01 versus pre-protocol) and there were no postoperative deaths. Median hospital stay was 11 days (range, 5-55 days). The introduction of a minimally invasive protocol utilising ERC and re-laparoscopy offers an effective modern algorithm for the management of bile leaks after laparoscopic cholecystectomy.