ERCP Group Research Articles

ROLE OF ERCP;

Objective: To determine the efficacy of ERCP in acute severe biliary pancreatitis inrelation to rate of complications and hospital stay. Patients and Methods: 30 patents wereincluded in the study, divided into ERCP group & Non ERCP group. The study was conducted atSurgical Unit-I, Holy Family Hospital Rawalpindi from July 2009 to April 2011. ERCP Groupcomprised of 11 patients and non ERCP Group 19 patients. All patients having severe acutebiliary pancreatitis raised alkaline phosphatase and common bile duct diameter >8mm wereincluded in the study. Results: In ERCP Group, there were 3 males and 4 females with mean age42.77 ± 14 years. In non ERCP group there were 17 males and 2 females with mean age 46.76 ±13 years. ERCP was done within 3 day in 8 patients and within 7 day in 5 patients in ERCP group.The rate of complications in both groups was insignificant (P= .92). The length of hospital stayalso does not differ significantly between two groups (P=.874). Conclusions: In our set up therewas no significant difference in outcome in ERCP and non-ERCP group of severe acutepancreatitis. However, in ERCP group intervention was mostly performed after 72hrs.

Gallstone Pancreatitis Without Cholecystectomy

Current guidelines recommend that patients with an initial episode of gallstone pancreatitis receive cholecystectomy. However, for various reasons, many patients do not. To determine the risk of developing recurrent gallstone pancreatitis in patients who never receive a cholecystectomy. Retrospective cohort study using electronic medical records. Inpatient and outpatient. All patients in Kaiser Permanente Southern California with a primary diagnosis of acute gallstone pancreatitis hospitalized from January 1, 1995, through December 31, 2010, with no previous diagnosis of gallstone pancreatitis documented in the medical record. Endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy and/or stent placement, or no intervention. Recurrent acute pancreatitis. A total of 1119 patients were identified. The median age at diagnosis was 63 years. Among the patients, 802 received no intervention and 317 received ERCP. After a median follow-up of 2.3 years, the overall risk of recurrent pancreatitis was 14.6%; it was 8.2% and 17.1% in patients who had ERCP and no intervention, respectively (P < .001). The median time to recurrence was 11.3 and 10.1 months in the patients who had ERCP and no intervention, respectively. Kaplan-Meier estimates of recurrence for 1, 2, and 5 years in the ERCP group were 5.2%, 7.4%, and 11.1%, compared with 11.3%, 16.1%, and 22.7% in the no-intervention group (hazard ratio = 0.45; 95% CI, 0.30-0.69; P < .001). Charlson Comorbidity Index and intensive care unit stay were independently associated with recurrence, whereas age, sex, and admission Ranson score were not associated. In patients who did not undergo cholecystectomy, the risk of recurrent pancreatitis is significant. Endoscopic retrograde cholangiopancreatography mitigates this risk and should be considered during initial hospitalization if cholecystectomy is not done.

Mo1458 The Incidence of Post ERCP Pancreatitis, Bleeding, Perforation and ERCP Related Mortality, and Clinical Risk Factors for Post ERCP Pancreatitis: a Population Based Study

Surgical Gastrostomy to Access the Bypassed Stomach: Same Day or Delayed ERCP? Carlos R. Gonzalez*, James L. Watkins, Lee Mchenry, Evan L. Fogel, Glen A. Lehman, Nicholas J. Zyromski Surgery, IU school of medicine, Indianapolis, IN; Gastroenterology, Indiana University Hospital, Indianapolis, IN Background: Endoscopic access to the pancreatobiliary system following Rouxen-Y gastric bypass is challenging. Double balloon enteroscopy can be performed, however cannulation of the native papilla is suboptimal. ERCP via the gastric remnant is preferred but requires surgical gastrostomy placement into the gastric remnant. This analysis compared patients having same day (SD-ERCP) versus delayed (D-ERCP) endoscopic retrograde cholangiopancreatography following surgical access to the gastric remnant. Methods: 24 consecutive patients requiring open surgical gastrostomy into the gastric remnant were analyzed: 13 patients had SD-ERCP and 11 had D-ERCP. Demographic and clinical data were compared. Appropriate statistics were applied; p 0.05 was considered statistically significant. Results: The majority of patients were female (96%) and Caucasian (83%). The median age was 47 years (range 30 to 60). ERCP indications included suspected sphincter of Oddi dysfunction vs chronic pancreatitis (83%); cholangitis, common bile duct stricture, bile leak, and retained bile duct stent (4% each). In D-ERCP group, ERCP was performed 41 / 4 days after gastrostomy. The duration of gastrostomy tube maintenance was 42 / 3 days in SD-ERCP compared to 51 / 4 days in D-ERCP (p 0.02). Following surgical gastrostomy, hospital length of stay was 5 / 1 days in SD-ERCP and 5 / 1 days in D-ERCP (p 0.88). Two patients (8%) developed superficial surgical site infection (SD-ERCP 1, D-ERCP 1), one was severe. One patient (4%) in the D-ERCP group developed delayed abdominal wall hematoma. Successful ERCP was achieved in 23 patients (96%). No mortality occurred in either group. Conclusions: After gastrostomy placement in the gastric remnant, same day ERCP decreased length of time required for gastrostomy tube maintenance compared to delayed ERCP. Similar perioperative outcomes, (including a similar minor complication profile) were observed in both same day and delayed ERCP groups. In the bypassed stomach, same day ERCP after surgical gastrostomy provides safe and practical access to the pancreatobiliary system.

Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis

Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis

Early endoscopic therapy for elderly patients with acute severe biliary pancreatitis

Objective To evaluate the clinical effects of early endoscopic therapy for elderly pa- tients with acute severe biliary pancreatitis. Methods Ninety-two elderly patients with acute severe biliary pancreatitis were randomly divided into 2 groups ： ERCP group （ n = 43 ） and non-ERCP group （ n = 49）. Se- rum TNF-α, IL-6, IL-8, the recovery time of blood amylase, the duration of abdominal pain, hospitaliza- tion, mortality and complications were compared. Results ERCP group showed a greater decrease in serum TNF-α, IL-6 and IL-8 levels than the control group （ 45.16 ± 13.48 ） Ixg/L v. s. （ 176. 89 ± 47.35 ） μg/L, （31.76±13.85）μg/Lvs. （68.48 ±24.87）μg/L, （113.39± 63. 78 ） μg/L v.s. （309.86±117.13） μg/L） （P 〈0. 05 ）. The duration of abdominal pain, the recovery time of blood amylase and hospitalization in ERCP group were significantly shorter compared to the non-ERCP group [ （ 10. 2 ±1.7） d v.s. （ 13.2± 2.4）d, （3.3±1.0）dv.s. （5.5±1.2）d, （15±1.6）dv.s. （20 ±3.0）d] （P〈0.05）,andcomplication rate of the ERCP group was lower, too （5% v.s. 22% , P 〈 0. 05 ）. Conclusion Early ERCP is safe and highly effective for the elderly patients with acute severe biliary pancreatitis. Key words: Aged ; Pancreatitis ; Acute disease ; Cholangiopancreatography, endoscopic retro- grade ; Tumor necrosis factor-alpha; Interleukins

Mo1458 Patients, Endoscopist's and Nursing Staff Radiation Exposure During Interventional ERCP Procedures

Mo1458 Patients, Endoscopist's and Nursing Staff Radiation Exposure During Interventional ERCP Procedures

Su1370 Prevalence of Pancreatobiliary Malignancy in Patients Presenting With Obstructive Jaundice and Biliary Stricture or Mass Lesion on CT/MRI Scans and Evaluation of EUS-FNA in Their Management

Su1370 Prevalence of Pancreatobiliary Malignancy in Patients Presenting With Obstructive Jaundice and Biliary Stricture or Mass Lesion on CT/MRI Scans and Evaluation of EUS-FNA in Their Management

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: A systematic review

There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms "common bile duct stones,""cholecystectomy,""bile duct exploration,""ERCP" (endoscopic retrograde cholangiography), and "endoscopic sphincterotomy." There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one-stage management had the advantage of providing a shorter hospital stay.

ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience

Comparative data regarding complications associated with ERCP alone or when performed with cholangiopancreatoscopy (CP) are lacking. To determine whether ERCP complications are more frequent when concomitant CP is performed. A retrospective query of a prospectively maintained database of ERCP, CP, and complications. Consensus criteria complications and additional adverse events (AEs), including unplanned medical evaluation, cardiopulmonary/sedation events, and others. Academic, tertiary referral center. A total of 4214 ERCPs were performed (337 sphincter of Oddi manometry cases excluded) during the study period, of which 3475 ERCPs and 402 ERCPs with CP were analyzed. There were 28 of 402 AEs (7.0%) in the ERCP with CP group and 101 of 3475 (2.9%) in the ERCP-only group (odds ratio [OR], 2.50; 95% CI, 1.56-3.89). Subgroup analysis revealed a significantly higher rate of cholangitis in the CP group versus ERCP group (1.0% vs 0.2%; OR, 4.98; 95% CI, 1.06-19.67) and similar rates of pancreatitis (2.2% vs 1.3%; OR, 1.75; 95% CI, 0.74-3.65) and perforation (1.0% vs 0.3%; OR, 3.16; 95% CI, 0.73-10.75). Retrospective review of a complications database that relies on physician self-reporting. AEs from CP may be more than double those of ERCP alone (when sphincter of Oddi manometry cases are excluded). CP appears to be associated with a significantly higher rate of cholangitis, possibly because of intermittent intraductal irrigation required during the procedure.

Two-stage Versus Single-stage Management of Patients with Choledocholithiasis: Meta-analysis of Randomized Controlled Trials

Purpose: Current management of patients with choledocholithiasis involves two stages consisting of ERCP and laparoscopic cholecystectomy (LC). Following the advent of techniques of laparoscopic ductal stone clearance, an alternative single-stage laparoscopic treatment was introduced for these patients. Various randomized controlled trials (RCTs) done in past to compare these 2 modalities but with different and controversial results. Therefore, we conducted meta-analysis to compare the two-stage versus single-stage process for management of choledocholithiasis. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (5/2010). RCTs comparing ERCP and LC versus single-stage laparoscopically-assisted CBD stone extraction were included. Standard forms were used to extract data by two independent reviewers. The effects of both the methods were analyzed by calculating pooled estimates for stone extraction efficacy, complications, and cross-over to other techniques. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. All were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Results: Five trials met inclusion criteria (N=607). Trials were of adequate quality (Jadad score ≥2). Three trials used ERCP pre-cholecystectomy whereas two other trials used ERCP post-cholecystectomy. No significant heterogeneity was noted for any of the outcomes. CBD stone extraction was noted in 89.0% with the two-stage process whereas 84.6% in the single-stage laparoscopy-assisted CBD stone removal. Trend of higher stone extraction was noted in the two-stage ERCP and laparoscopic cholecystectomy group but did not reach a significant level (OR 1.39; 95% CI: 0.81-2.38, p=0.23). Similarly, a low incidence of lower complications and less cross-over to other techniques for stone removal were noted in ERCP group, but again, did not reach a significant level. (OR 0.77; 95% CI: 0.49-1.25, p=0.26; OR 0.81; 95% CI: 0.49-1.35, p=0.45), respectively. Funnel plot revealed no publication bias. Conclusion: The two stage process consisting of ERCP-assisted CBD stone extraction with LC resulted in similar outcomes to the single stage laparoscopically-assisted CBD stone. However there was trend towards a higher stone extraction and less complication rates with the two stage process. Future multicenter studies with higher number of subjects are required before making a final conclusion.

Prospective randomized trial of EUS versus ERCP-guided common bile duct stone removal: an interim report (with video)

EUS is being increasingly utilized for the diagnosis of choledocholithiasis and microlithiasis, especially in patients with biliary colic. Simultaneously, there is also a rising interest in the use of EUS for therapeutic interventions. Our goal was to assess the effectiveness of EUS-directed common bile duct (CBD) stone removal to compare its safety and effectiveness with ERCP-directed intervention. Interim results of a prospective, randomized, single-center blinded clinical trial. A single tertiary care referral center. Fifty-two patients with uncomplicated CBD stones were prospectively randomized to CBD cannulation and stone removal under EUS or ERCP guidance. MAIN OUTCOME MEASUREMENTS AND INTERVENTIONS: Primary outcome measure was the rate of successful cannulation of the CBD. Secondary outcome measures included successful removal of stones and overall complication rates. CBD cannulation followed by stone extraction was successful in 23 of 26 patients (88.5%) in the EUS group (I) versus 25 of 26 patients (96.2%) in the ERCP group (II) (95% CI, -27.65%, 9.88%). Overall, there were 3 complications in the EUS group and 4 complications in the ERCP group. The current study is an interim report from a single center report and performed by a single operator. Our preliminary analysis indicates that outcomes following EUS-guided CBD stone retrieval are equivalent to those following ERCP. EUS-related adverse events are similar to those following ERCP. ERCP and EUS-guided stone retrieval appears to be equally effective for therapeutic interventions of the bile duct. Additional studies are required to validate these preliminary results and to determine predictors of success of EUS-guided stone removal.

ERCP with Cholangiopancreatoscopy (CP) Is Associated with Higher Rates of Endoscopic Complications Than ERCP Alone

Background: Whether ERCP complications are higher when CP is performed is unknown. Methods: Our prospectively entered database was queried for ERCPs and complications. CPs were extracted. A data collection sheet included indications, interventions, complications by consensus criteria, and other adverse events (unplanned medical evaluation, cardiopulmonary, sedation-related, infection). Patients undergoing sphincter of Oddi manometry (SOM) were excluded. STATA 8.2 was used for analyses. Results: Between July 2001 and October 2007, a total of 4214 ERCP's were performed, of which 337 (8.0%) were SOM and excluded. Of the 3877 remaining ERCP's, CP was performed in 402 (10.4%). 129 adverse events (AE) were reported and analyzed (101 after ERCPs, 28 after CPs). In patients with AEs, indications for ERCP and CP, respectively, included: evaluation of biliary (CBD) (35.6%, 46.4%) and pancreatic (PD) stricture (16.8%, 17.9%), therapy of CBD stones (16.8% and 32.1%) and PD stones (6.9% and 10.7%); sphincterotomies were performed in 59.4% and 28.6% of procedures. Pancreatoscopy comprised 7/28 (25.0%) of CPs. Interventions performed at time of ERCP with CP in patients with AEs: CBD (N = 4) and PD (N = 3) stricture dilation, CBD (N = 15) and PD (N = 4) tissue sampling, CBD (N = 4) and PD (N = 2) EHL, and prophylactic or therapeutic PD stents (N = 5). CP diagnoses included CBD (N = 5) and PD stones (n = 3), PSC (n = 3), CCA (n = 6), chronic pancreatitis (n = 2), IPMN (n = 4), and other (n = 5). Reported AEs (see Table) were significantly higher in the CP compared to ERCP group [28/402 (7.0%) vs 101/3475 (2.9%)], (OR 2.50, 95% CI [1.56-3.89]). Subgroup analyses revealed a significantly higher rate of cholangitis (1.0% vs 0.2%, OR 4.98, 95%CI [1.06-19.67]) and a trend toward a higher rate of pancreatitis (2.2% vs 1.3%, OR 1.75, 95%CI [0.74-3.65])and perforation (1.0% vs 0.3%, OR 3.16, 95%CI [0.73-10.75] in the CP group. Conclusions: 1) Adverse events for cholangiopancreatoscopy are more than double that of ERCP when SOM patients are excluded. 2) CP is associated with significantly higher consensus criteria complications 3) Subgroup analysis showed significantly higher rates of cholangitis in the CP group likely related to fluid irrigation 4) The increased risk for complications should be discussed with patients undergoing ERCP when CP is planned. Tabled 1Consensus Complications and Other Adverse Events Procedures with Complications Pancreatitis ∗ Total complications by consensus criteria was significantly higher for ERCP with CP (4.2% vs 2.2%. OR 2.00, 95%CI [1.10-3.46] Perforation ∗ Total complications by consensus criteria was significantly higher for ERCP with CP (4.2% vs 2.2%. OR 2.00, 95%CI [1.10-3.46] Bleeding ∗ Total complications by consensus criteria was significantly higher for ERCP with CP (4.2% vs 2.2%. OR 2.00, 95%CI [1.10-3.46] Cholangitis ∗ Total complications by consensus criteria was significantly higher for ERCP with CP (4.2% vs 2.2%. OR 2.00, 95%CI [1.10-3.46] Unplanned Medical Evaluation Cardiopulmonary/Sedation Events Other CP(N = 28) 9 4 0 4 6 2 3 ERCP(N = 101) 45 11 12 7 8 10 8 ∗ Total complications by consensus criteria was significantly higher for ERCP with CP (4.2% vs 2.2%. OR 2.00, 95%CI [1.10-3.46] Open table in a new tab

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

EUS may be used to reduce the need of diagnostic ERCP. Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. A randomized study. A university medical unit. Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.

Efficacy of postprocedure administration of gabexate mesylate in the prevention of post-ERCP pancreatitis: a randomized, controlled, multicenter study

Gabexate mesylate reduces the incidence of post-ERCP pancreatitis. Patient-related risk factors associated with pancreatitis can be identified before ERCP, but the procedure-related factors are recognized only at the end of the procedure. This study's aim was to evaluate whether gabexate mesylate administered after ERCP reduces the incidence of pancreatitis. Randomized, prospective, double-blind, multicenter trial. Tertiary care centers. A total of 608 patients undergoing ERCP were treated with gabexate mesylate 500 mg within 1 hour before ERCP (group A, 203 patients) or within 1 hour after ERCP (group B, 203), or with saline solution (group C, 202). The incidence and severity of pancreatitis and hyperamylasemia, as well as factors associated with the development of pancreatitis. The groups were similar for demographic characteristics, indications to ERCP, risk factors for pancreatitis, and therapeutic procedures. The incidence of pancreatitis was 3.9% in group A, 3.4% in group B, and 9.4% in group C (P<.01). Two patients (in groups A and C) developed necrotizing pancreatitis, and 1 died. Hyperamylasemia occurred in 23.6% in groups A and B, and in 24.7% in group C. Levels of amylase, the incidence of abdominal pain, and other complications occurred similarly. Female sex (odds ratios [OR] 2.7, 95% CI 1.2-5.9) and difficult cannulation (OR 5.6, 95% CI 2.6-12.3) were independently associated with pancreatitis. The administration of gabexate mesylate after ERCP protects against the development of pancreatitis similarly to the preprocedure administration. Factors associated with pancreatitis were mainly recognized after ERCP. We suggest administering gabexate mesylate after ERCP only in those patients recognized to be at risk of developing pancreatitis.

An Economic Evaluation from Randomized Trial Data Comparing ERCP to MRCP in Suspected Biliary Obstruction

Background: MRCP can prevent unnecessary ERCPs and their complications in patients with biliary obstruction (BO). Aim: To determine differences in costs between MRCP and ERCP-first strategies in patients with an intermittent probability of BO, and to identify predictors of resource use. Methods: Patients with an intermediate probability of BO based on clinical and ultrasound (US) findings were randomized to MRCP or ERCP, and followed for a year. The number of procedures, and medical direct and indirect Canadian costs (in CDN $) were analyzed per intention-to-treat. Multivariate linear regression models identified independent predictors of resource utilization. Results: 131 patients were randomized to MRCP and 126 to ERCP. Groups were similar in age (55.8 ± 17.7 yrs vs 52.3 ± 18.4 yrs), gender (60% vs 65% female), symptoms, and post-cholecystectomy status (44% vs 34%). Mean follow-ups were 10.3 ± 3.0 mos for MRCP and 10.1 ± 3.3 mos for ERCP. The proportion of additional procedures (58.8% vs 21.4%, CI on difference [0.26; 0.48]) and their total numbers (151 vs 202, CI on difference [14.2, 87.8]) were greater in the MRCP group. No clinically relevant difference was observed in days away from usual activities (268.5d, mean = 2.05d, SE [4.85d] for MRCP, and 431d, mean = 3.42d, SE [7.66d] for ERCP, CI on mean difference [-0.92; 1.55d]). Except for those related to diagnostic ERCP, all other direct medical costs were greater in the MRCP group (average (per patient) and total opportunity loss of CDN$579.55 and CDN$ 79,745.90). In contrast, indirect costs were greater in the ERCP group (average and total savings of CDN$ 36.43 and CDN$ 9,911.29). When summing direct and indirect costs, an ERCP-first strategy resulted in net total and average savings of CDN$ 69,830.37 and CDN$ 543.17 respectively. Multivariate linear regression showed that, in the ERCP group, pre-randomization US findings of CBD (beta = 1.66) and intrahepatic duct dilation (beta = 3.08) were associated with a greater number of post-ERCP procedures, while suspected CBD stone (beta = −2.10) or chronic pancreatitis (beta = −3.39) were negative predictors. In the MRCP group, an elevated serum bilirubin (beta = 0.017), pre-randomization US suspicion of a CBD stone (beta = 2.68), or of an ampullary lesion (beta = 13.6) were associated with a greater likelihood of additional tests. Conclusion: This economic analysis of a medical effectiveness randomized trial suggests that ERCP-first is a preferred strategy for the management of patients with an intermediate probability of biliary obstruction. Initial abdominal US findings provide valuable prognostic information which can improve downstream resource utilization.

Combined EUS and ERCP for Distal Biliary Obstruction: Technical Feasibility, Success Rates of Biliary Decompression and Tissue Sampling

Background: While endoscopic ultrasound (EUS) and ERCP are commonly performed procedures in the evaluation and management of presumed malignant biliary obstruction, there is a paucity of literature describing the use of combined procedures. Methods: We retrospectively reviewed all EUS and ERCP performed on the same day between 7/02-7/06. EUS with a pre-procedure indication of a biliary stricture or suspected mass in the head of the pancreas were evaluated. The indication of the ERCP was jaundice or increased liver enzymes. Exclusion criteria included: choledocholithiasis, pancreatic cyst management, prior sphincterotomy, prior biliary or pancreatic stents, non-visualized papilla due to tumor in-growth, hilar strictures, known or presumed PSC, and surgically altered anatomy. For a comparison, ERCP done alone over the same time period with the same indications and exclusion criteria were reviewed. Data extracted included medication use, technical success of placing a biliary stent, and the results of all tissue sampling. All pathology specimens were reported as malignant, suspicious, atypical, or benign. Results: Fifty-three combination procedures (EUS/ERCP) and 124 ERCP met the study criteria. The mean midazolam dose was higher in the EUS/ERCP group than in the ERCP alone group (6.36 mg vs. 5.53 mg, p = 0.0086). The mean fentanyl equivalent dose (fentanyl 100 mcg = merperidine 75 mg) was also higher in the EUS/ERCP group (219.1 mcg vs. 192.9 mcg, p = 0.029). There was no difference in the use of an adjuvant medication (i.e. droperidol, promethazine, diphenhydramine) between the groups (42.7% vs. 50.9%, p = 0.3). Successful cannulation and stent placement was achieved in 52/53 in the EUS/ERCP group and 118/124 in the ERCP group (98.1% vs. 95.2%, p = 0.3). Tissue sampling was performed more often in the EUS/ERCP group than the ERCP group (94.3% vs. 63.7%, p < 0.001). There were no significant differences in the percentage of studies in which biliary brushings (56.6% vs. 62.9%, p = 0.4) or forceps biopsies were obtained (17.0% vs. 12.1%, p = 0.3). EUS/FNA was performed in 56.6%. Combining all tissue sampling techniques, the EUS/ERCP group more often achieved a definitively malignant pathology result as compared to the ERCP group (70% vs 32.9%, p < 0.001). Conclusion: Same day EUS/ERCP with moderate sedation for presumed malignant distal bile duct obstruction appears technically feasible. If pathologic specimens are taken, a combined procedure results in a higher yield of definitively positive results, specifically due to the ability to perform FNA. Combined procedures require minimal added sedation and do not limit the ability to drain an obstructed biliary system.

Same-Day Combined EUS Followed By ERCP Procedures Under Conscious Sedation Is Well Tolerated and Safe

Background: At our institution combined approach with EUS followed by ERCP is sometimes performed for patients with suspected pancreatico-biliary diseases. There is little data on this tandem approach in regards to tolerability and safety. Aim: The purpose of this study is to retrospectively analyze the cohort of patients with obstructive jaundice who underwent same day tandem procedures, EUS followed by ERCP, compared with a control group who underwent EUS only. Methods: All 56 patients who underwent EUS followed by ERCP (group A) from 1/1/2004 to 11/20/2006 were included in the study.

Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography‐guided fine‐needle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can now provide a cytopathological diagnosis of underlying pancreatic malignancy with higher success rates than endoscopic retrograde pancreatography (ERP). To determine the significance of EUS-FNA for the diagnosis of pancreatic mass without biliary stricture, the value of cytopathological diagnosis obtained by EUS-FNA was retrospectively compared with that by ERP, and the complications associated with these procedures evaluated. Eighty-three patients who were suspected to have a pancreatic mass (excluding a cystic mass), without biliary stricture on conventional ultrasound and/or computed tomography were enrolled. The EUS-FNA biopsy was performed in 53 patients and cytology utilizing ERP was performed in 30 patients. The sampling rate of adequate specimen was 100% in both groups. In the EUS-FNA group, the overall results for the available samples were sensitivity 92.9% and accuracy 94.3%. In contrast, in the ERCP group, the overall results were sensitivity 33.3% and accuracy 46.7%. There was a significant difference between the two groups (P < 0.01). With regard to complications, there was a significant difference (P < 0.01) in the frequency of post-procedure pancreatitis between the EUS-FNA group and ERP group (0%, 0/53 vs 33.3%, 10/30, respectively). Endoscopic ultrasonography-guided fine-needle aspiration is safer and more accurate for the cytopathological diagnosis of suspected pancreatic masses without a biliary stricture as compared with cytology during ERP. Endoscopic ultrasonography with FNA should be considered a preferred test (prior to attempting endoscopic retrograde cholangiopancreatography) when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction, or when emergent decompression of an obstructed biliary tree is not considered clinically necessary due to lack of signs and symptoms of cholangitis.

The Effectiveness of ERCP Versus MRCP: Final Results of a Randomized Clinical Trial in Patients with an Intermediate Probability of Bile Duct Obstruction

Background: Many noninvasive methods of cholangiography, have made us reconsider the role of ERCP in the management of patients with suspected biliary obstruction. Aim: The aim of this study was to assess the effectiveness of MRCP compared to ERCP in patients with this condition. Methods: Following clinical suspicion, laboratory blood work and ultrasound, patients were categorized as having an intermediate probability of bile duct obstruction using a validated predictive model, and were randomized to MRCP or ERCP in a medical effectiveness trial that included a follow-up period of 12 months. Patients were managed according to standardized clinical paths. The main outcome was the occurrence of negative pre-defined outcomes considered disease- or bilio-pancreatic procedure-related. Secondary outcomes were pertinent durations of hospitalization and quality of life measurements (SF-36). Results: Of 350 patients screened over 54 months, 126 patients were randomized to ERCP and 131 to MRCP. ERCP and MRCP groups were similar in age (52.3±18.4 years vs 55.8±7.7 years), sex (65% vs 60% female), presenting symptoms, and post-cholecystectomy status (34% vs 44%). Biliary obstruction was suspected on clinical grounds (72%) or because of ultrasonographic findings (28%). At randomization, bile duct stones and neoplasms were noted in 21% and 24%, and 6.6% and 5.4%, while no obstruction was noted in 53% and 50% of ERCP and MRCP patients, respectively. Mean durations of follow-up were 8.0±5.1 mos for ERCP and 8.4±4.9 mos for MRCP; additional diagnostic or therapeutic tests were performed in 58% (95% CI: 49-67%), and 59% (95% CI: 50-67%), respectively. No clinically significant overall differences in quality of life were noted between both groups. 38% of ERCP's performed in the ERCP group were therapeutic, while 51% of MRCP patients went on to have an ERCP (therapeutic in 90%). Negative outcomes were noted in 19.1% (95% CI: 12.3-25.8%) of MRCP and 14.3% (95% CI: 8.2-20.4%) of ERCP patients (difference of 4.8%, 95% CI: -4.3 to +13.9%.), resulting in respective durations of hospitalization of 4.6±7.5 versus 5.6±8.5 days (P=NS). In both groups, negative outcomes were disease related (72%) or procedure-related (28%). Conclusion: In this medical effectiveness randomized trial, a policy of early MRCP did not exhibit significant advantages over one of early ERCP in the work-up of patients with an intermediate probability of biliary obstruction.

A Comparative Study of Diagnostic Value of Cytologic Sampling by EUS-Guided Fine Needle Aspiration and that by ERP for the Management of Pancreatic Mass Without Biliary Stricture

Background and Aim: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can now provide a cytopathological diagnosis of underlying pancreatic malignancy with higher success rates than endoscopic retrograde pancreatography (ERP). To determine the significance of EUS-FNA for the diagnosis of pancreatic mass without biliary stricture, we retrospectively compared the value of cytopathological diagnosis obtained by EUS-FNA with that by ERP, and evaluated the complications associated with these procedures. Methods: Fifty-three patients who were suspected to have a pancreatic mass (excluding a cystic mass), without biliary stricture on conventional ultrasound and/or computed tomography were enrolled. EUS-FNA biopsy was performed in 32 patients and the cytology utilizing ERP was performed in 21 patients. Results: The sampling rate of adequate specimen was 100% in both groups. In EUS-FNA group, the overall results for the available samples were sensitivity 91.7% and accuracy 93.8%. On the other hand, in the ERCP group, the overall results were sensitivity 35.3% and accuracy 47.6%. There was a significant difference between 2 groups (p<0.01). With regard to complications, there was a significant difference (p<0.01) in the frequency of post procedure pancreatitis between EUS-FNA group and ERP group (0% (0/34) vs. 33.3% (7/21), respectively). Conclusion: EUS-FNA is safer and more accurate for the cytopathological diagnosis of suspected pancreatic masses without a biliary stricture as compared with the cytology during ERP. EUS with FNA should be considered a preferred test (prior to attempting ERCP) when a cytological diagnosis of a pancreatic mass is required especially when there is no biliary obstruction or emergent decompression of an obstructed biliary tree is not considered clinically necessary due to lack of signs and symptoms of cholangitis.