Indications For Endoscopic Retrograde Cholangiopancreatography Research Articles

Enteroscopy-assisted ERCP in patients with surgically altered anatomy: multicenter prospective registry (SAMISEN-B) using Motorized Spiral Enteroscopy

BACKGROUND & STUDY AIMS: Prospective study of efficacy and safety of Motorized Spiral Enteroscopy (MSE) to perform biliary endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy at 5 European centers. PATIENTS & METHODS: Consecutive patients with biliary indications for enteroscopy-assisted ERCP. Objectives were technical success, adverse event rate and patient radiation exposure. RESULTS: 89 patients were enrolled, 1 pancreatic indication excluded, all with variations of Billroth II reconstruction (29.5%) or Roux-en-Y reconstruction (70.5%), either with naive papilla (39%) or hepaticojejunostomy (61%). Main indications were anastomotic stricture treatment and/or biliary stone removal. Enteroscopy to reach the bile duct was possible in 65/88 patients (74%), bile duct cannulation in 54/88 (61%) and therapeutic ERCP was technically successful in 48/88 (54%). In Billroth II variations technical success was achieved in 13/26 (50%) compared to 35/62 (57%, p=0.5792 Chi square) in Roux-en-Y reconstructions (including bariatric gastric bypass). ERCP with intact papilla was successful in 17/34 (50%) compared to 31/54 (57%, p=0.4968 Chi square) in hepaticojejunostomy. In July 2023 the study was prematurely terminated since MSE was withdrawn by the manufacturer because of safety issues. Overall, in 12/88 (14%) patients adverse events (AE) were recorded and 6 (7%) were considered serious. Only 1 SAE was attributable to MSE enteroscopy: perforation of the proximal oesophagus during enteroscope insertion. CONCLUSIONS: This prospective multicenter study was prematurely discontinued due to withdrawal of the MSE by the manufacturer because of safety issues. Technical success of MSE-assisted biliary ERCP in different types of surgically altered anatomy was 54%, which was lower than anticipated. There was one oesophageal perforation attributable to the use of MSE. (clinicaltrials.gov: NCT05129449)

Prevention of Infectious Complications in Acute Pancreatitis

AIM OF STUDY. The study was aimed to evaluate the effectiveness of treating acute pancreatitis by early enteral nutrition and selective introduction of nutritional mixtures directly into the initial sections of the jejunum, bypassing the duodenum.MATERIAL AND METHODS. A comprehensive treatment method for acute pancreatitis was developed based on the use of a pancreatoduodenal catheter. The method focuses on preventing intestinal failure syndrome by isolating the duodenum and preventing any liquid from entering it while ensuring the selective introduction of glucose-saline solutions and/or enteral nutritional mixtures directly into the initial sections of the jejunum. Several Russian clinics are currently conducting the research approved by local ethics committees. This article presents preliminary results from the data analysis. The study included moderate to severe forms (according to the 2012 Atlanta classification) of acute biliary pancreatitis without indications for endoscopic retrograde cholangiopancreatography, as well as alimentary-alcoholic pancreatitis. The first group of patients received standard therapy according to the 2020 clinical guidelines of the Russian Society of Surgeons. The second group received standard therapy combined with the new selective enteral nutrition method. The observation period lasted until the end of the hospital treatment, including five mandatory visits and a final visit to the physician. A follow-up survey was conducted three months or more after discharge to identify delayed episodes of acute pancreatitis complications, focusing on the incidence of infectious complications and surgical interventions.RESULTS. A total of 148 patients were treated. Patients were evenly distributed by etiology, gender, age, and body mass index. The analysis revealed that the number of patients with infectious complications decreased from 19.3% in the comparison group to 6.67% in the study group (p=0.041). The number of patients requiring surgical interventions was 5.0% in the study group compared to 19.3% in the comparison group (p=0.017).CONCLUSIONS. The study demonstrated that the use of the new method in the comprehensive treatment of acute pancreatitis, including early enteral feeding at the onset of the disease, may improve the course of the disease by reducing the incidence of infectious complications and the number of necessary surgical interventions.

Updates in Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialised endoscopic procedure for managing pancreatic and biliary diseases. Earlier in the 1970s, ERCP was mainly used for diagnostic purposes to evaluate the biliary and pancreatic ducts and surrounding structures. But nowadays, as noninvasive imaging studies advance, it is primarily used for therapeutic purposes though it is used for therapeutic and diagnostic purposes.Therapeutic ERCP is broadly used in conditions that lead to impairment in bile flow and leak. The requirement of the ERCP extended further for evaluation of pancreatitis of unknown aetiology, preoperative evaluation of the patient with chronic pancreatitis and evaluation of the sphincter of Oddi by manometry.Patients should be selected with a clear-cut indication for ERCP, avoiding unnecessary or marginally indicated ERCP, especially in high-risk patients. ERCP is usually performed using a dedicated side-viewing endoscope with the patient positioned prone on a fluoroscopy table under sedation or general anaesthesia. Proper positioning of the duodenoscope is the key to cannulation of the pancreatic or common bile ducts.

Endoscopic approach for biliopancreatic disease after pancreaticoduodenectomy: a 10-year single-center experience.

In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD). This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected. 133 patients were included (80M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20months (IQR 6-40.1). Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up.

Charting Unexplored Territories: ERCP Indications and Complications in Pediatric Patients; A Cross-Sectional Study from 2022 to 2023

Background: There are ongoing concerns about the safety of endoscopic retrograde cholangiopancreatography (ERCP) in children, as recorded cases have shown complications. Objectives: The objective of this study is to investigate the indications, complications, and outcomes of ERCP in pediatric patients. Methods: This cross-sectional study was conducted at Namazi and Abu Ali Sina Hospitals between September 2022 and December 2023. The study focused on pediatric patients aged 1 month to 18 years undergoing ERCP. The demographics, indications for ERCP, pre-procedural imaging findings, and complications within 72 hours and up to 6 months after ERCP were extracted from medical records. Results: During the study period, a total of 100 ERCP procedures were performed on 56 pediatric patients. The mean age of the patients was 10.22 ± 4.80 years, with females accounting for 53.6% of the group. The main indications for performing ERCP were the presence of a stricture after orthotopic liver transplantation (22%) and the presence of a common bile duct stone (19%). The incidence of complications was notable for acute pancreatitis (3%) and bleeding (2%), while the failure rate for ERCP operations was determined to be 4%. Conclusions: The infrequent occurrence of failures and complications highlights the substantial benefit of ERCP in treating biliary and pancreatic illnesses in children.

Indication for endoscopic retrograde cholangiopancreatography and development of hemorrhage: a systematic review and meta-analysis

Abstract Background Hemorrhage is a common complication associated with endoscopic retrograde cholangiopancreatography (ERCP), usually following sphincterotomy. Studies investigating risk factors for hemorrhage including ERCP indication have been conflicting. Therefore, we conducted a systematic review and meta-analysis to characterize the association between the ERCP indication and hemorrhage. Methods Database searches of MEDLINE, EMBASE, and CENTRAL were conducted to identify articles up to December 12, 2022. Randomized trials or observational studies of adult patients undergoing ERCP were included. Quality assessment using the Cochrane Risk of Bias 2.0 and Newcastle-Ottawa Scales for randomized trials and observational studies respectively was conducted. A random effects meta-analysis generating pooled odds ratios with 95% confidence intervals was conducted. Results A total of 1323 articles were identified of which 26 were included with up to 25 121 subjects in each meta-analysis. Rates of sphincterotomy (median 96.1%; IQR 60.5–100), biliary stent placement (median 17.2%; IQR 10.6–34.4), antiplatelet use (median 6.0%; IQR 0–10.1), and anticoagulant use (median 1.9%; IQR 0%–3.2%) varied among included studies. No specific indication was associated with hemorrhage in the meta-analyses including cholangitis (OR 1.50; 95% CI 0.97–2.32), choledocholithiasis/biliary stone (OR 1.28; 95% CI 0.95–1.73), malignancy (OR 0.97; 95% CI 0.66–1.42), sphincter of Oddi dysfunction (OR 1.32; 95% CI 0.72–2.40), and acute pancreatitis (OR 0.81; 95% CI 0.44–1.49). Conclusions Overall, no indication was significantly associated with increased hemorrhage following ERCP. However, given limitations in the included studies (ie, significant heterogeneity between studies), additional research to better characterize these associations is needed. Protocol Registration Number PROSPERO (CRD42021283978).

Assessing Patient Radiation Exposure in Endoscopic Retrograde Cholangiopancreatography: A Multicenter Retrospective Analysis of Procedural Complexity and Clinical Factors.

Endoscopic retrograde cholangiopancreatography (ERCP) procedures can result in significant patient radiation exposure. This retrospective multicenter study aimed to assess the influence of procedural complexity and other clinical factors on radiation exposure in ERCP. Data on kerma-area product (KAP), air-kerma at the reference point (Ka,r), fluoroscopy time, and the number of exposures, and relevant patient, procedure, and operator factors were collected from 2641 ERCP procedures performed at four university hospitals. The influence of procedural complexity, assessed using the American Society for Gastrointestinal Endoscopy (ASGE) and HOUSE complexity grading scales, on radiation exposure quantities was analyzed within each center. The procedures were categorized into two groups based on ERCP indications: primary sclerosing cholangitis (PSC) and other ERCPs. Both the ASGE and HOUSE complexity grading scales had a significant impact on radiation exposure quantities. Remarkably, there was up to a 50-fold difference in dose quantities observed across the participating centers. For non-PSC ERCP procedures, the median KAP ranged from 0.9 to 64.4 Gy·cm2 among the centers. The individual endoscopist also had a substantial influence on radiation dose. Procedural complexity grading in ERCP significantly affects radiation exposure. Higher procedural complexity is typically associated with increased patient radiation dose. The ASGE complexity grading scale demonstrated greater sensitivity to changes in radiation exposure compared to the HOUSE grading scale. Additionally, significant variations in dose indices, fluoroscopy times, and number of exposures were observed across the participating centers.

Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals.

No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors. Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service. From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available. One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience.

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications. To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty. This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins's adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis. A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96). There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.

ERCP-induced perforation: review and revisit after half a century.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure. We aimed to investigate ERCP-induced perforations at our institution and conduct a comprehensive review of literature on ERCP-induced perforations (EIP) since the introduction of this procedure as a therapeutic intervention. This was a case-control study, in which charts of all patients diagnosed with ERCP-induced duodenal perforation were reviewed and compared to a control group without perforation. Patient's sociodemographic and clinical data, including ERCP procedure-related data, were gathered. A total of 996 ERCP procedures were performed; only 13 patients proved to have EIP. Obstructive jaundice was the most common indication for ERCP. The main predisposing factor was difficult cannulation (P = 0.003). In total, five patients required surgical treatment; the majority of them had type I perforation, whereas type IV was the most common in patients who were treated conservatively. The overall mortality rate was 15%, the surgical group had a slightly higher mortality rate. Fifty years after the introduction of ERCP for therapy, it remains an invasive procedure that carries significant morbidity and mortality, even in skilled hands or at high- volume units. Conservative management of perforation yields favorable outcomes in selected patients.

The Course of Endoscopic Treatment Success in Biliary Complications After Living Donor Liver Transplantation.

Our aim was to present the results of endoscopic retrograde cholangiopancreatography (ERCP) after living donor liver transplantation (LDLT) between February 2015 and June 2021. Clinical data included LDLT indications, time to perform ERCP after LDLT, number of ERCP procedures, indications for ERCP, and all treatment outcomes, including ERCP, percutaneous, and surgical interventions. We compared the obtained data with our previous study published by our team in 2018, which included 446 patients who underwent ERCP for biliary complications after LDLT between 2005 and 2015. We performed ERCP in 283 of 1506 patients with LDLT who underwent duct-to-duct anastomosis during transplantation and then developed biliary complications. Our endoscopic success rates were 60.9% and 71.0% in the previous and present studies, respectively. Our findings suggest that the success rate of endoscopic treatment of biliary complications in patients with LDLT increases in correlation with the increasing experience of clinicians treating these patients.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue.

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Safety and efficacy of endoscopic retrograde cholangiopancreatography in pediatric pancreatic and biliary disorders.

There is sparse data from India on indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) using standard adult duodenoscope in the pediatric population. Retrospective analysis of prospectively maintained electronic endoscopy and clinical database was performed to identify pediatric patients (age ≤ 18years) who underwent ERCP between January 2017 and December 2022. Demographics and procedural details including indications, cholangio-pancreatogram findings, endotherapy type performed, technical and clinical success and complications were noted. As many as 150 pediatric patients were included of whom 88 had pancreatic (mean age-13.7years) and 62 had biliary disease (mean age- 14.9years). Common pancreatic ERCP indications were chronic pancreatitis (n = 45 [51.1%]), pancreatic duct disruption fistula (n = 21 [23.9%]) and recurrent acute pancreatitis (n = 16 [18.2%]). Among biliary indications were choledocholithiasis (n = 29 [46.8%]), benign bile duct strictures (n = 13 [21%]), bile duct injury/leak and biliary stent removal (n = 7 [11.3%]) , choledochal cyst (n = 5 [8.1%]) and pancreatic mass causing biliary compression (n = 1 [1.6%]). Technical success in pancreatic and biliary ERCP was 94.3% and 95.2%, respectively, and clinical success was 84.1% and 93.5%, respectively. Most common complications following pancreatic ERCPs were acute pancreatitis (n = 9 [10.2%]) (mild = 5, moderate = 4) patients and post sphincterotomy bleed in one (1.1%). Among biliary ERCPs, post ERCP pancreatitis was seen in (n = 3 [4.8%]) (mild = 2, moderate = 1). ERCP can be safely and effectively performed in children using standard duodenoscope. Chronic pancreatitis, choledocholithiasis and pancreatic divisum are common pediatric ERCP indications.

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

BackgroundTo improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP.MethodsWe performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children.ResultsBased on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03).ConclusionsERCP appears to be performed safely in children with a similar success rate as in the adult population.

Risk of Complications After Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Propensity-Matched Analysis.

Studies have suggested higher complication rates after endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy. We performed a propensity-matched cohort analysis to assess the risk of ERCP-related complications among pregnant women in the United States. The TriNetX database was analyzed to identify pregnant and non-pregnant females between 18 and 50years of age who underwent ERCP. One-to-one propensity score matching was performed for age and race. Outcomes included risk of post-ERCP pancreatitis (PEP), gastrointestinal (GI) bleeding, perforation within 7days, and infections within 30days of ERCP. Subgroup analysis was performed to assess the risk of PEP based on indication for ERCP. The risk of PEP was higher in the pregnant cohort compared to controls, 10.3% vs 6.08%, adjusted odds ratio (aOR) 1.77, 95% confidence interval (CI) 1.20-2.61; p = 0.003. We found no difference in the risk of GI bleeding, perforation, and infections between the two cohorts. There was no difference in the risk of PEP in the pregnant cohort compared to controls who underwent ERCP for acute choledocholithiasis (4.2% vs 2.1%, aOR 1.98, 95% CI 0.97-4.03, p = 0.5) or ascending cholangitis (18.6% vs 14.7%, aOR 1.32, 95% CI 0.52-3.39, p = 0.55). There was no difference in the risk of PEP in the pregnant cohort after sensitivity analysis based on age, race, obesity, and indomethacin use. Pregnant females are at an increased risk of PEP but not GI bleeding, perforation, and infections when compared to non-pregnant controls. Clinicians should be cautious when proceeding with ERCP during pregnancy.

ERCP-induced perforation: review and revisit after half a century

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure. We aimed to investigate ERCP-induced perforations at our institution and conduct a comprehensive review of literature on ERCP-induced perforations (EIP) since the introduction of this procedure as a therapeutic intervention. Methods: This was a case-control study, in which charts of all patients diagnosed with ERCP-induced duodenal perforation were reviewed and compared to a control group without perforation. Patient’s sociodemographic and clinical data, including ERCP procedure-related data, were gathered. Results: A total of 996 ERCP procedures were performed; only 13 patients proved to have EIP. Obstructive jaundice was the most common indication for ERCP. The main predisposing factor was difficult cannulation (P = 0.003). In total, five patients required surgical treatment; the majority of them had type I perforation, whereas type IV was the most common in patients who were treated conservatively. The overall mortality rate was 15%, the surgical group had a slightly higher mortality rate. Conclusions: Fifty years after the introduction of ERCP for therapy, it remains an invasive procedure that carries significant morbidity and mortality, even in skilled hands or at high- volume units. Conservative management of perforation yields favorable outcomes in selected patients.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum.

Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV. Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected. Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology-assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%. The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology-assisted rendezvous ERCP can be considered.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

ADVERSE OUTCOMES OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AT GASTROENTEROLOGY AND HEPATOLOGY CENTERS IN SULAYMANIYAH AND DUHOK CITY

Background &#x0D; Endoscopic retrograde cholangiopancreatography (ERCP) has a significant and managing management of pancreaticobiliary diseases in Iraq and Kurdistan. Evaluating ERCP adverse outcomes is essential in raising the effectiveness and safety of ERCP.&#x0D; Objectives &#x0D; To review and measure the rate of ERCP complications in our centre and compare our results with other countries.&#x0D; Patients and Methods&#x0D; The present study was a prospective cross-sectional study carried out in the Kurdistan Center of Gastroenterology and Hepatology (KCGH) in Sulaimani city and Azadi Gastroenterology and Hepatology Center in Duhok city, Kurdistan region-Iraq through the period of one year from 1st of November 2020, to 31st of October, 2021 on a sample of two hundred patients underwent ERCP; 140 patients from Sulaimani city and 60 patients from Duhok city. The researcher followed up with the patients one month after completing ERCP through direct interviews or by phone calling to observe any ERCP adverse outcomes.&#x0D; Results&#x0D; The most typical indication for ERCP among studied patients was choledocholithiasis (43.7%), followed by; stent removal with occlusion cholangiography (12%) and biliary malignancy (11.6%). The commonest findings of ERCP among studied patients were bile duct dilation (42.3%), filling defects (33.8%) and bile duct strictures (14.7%). The post-ERCP complications were present in 45 (22.5%) patients, including pancreatitis (12.5%), cholangitis (4.5%), hypoxia (3.5%), bleeding (1.5%), perforation (1.5%) and death (0.5%). &#x0D; Conclusion&#x0D; The adverse outcomes of ERCP in KCGH in Sulaimani City and the Gastroenterology and Hepatology centre in Duhok city are increased in the last year.

Endoscopic Retrograde Cholangiopancreatography on Pediatric Patients: Experience of a Portuguese Adult Gastroenterology Department

Introduction: Experience with endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population is limited. Few medical centers have experts specifically trained in pediatric therapeutic endoscopy. As a result, patients are generally referred to adult endoscopists with high experience in the procedure. The aim of this study was to characterize the experience of an adult endoscopy unit with ERCP on pediatric patients, with a special focus on very young patients. Methods: We retrospectively analyzed indications, technical success rate, final clinical diagnosis, and complications of ERCPs in children <18 years at our tertiary referral hospital center between January 1994 and June 2022. Results: Sixty-five ERCPs were performed on 57 children with a median age of 13 years (range 1–17 years). Eleven ERCPs were performed on 9 patients up to 5 years old. Indications for ERCP were as follows: biliary obstruction (n = 40), mainly due to choledocholithiasis, lithiasic acute pancreatitis (n = 19), recurrent pancreatitis (n = 3), stent extraction (n = 2), and post-operative biliary fistula (n = 1). The cannulation success rate was 95.1%. Therapeutic interventions were performed in 79% of ERCP. All patients were followed up as inpatients. Complications were recorded in two procedures (3.1%), and no procedure-related mortality occurred. Conclusion: In our experience, ERCP in children can be safely performed with high success rates by advanced adult-trained expert endoscopists at a high-volume center.