Indications For Endoscopic Retrograde Cholangiopancreatography Research Articles

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

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.

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.

A78 BILIARY STENT USE IN ERCP: A QUALITY ASSURANCE STUDY ASSESSING ADHERENCE TO CLINICAL GUIDELINES AND COST OUTCOMES

Abstract Background A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy. Purpose To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost. Method A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes. Result(s) A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%). Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000. Conclusion(s) Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A129 A RETROSPECTIVE ANALYSIS OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH PANCREATICODUODENECTOMY

Abstract Background Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP). Post-surgical anatomy frequently encountered in clinical practice that affects ERCP success includes Billroth II, roux-en-y gastric bypass, roux-en-y hepaticojejunostomy and pancreaticoduodenectomy (PD). While ERCP has a success rate of 90-95% in patients with native anatomy, the data is less robust in patients with PD anatomy. Advancement of the endoscope to the surgical anastomoses remains challenging as PD anatomy requires accurate identification of the afferent limb, and encourages acute bowel angulation and loop formation. In addition, navigation to the anastomosis may be more challenging with a sideviewing endoscope. Although forward viewing endoscopes may more readily reach the surgical anastomosis, cannulation may be difficult without an elevator or device-appropriate instruments. As a result, a retrospective analysis of technical and clinical success rates in ERCP was analyzed in post-PD patients. Purpose The purpose of this study was to evaluate the technical and clinical success of ERCP in patients with post-PD anatomy. Method A retrospective analysis was conducted on all patients with post-PD anatomy referred to our institution between 2006 to 2021 for ERCP. Demographic and procedural details including gender, age, indications, primary malignancy, and anastomosis identification were collected. Major outcomes included technical success (TS) rate (successful biliary or pancreatic intervention) and clinical success (CS) rate (improvement in patient symptomatology or normalization of bilirubin level). Result(s) A total of 47 patients underwent 102 ERCPs for biliary (n = 98; 96.1%) and pancreatic (n = 4; 3.9%) indications. There were 31 (66.0%) male patients and 16 (34.0%) female patients. The average age of patients was 61.5 years. The most common primary malignancies included pancreatic adenocarcinoma (n = 26; 55.3%), pancreatic neuroendocrine tumour (n = 5; 10.6%), and ampullary adenocarcinoma (n = 4; 8.5%). The most common indications for ERCP included obstructive jaundice (n = 22; 21.6%), stent evaluation (n = 30; 29.4%), and cholangitis (n = 35; 34.3%). Surgical anastomosis was identified in 90 (88.2%) patients. The overall TS and CS rates were 82.4% and 75.5%, respectively. When adjusted for anastomosis identification, the overall TS and CS rates were 93.3% and 82.2%. Conclusion(s) Despite the challenges of conducting ERCP in patients with post-PD anatomy, this retrospective analysis demonstrates an adequate overall TS and CS rate. Although endoscope advancement to the surgical anastomoses may be challenging, TS and CS rates improved if the anastomosis was reached and identified. The advent of endoscopic enteroenterostomy formation, balloon-assisted enterscopy, and rigidizing overtubes may assist in reaching surgical anastomoses. As a result, consideration should be undertaken to attempt ERCP in post-PD patients. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Association between type of major duodenal papilla and difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography in adults: a cross-sectional study with bootstrap method.

The type of major duodenal papilla could be associated with difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography (ERCP) in adults. This retrospective cross-sectional study included patients undergoing ERCP for the first time by an expert endoscopist. We defined the type of papilla according to the endoscopic classification of Haraldsson in type 1-4. The outcome of interest was difficult biliary cannulation, defined according to the European Society of Gastroenterology. To assess the association of interest, we calculated crude and adjusted prevalence ratios (PRc and PRa, respectively) and their respective 95% confidence intervals (CI) using Poisson regression with robust variance models, employing bootstrap methods. For the adjusted model we included the variables age, sex, and indication for ERCP, according to an epidemiological approach. We included 230 patients. The most frequent type of papilla was type 1 (43.5%), and 101 (43.9%) of the patients presented difficult biliary cannulation. The results were consistent between the crude and adjusted analyses. After adjusting for age, sex, and ERCP indication, the prevalence of difficult biliary cannulation was highest in patients with papilla type 3 (PRa 3.66, 95%CI 2.49-5.84), followed by patients with papilla type 4 (PRa 3.21, 95%CI 1.82-5.75), and patients with papilla type 2 (PRa 1.95, 95%CI 1.15-3.20) compared to patients with papilla type 1. In adults undergoing ERCP for the first time, patients with papilla type 3 had a greater prevalence of difficult biliary cannulation than patients with papilla type 1.

Safety and indications for endoscopic retrograde cholangiopancreatography in liver transplant patients: an analysis of the United States' National Inpatient Sample database.

Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients. We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10th revision. Multivariate logistic regression analysis was conducted to determine the odds of post-ERCP complications in liver transplant recipients. Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% vs. 0.53%, respectively). However, the adjusted odds of post-ERCP pancreatitis (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.86-1.49; P=0.36) and bleeding (aOR 1.41, 95%CI 0.58-3.46; P=0.45) were similar in both the liver transplant and no-transplant groups. There was no difference in the odds of post-ERCP cholangitis (aOR 1.26, 95%CI 0.80-2.01; P=0.32), and sepsis (aOR 0.94, 95%CI 0.66-1.34; P=0.76) between liver transplant and no transplant groups. Biliary stricture was the most common indication for ERCP in the liver transplant group, whereas choledocholithiasis was the main reason for ERCP in the general adult population. ERCP is a safe procedure for treating biliary complications in liver transplant patients. The odds of post-ERCP complications (pancreatitis, bleeding, sepsis, cholangitis) in liver transplant patients are comparable to those in patients with no transplantation.

Diagnosis and Management of ERCP Complications: The Results of 15000 Cases from Two Centers

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a method of diagnosing and treating pancreaticobiliary diseases. ERCP differs from other endoscopic procedures with a greater risk of developing complications. The study aims to share experiences in diagnosing and managing complications in 15000 ERCP cases performed by two general surgeons in two separate general surgery ERCP units in 13 years and to determine appropriate diagnosis and treatment approaches in patients with complications. Materials and Methods: This study retrospectively evaluated the data of 15000 patients who underwent ERCP with various diagnoses between June 2009 and June 2022 in General Surgery Clinics in two different centers. Age, sex, ERCP indications, comorbidity, and clinical findings of the patients were recorded. Results: All patients who underwent ERCP were divided into two groups according to the incidence of complications. The patients who developed complications had higher ages, hospitalization days, and intensive care unit admission rates. Comorbidity increased the rate of complication development: amylasemia and acute pancreatitis were the most developed complications, respectively. Women developed more post-ERCP pancreatitis (PEP). Pre-incision, the number of ERCPs applied was not found to affect PEP development. Choledochal stone was the most important indication for ERCP in patients who developed PEP. Conclusion: ERCP is an invasive procedure, and complications such as acute pancreatitis, hemorrhage, perforation, cholangitis, and cholecystitis develop after this procedure. Determining these complications and related risk factors will be beneficial in terms of patient satisfaction and health expenditures.