Indications For Endoscopic Retrograde Cholangiopancreatography Research Articles

Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones

IntroductionEndoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. MethodsA retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). ResultsOne hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3–40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272–0.979], an intra-diverticular papilla OR 0.179 [0.035–0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068–0.385] and a stenosis of the common bile duct OR 0.068 [0.008–0.605]. The success rate of the second line treatment was 73%. ConclusionEndoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.

S3081 The Common Clinical Manifestations and Interventions for Post-Pancreaticoduodenectomy-Related Adverse Events

INTRODUCTION: Despite improvements in surgical technique in pancreaticoduodenectomy (PD), postoperative morbidity is still present 30-40% of the time. Thus, as the indications for pancreatic resection have broadened, endoscopic retrograde cholangiopancreatography (ERCP) has become essential in the management of post-PD-related adverse events (AE). In this study, we characterized the common clinical manifestations and interventions performed for post-PD-related AEs. METHODS: We retrospectively evaluated patients with prior classic or pylorus-preserving PD who received ERCP from 01/13/06 - 01/16/19. The pertinent demographic information, oncologic history, and follow-up information were extracted. Outcomes included technical success rate - the ability to treat stricture with dilation or stent placement, and clinical success rate - a documented decrease in bilirubin to normal or 50% of peak value within 2 weeks. Statistical analysis was done using Stata/SE version 16.0. RESULTS: A total of 28 patients (75% male; median age 66 years, range 22-86 years) with prior PD received 66 ERCPs for choledochojejunostomy (25 patients received 63 ERCPs) and pancreaticojejunostomy (3 patients received 3 ERCPs) evaluation. All 3 ERCPs for pancreatic assessment were unsuccessful. PD was most commonly performed for pancreatic adenocarcinoma (n = 15) and pancreatic neuroendocrine tumor (n = 5) [Table 1]. A total of 11 patients received neoadjuvant therapy: 8 had chemoradiation, 3 had chemotherapy only. Most cases were performed with an advanced fellow and had a median duration of 56.5 min (range 12.0-161.0). The most common indications for initial ERCP were cholangitis (n = 15) and biliary obstruction without cholangitis (n = 7). An additional 38 ERCPs were necessary in 9 patients (median 4 ERCPs/patient; range 2-13/patient) most commonly for cholangitis (n = 17) and biliary stricture (n = 10) [Table 2]. All strictures were treated with balloon dilation and a total of 38 stents were placed. The technical success rate was 81.0% (51/63 ERCPs) and the clinical success rate was 76.2% (48/63 ERCPs). Procedure-related-AEs occurred in 5/66 ERCPs (7.6%): 4 cases of self-resolving fever, 1 case of mild cholangitis. CONCLUSION: Patients with prior PD commonly require routine ERCP for the management of postoperative AEs. ERCP is an effective and safe treatment modality for post-PD-related hepatobiliary sequela, but improvements are necessary for pancreatic intervention.Table 1Table 2

Cholangiopancreatoscopy: Expanding the Diagnostic Indications of Endoscopic Retrograde Cholangiopancreatography.

Besides the adverse effects associated with endoscopic retrograde cholangiopancreatography (ERCP), indirect visualization of the biliopancreatic system through fluoroscopy has limited its diagnostic and therapeutic efficacy. Direct visualization through cholangiopancreatoscopy may overcome this limitation and allow the resolution of many dilemmas related to the diagnostic and therapeutic drawbacks of ERCP. Herein, we discuss the current indications of single-operator cholangioscopy (SOC) concerning the diagnostic interventions within the biliopancreatic system. The current role of SOC in the diagnosis of pancreatobiliary stenosis, primary sclerosing cholangitis, intraductal papillary mucinous neoplasm, and pre-surgical mapping of neoplastic lesions were reviewed. There is growing data in the literature supporting the early implementation of SOC in the diagnostic algorithm of pancreatobiliary diseases. In selected cases, this could prevent diagnostic delay and reduce the risks and costs related to repeated ERCPs. This potential characterizes SOC as safety and cost-effective.

Prevalence of Endoscopic Retrograde Cholangiopancreatography Complications and Amylase Sensitivity for Predicting Pancreatitis in ERCP Patients.

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure that is widely used for diagnosis and treatment of biliary and pancreatic diseases. With respect to its growing application, the present study aims to evaluate ERCP outcomes and complications. This cross-sectional study was performed using the data from 824 patients who underwent ERCP during 2014-2017 in Qom Shahid Beheshti hospital. Data were collected by a checklist and analyzed using SPSS V22. Among 824 patients, 397 (48.18%) were male and 427 (51.82%) were female with a mean age of 47 ± 6 years. The most common indications for ERCP were choledocholithiasis (78.28%) and cholestasis (20.27%), respectively. Total prevalence of complications was 15.66% and mortality rate was 0.72%. The most common complications were pancreatitis (9.59%) and bleeding (3.28%), respectively. A serum amylase level of greater than 160 could predict pancreatitis with sensitivity of 93.3% and specificity of 90.3%. Endoscopic retrograde cholangiopancreatography-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high-risk patients may increase the mortality of the procedure.

Endoscopic retrograde cholangiopancreatography (ERCP) in critically ill patients is safe and effective when performed in the endoscopy suite.

Background and study aims Critically ill patients may require endoscopic retrograde cholangiopancreatography (ERCP) but performing ERCP in the intensive care unit (ICU) poses logistic and technical challenges. There are no data on ICU patients undergoing ERCP in the endoscopy suite. The primary aim of this study was to report outcomes, including safety, when ERCP in critically ill patients is performed in the endoscopy suite. Patients and methods We queried our institutional endoscopy database to identify all ICU patients who underwent ERCP at a single academic medical center from 04/01/2010 to 11/30/2017. Only patients admitted to an ICU prior to ERCP were included. Results Of 7,218 ERCPs performed during the study period, 260 ERCPs (3.6 %) were performed in 231 ICU patients (mean age 61y; 53 % male); nearly all ICU patient ERCPs (n = 258; 99 %) occurred in the endoscopy suite. ERCP indications included cholangitis (50 %), post-liver transplant cholestasis (15 %), and bile leak (10 %). All ERCPs were performed with anesthesiology, most with general anesthesia (60 %) and in the prone position (60 %). Most patients (73 %) had sepsis. Prior to ERCP, 17 % of patients required vasopressors; vasopressors were begun during ERCP in 4 %. The cannulation success rate was 95 % (94 % in native papillae). Adverse events occurred in 9 % (n = 23) of cases with post-ERCP pancreatitis most common. No patients died during or within 24 hours of ERCP. Mortality at 30 days was 16 %, all attributed to underlying disease. Conclusions When advanced ventilatory and hemodynamic support is available, critically ill patients can safely and effectively undergo ERCP in the endoscopy suite.

Endoscopic Retrograde Cholangiopancreatography (ERCP) profile of a tertiary care hospital in Peshawar: indications, procedures, and complications

Introduction: Endoscopic Retrograde Cholangio-pancreatography (ERCP), being a useful though technically demanding diagnostic and therapeutic procedure to evaluate and treat diseases of biliary and pancreatic ducts is dependent in large part for its success on the skill of the operator.&#x0D; Objective: To determine the indications, procedures performed and success rate of ERCP at a tertiary care center of Peshawar.&#x0D; Materials &amp; Methods: A descriptive cross-sectional study was carried out at the Endoscopy Unit of Rehman Medical Institute (RMI) from January 2020 to April 2020 using universal sampling technique. All ERCP procedures done in the endoscopy unit from January 2019 to December 2019 were included in the study regardless of their age, gender, ethnicity or presenting complains. Any ERCP that did not have complete data were excluded from the study. Data were collected in a structured Performa. Data were analyzed in Microsoft Excel for descriptive statistics.&#x0D; Results: A total of 161 ERCP procedures were performed during the study duration, of which 84(52.2%) were in males while 77(47.82%) were in females; the mean age was 54.82 ± 15.83 years. Biliary Stent placement (51.6%) was the most commonly performed procedure followed by Biliary Stone extraction (22.4%). Failed ERCP accounted for 30(18.6%) cases. The main indication for ERCP was Obstructive Jaundice (65.8%) followed by Common Bile duct (CBD) stones (42.9%). The least common indication was Dilated Intrahepatic Duct (1.86%). Only 4 cases of minor bleeding were observed during the procedure which were controlled during the procedures. No major complications have been seen on follow-up.&#x0D; Conclusion: Obstructive Jaundice is major contributor to ERCP’s being performed. It is a relatively safe procedure in the hands of an experienced operator.&#x0D; Keywords: Obstructive Jaundice; Retrograde Cholangiopancreatography; Gallstones; Pancreatic Duct.

Criteria for the Selection of Diagnostic Signs of Chronic Pancreatitis with Obstruction of the Main Pancreatic Duct

Introduction. Clinical outcomes of surgery for patients with chronic pancreatitis (CP), considering low rates of 10-year survival, are often unsatisfying for surgeons. Due to the absence of common diagnostic criteria, especially at an early stage of the disease, patients of young and working age undergo surgery at different periods and with different methods. The development of optimal criteria for the selection of diagnostic signs of chronic pancreatitis will improve treatment outcomes.The aim of the study is 1) to perform a comparative assessment of the informative value of methods that specify diagnostics of CP with obstruction of the main pancreatic duct; 2) to develop criteria for the selection of diagnostic signs to highlight the main types of structural changes in the pancreas in chronic pancreatitis with obstruction of the main pancreatic duct.Materials and methods. The study included radiological findings of 231 patients with CP with obstruction of the main pancreatic duct operated from 1996 to 2018 in Omsk regional surgical hospital. X-ray investigations were performed in 120 patients, ultrasound investigations were performed in 231 patients, multislice spiral computed tomography (MSCT) was performed in 226 patients, MRI was performed in 18 patients, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 22 patients and angiography was performed in 5 patients. All patients were divided into two groups: control (n ​​= 88, until 2008) and case (n = 143, after 2008), where new methods of surgery were used and the structure of the applied diagnostic methods has been changed.Results. Ultrasound sensitivity was 74.5%, fistulography/virsungography sensitivity was 80%, MSCT sensitivity was 97.8%, MRI sensitivity was 88.9% and ERPC sensitivity was 95.5%. The use of invasive diagnostic methods in the main group of patients was minimized with the priority of MSCT. The main criteria for the selection of diagnostic signs of CP were determined as follows: obstruction of the main pancreatic duct (with localization at the level of the pancreatic head exclusively or along its entire length), dilatation of the main pancreatic duct (more than 3 mm), local damage to the pancreatic head with an increase in its size over 32 mm, cystic formations (more than 5 mm) in the projection of any part of the pancreas. The main types of structural changes in the pancreas were identified as follows: 1. CP with obstruction of the main pancreatic duct at the level of the pancreatic head exclusively; 2. CP with obstruction of the main pancreatic duct along its entire length with an increase in the size of the pancreatic head; 3. CP with obstruction of the main pancreatic duct along its entire length without an increase in the size of the pancreatic head.Conclusion. 1) MSCT has the highest sensitivity in CP diagnostics (98.6%). MRI (Magnetic Resonance Cholangiopancreatography (MRCP)) complements MSCT and replaces it in case of patients intolerance to contrast media. Indications for ERCP should be minimized. 2) The designed criteria for the selection of diagnostic signs of CP will optimize diagnostics of chronic pancreatitis with obstruction of the main pancreatic duct and highlight the main types of structural changes in the pancreas, the fact being important for validation of surgical treatment methods and techniques.

Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training.

Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P=0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).

Tu1021 COMPARISON OF PERFORMANCE AND ACCURACY OF REVISED 2019 ASGE GUIDELINES IN PREDICTING CHOLEDOCHOLITHIASIS AGAINST 2010 ASGE GUIDELINES: OUTCOMES FROM A LARGE HOSPITAL SYSTEM COMPRISING 14 HOSPITALS

The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients while advocating for using noninvasive studies for intermediate and low risk individuals. Both guidelines recommend direct endoscopic retrograde cholangiopancreatography (ERCP) for ascending cholangitis and choledocholithiasis on imaging. As per 2010 guidelines, total bilirubin > 4 mg/dl and total bilirubin between 1.8 to 4 mg/dl along with dilated bile duct on imaging met criteria for direct ERCP. In 2019 guideline, this was changed to total bilirubin > 4 mg/dl in combination with CBD dilation > 6 mm as an indication for direct ERCP. We aim to compare the performance and diagnostic accuracy of 2019 vs 2010 criteria for predicting choledocholithiasis. From a prospectively maintained database (2013 to 2019) of over 10,000 ERCPs performed by 70 Gastroenterologist’s in our hospital system comprising of 14 hospitals, a random sample of 1400 ERCPs with indication of choledocholithiasis was selected. Data regarding demographics, total bilirubin level, imaging studies such as abdominal ultrasound, computed tomography of abdomen or magnetic resonance cholangiopancreatography (MRCP), Intraoperative cholangiogram (IOC), Endoscopic ultrasound (EUS) and ERCP results were retrospectively collected by chart review. Patients with prior sphincterotomy were excluded. From a random sample of 1400 ERCPs, 843 patients had native papilla and were included in the study. Both 2010 and 2019 guidelines were applied to the same patient population. Overall, 61.2% (518) were deemed high risk and met criteria for direct ERCP as per 2010 guidelines compared to only 37.7% (318) as per revised 2019 guidelines. This difference of 200 patients (24%) was statistically significant as per z statistics comparing two population proportions (p value < 0.001). Choledocholithiasis were found at ERCP in 76.5% (395/518) as per 2010 guidelines, compared to 82.1% (261/318) of those who met the 2019 high risk criteria. Once again, this difference (76.5% vs 82.07%, respectively) was statistically significant (p value < 0.001). In our patient cohort, overall specificity of 2010 guidelines was 46.9% and this improved to 75.0% as per 2019 criteria (Table 1). Our study shows that the strategy proposed by updated 2019 ASGE guidelines is more specific for detection of choledocholithiasis when compared to the 2010 criteria. These findings suggest adherence to the new guidelines would potentially minimizes the procedure adverse events for those individuals who do not meet the high-risk criteria.

Su1450 OUTCOMES OF ERCP IN PATIENTS WITH ACUTE STROKE: A NATIONAL STUDY

There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent acute stroke. The objective of this study is to better assess safety and outcomes in patients with admission for acute stroke that undergo ERCP for a variety of reasons during the same admission in a national inpatient database. The National Inpatient Sample (NIS) is the largest all-payer inpatient database in the United States. Data from the years 2008 to 2014 were collected. Patients older than 18 years with an admission diagnosis of acute stroke (ischemic or hemorrhagic) and who underwent ERCP were included. Case-control matching (2:1) for patients that underwent ERCP but did not have acute stroke was done based on age and sex. Complications related to the ERCP were measured against these case controls. Limitations of the study are that the NIS is an administrative database which predisposes to errors from coding inaccuracies as well as the inability to distinguish temporal relationships between variables. Between 2008 and 2014, there were 562 patients older than 18 years with acute stroke who underwent inpatient ERCP during the same hospital admission. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP occurred more frequently in the stroke group (13.8% vs. 8.7%, p=0.001). The rate of post-ERCP pancreatitis (10.4% vs. 7.4%, p=0.04) as well as post-ERCP bleeding (2.5% vs. 1.2%, p=0.07) was higher in the stroke group compared to the control. The risk of bleeding was not statistically different between groups however. This is outlined in Table 3.The primary indication for ERCP in patients with acute stroke was biliary stricture while that in the control group was biliary pancreatitis (Table 2). Although overall complications are higher in the acute stroke setting, ERCP can be performed when indicated. Caution should be exercised to avoid or minimize complications such as risks of post-ERCP pancreatitis and bleeding. Prospective randomized controlled studies are needed to better define the timing of the ERCP in this setting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk factors for 30-day readmission and indication for ERCP following laparoscopic cholecystectomy: a retrospective NSQIP cohort study.

Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP. We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operativecharacteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention. Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001). Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Prevalence and Factors Associated with Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Children.

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). To assess the prevalence and factors associated with post-ERCP pancreatitis (PEP) in a Chinese pediatric population. Sixty-six children who underwent ERCP between March 2018 and March 2019 at Shanghai Children's Medical Center were retrospectively recruited for the study. Clinical data, including demographics, indications, comorbidities, and procedural data, were reviewed to identify the prevalence and factors associated with PEP. Ninety-two ERCPs were performed on 66 pediatric patients aged from 8months to 14years. The indications for ERCP were chronic pancreatitis (49, 53.2%), pancreaticobiliary maljunction (19, 20.7%), pancreas divisum (19, 20.7%), and pancreatic pseudocyst (5, 5.4%). All ERCPs were performed for therapeutic purposes. PEP was identified in 19 (20.7%) patients; there were ten mild cases, eight moderate cases, and one severe case. The univariate analysis revealed that a history of chronic pancreatitis was negatively associated with PEP (P = 0.033), and sphincterotomy was positively associated with PEP (P = 0.01). The multivariate analysis showed that sphincterotomy was a risk factor for PEP (P = 0.017, OR 4.17; 95% CI, 1.29, 13.54). Our data revealed a high prevalence of PEP in a Chinese pediatric population. Chronic pancreatitis was a protective factor, and sphincterotomy was a risk factor for PEP development.

Endoscopic retrograde cholangiopancreatography results three days after a failed pre-cut.

deep cannulation of the common bile duct is essential in endoscopic retrograde cholangiopancreatography (ERCP). However, cannulation is not possible in approximately 20 % of the cases with the usual techniques. Pre-cutting is an alternative that allows cannulation in difficult cases although its success is not guaranteed. Repeating the ERCP within three days of a failed pre-cut is an acceptable option. to determine if an ERCP performed three days after a failed pre-cut papillotomy allows the bile duct to be cannulated without increasing complication rates. patients who underwent an ERCP plus pre-cut were included, in whom the common bile duct could not be cannulated and who also underwent a new ERCP three days after the initial pre-cut. The primary objective was a successful biliary cannulation in the second ERCP and the secondary objective were the complications of the initial pre-cut. forty patients with an average age of 65 years were identified and 57 % were male. The indications for ERCP were choledocholithiasis in 95 %, biliary fistula in 2.5 % and pancreatic neoplasia in 2.5 %. The ERCP was repeated three days later in 92.5 % of the cases and the biliary cannulation was successful in 78.3 %. a new ERCP performed within three days of a failed pre-cut is justifiable since it has a significant success rate. Bile duct cannulation is achieved in three out of four patients, with an acceptable percentage of complications.

Diagnostic performance of 64-MDCT in detecting ERCP-proven periampullary duodenal diverticula.

To determine the diagnostic performance of 64-slice multidetector computed tomography (64-MDCT) in detecting periampullary duodenal diverticula. Medical profiles of 120 endoscopic retrograde cholangiopancreatography (ERCP)-proven patients with (n = 100) and without (n = 20) periampullary duodenal diverticula who had undergone 64-MDCT were retrospectively reviewed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 64-MDCT in detecting periampullary duodenal diverticula were calculated. Potential factors that might influence the diagnostic performance of 64-MDCT in such patients were also examined. Patients were 60 males and 60 females with the mean age of 68.8 ± 12.7 (27-93) years. Indications of ERCP were common bile duct stricture (n = 62) or stone (n = 41), biliary cholestasis (n = 16) and acute cholangitis (n = 1). The sensitivity, specificity, PPV, and NPV of 64-MDCT in detecting periampullary duodenal diverticula were 76%, 100%, 100%, and 45.5%, respectively. The size of diverticula was the only predictor of 64-MDCT performance, with better results observed in larger (> 20mm) diverticula. 64-MDCT is a highly specific imaging modality in detecting periampullary duodenal diverticula. The diagnostic performance of 64-MDCT increases for larger diverticula.

The synergistic impact of NSAIDs and aggressive hydration therapy on the rate of post-ERCP pancreatitis in high -risk and low -risk patients.

The main complication of Endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Based on demographic characteristics and underlying issues and ERCP indication, patients are categorized as high risk or low risk. There have been no studies on the synergistic effects of NSAIDS and hydration therapy, separately sorted by the risk assessment of PEP in different groups of patients. This study included 281 eligible participants after exclusion. According to demographic characteristics and co-morbidities, the patients were divided to high risk and low risk. The high-risk group was divided randomly into two subgroups and both of them received NSAIDs (100 mg rectal Diclofenac). One group received standard hydration (1.5mg/kg/hr), another the other received aggressive hydration (3mg/kg/h). The low-risk group received standard hydration. One of its subgroups received NSAIDs, while others did not. The efficacy of these preventions was compared across 4 subgroups. The mean age was 59.85±17.17. Eight hours after ERCP, the amylase and lipase were significantly higher in the high-risk group with standard hydration (P=0.00). Amylase, lipase 8 hours, between two low risk subgroups, NSAIDs had no significant effect (P=0.38, P=0.95, respectively). After adjustment based on cannulation, manipulation and duration of time, the results had no change (P=0.64, P=0.19, P=0.61). The aggressive hydration could significantly decrease the risk of PEP. However, the low-risk group was exposed to the lowest risk of PEP. NSAIDs could not help to decrease the rate PEP in the low-risk groups alone. Overall, it seems hydration and NSAIDs therapy had synergistic outcome in high-risk patients.

Endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy in patients with surgically altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) allows a diagnostic and therapeutic evaluation of pancreatobiliary diseases. However, the procedure in patients with surgically altered gastrointestinal anatomy represents a technical challenge. to report the diagnostic and therapeutic outcome of device-assisted enteroscopy (DAE) ERCP in patients with a surgically altered gastrointestinal anatomy. a prospective cohort of patients with a history of surgically altered gastrointestinal anatomy undergoing DAE-ERCP in a referral center was used. A double-balloon enteroscope was used to reach the papillary area or the bilio-enteric anastomosis. The clinical and endoscopic characteristics, and technical, diagnostic and therapeutic success were described. Clinical and endoscopic differences were evaluated according to diagnostic success, as well as the biochemical response in those patients with therapeutic success. ninety-six procedures were included in the study in 75 patients. Roux-en-Y hepaticojejunostomy (RYHJ) was the main surgical anatomy (82.3%) and cholangitis was the main indication for ERCP (49%). Diagnostic success was obtained in 69.8% of the participants. Of these, therapeutic success was obtained in 83.6% (overall success 58.3%). Cases with a diagnostic success had a higher frequency of cholangiography compared to those without diagnostic success (94% vs 0%, p < 0.001), as well as a lower probability of a failed cannulation (1.5% vs 100%, p < 0.001). A significant improvement was observed in patients with a therapeutic success in bilirubin, transaminases and alkaline phosphatase levels (p < 0.05). ERCP by means of double-balloon enteroscopy is a useful technique in patients with a surgically altered gastrointestinal anatomy, in whom access to the bile duct is required. However, these procedures are very challenging and diagnostic and therapeutic success where achieved in up to 60% of cases.

Endoscopic management and clinical outcomes of obstructive jaundice.

This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.

Indications for endoscopic retrograde cholangiopancreatography and cholecystectomy inbiliary pancreatitis.

Indications for endoscopic retrograde cholangiopancreatography and cholecystectomy inbiliary pancreatitis.

Treatment strategies of complicated extrahepatic bileduct stones

Complicated extrahepatic bile duct stone is defined as not easy to achieve the treatment standard of total stone clearance, stricture removal, unobstructed drainage and recurrence preventing in a single operation or combined with other liver diseases, which include hepatic hilar bile duct stones incarceration, distal bile duct stone incarceration, Mirizzi syndrome, residual cystic duct stones, recurrent extrahepatic bile duct stones, and combined with portal hypertension or intrahepatic bile duct stones. Through comprehensive and meticulous preoperative evaluation, we can clarify the cause of extrahepatic bile duct stones, the location of stones and bile duct stenosis, the variability of bile duct, the anatomy of the hepatoduodenal ligament, the condition of liver function and biliary tract infection, and make the proper surgery plan. During the surgery, we apply the perihilar surgical techniques, pancreatic hilar plate reduction techniques, Oddi sphincter incision and shaping, and choledochoscopic lithotripsy and lithotomy comprehensively to achieve the goal of reducing residual stone rate and recurrence rate. It is important that reasonably select endoscopic retrograde cholangiopancreatography indications, correctly hold indications of bilioenteric anastomosis, and prevent iatrogenic injury of extrahepatic bile ducts on the premise of clearing stones. Key words: Hepatolithiasis; Extrahepatic bileduct stone; Perihilar surgical techniques; Pancreatic hilar plate reduction techniques; Choledochoscope; Lithotripsy

79 A Multi-Center Comparison of Proceduralist Versus Radiology Technician-Driven Fluoroscopy in Endoscopic Retrograde Cholangiopancreatography: Best When You Do It Yourself!

INTRODUCTION: Patients are exposed to radiation during endoscopic retrograde cholangiopancreatography (ERCP) which may increase the cumulative risk of the development of cancer and/or of other radiation-related adverse events. ERCP utilizes radiological guidance to direct diagnosis and therapy of biliary and pancreatic pathology. There is limited data available evaluating if the amount of radiation directed to the patient during ERCP is different by endoscopist-directed fluoroscopy versus when ERCP is assisted by radiology technician. Our aim was to assess the difference in the dose of radiation administered to the patient when fluoroscopy during ERCP is operated by the endoscopist versus the radiology technician. METHODS: This is an IRB-approved multi-center retrospective chart review of patients who underwent ERCP between 07/2017 and 11/2018 at three high-volume academic centers. Patient-specific data was collected including demographics, cholecystectomy status and indication for ERCP. Procedural and fluoroscopic data were also obtained. Descriptive and inferential analyses were performed utilizing SPSS software. RESULTS: During the study period, a sample of 100 patients that underwent ERCP performed with radiology technician (RT) assistance (two tech-driven institutions; n = 50 each) and a sample of 50 patients with endoscopist-led fluoroscopy (ELF) were compared. Patient characteristics are summarized in Table 1. The most common indication for ERCP was choledocholithiasis (n = 26 vs. 24, RT vs ELF, respectively). Mean procedure time (34.6 vs. 26.6 min, RT vs. ELF; P = 0.056) and mean fluoroscopy time (5.2 vs. 4.9 min, RT vs. ELF; P = 0.897) were similar in both groups. The ELF group obtained a significantly greater number of images during ERCP (RT 9.9 vs. ELF 14.6, P &lt; 0.001). The mean dose of radiation (Gy/cm2) administered to the patient was significantly higher in the RT group (RT 40.6 vs. ELF 20.3; P = 0.016). CONCLUSION: Endoscopist-driven fluoroscopy during ERCP is associated with lower radiation dose compared to radiology technician assisted fluoroscopy at high volume ERCP centers. Endoscopists are also better at saving more images during an ERCP. Future education and training of radiation technicians may help reduce the radiation to the patients.