Indications For Endoscopic Retrograde Cholangiopancreatography Research Articles

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 < 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.

42 Safety of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients With Age ≥80: A Nationwide Analysis

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a necessary procedure for exploration and management of pancreaticobiliary ductal system disorders. Safety of ERCP in the elderly population with more underlying co-morbidities remains a concern. We aimed to study if ERCP, particularly for biliary calculus (BC)-related indications, is associated with higher complications including mortality in patients with age ≥80. METHODS: We performed a retrospective analysis using data from the National Inpatient Sample (NIS) from the year 2016. We included all adult patients admitted with BC who underwent ERCP, and we further identified those with concurrent pancreatitis and/or cholangitis, using ICD-10-CM codes. Patients with missing information on age, gender or inpatient mortality were excluded. We analyzed patients by two groups: age <80 and ≥80 years. Chi-square analysis and t-tests were used to compare categorical and continuous variables, respectively. Predictors of ERCP-related complications, including inpatient mortality, were assessed by multivariable logistic regression analysis. RESULTS: Total of 102,095 patients were included in the study who underwent ERCP for BC related etiology, out of which 20,530 (20.1%) were patients age ≥80 years. In the age ≥80 group, mean age was 85.4 years, and 56.5% patients were female. Unadjusted mean length of stay (6.3 vs. 5.3 days), hospitalization costs ($75,326 vs. $72,110) and inpatient mortality (2.2% vs. 0.8%) were significantly higher in patients with age ≥80. BC without pancreatitis or cholangitis was the most common indication for ERCP in both groups. Prevalence of complications related to ERCP were comparable between two groups except for cardiorespiratory complications and mortality (Table 1). On multivariate analysis, patients with age ≥80 had statistically no significant difference in complications in compared to patients with age <80 years (aOR: 0.96, 95% CI 0.92–1.01, P = 0.133). Among all patients, ERCP performed for biliary pancreatitis (BP) had 70% lower rate of complications while ERCP for cholangitis had 26% higher rate compared to ERCP for simple BC (Table 2). CONCLUSION: In the United States, about 1 in 5 ERCP for BC are performed in patients with age ≥80. Overall, BP is associated with significantly lower risk of complications. Among patients undergoing ERCP for BC-related indications, patients with age ≥80 do not carry a higher risk of ERCP-associated complications.

924 How Successful Is Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction Post-Pancreaticoduodenectomy?

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is the accepted therapy for the management of biliary obstructions, however, in patients who have had previous pancreaticoduodenectomy (PD) (i.e. Whipple’s procedure), due to the altered surgical anatomy, the ability to perform ERCP is challenging. In this study, we examine our experience at a large tertiary cancer-center in performing ERCPs for biliary obstructions in patients who are post-PD. METHODS: This was a retrospective review from 2006 to 2018 of all patients referred for the management of biliary obstructions post-PD. Outcomes included technical success (ability to treat the stricture, e.g. dilation or placement of a stent) and clinical success (decrease in bilirubin to normal or 50% of peak value within 2 weeks) rates. RESULTS: A total of 66 patients were included in the study. The mean age was 67.7 years (SD +/- 11.6) and 58 patients (87.9%) were male. The most common indications for PD were duodenal adenocarcinoma (20 patients, 30.3%) followed by pancreatic adenocarcinoma (16, 24.4%). In terms of surgery, the mean length of the afferent limb was 45.7 cm (SD +/- 6.34). The most common indications for ERCP were cholangitis (31 patients, 49%), followed by a biliary obstruction without cholangitis (11, 16.7%). The mean length of procedure was 66.7 minutes (SD +/- 34.8). The hepaticojejunostomy (and/or choledochojejunostomy) was reached in 56 patients (84.8%). The most common endoscope used was a therapeutic upper endoscope (31 patients, 47%), followed by a regular upper endoscope (11, 16.7%) and a pediatric colonoscope (10, 15.2%). Cannulation of the biliary tree was successful in 55 patients (83.3%). The most common location for the stricture was at the anastomosis (41 patients, 80.4%), followed by distal extra-hepatic (8, 15.7%). Successful stents were placed in 31 patients (47%). There were no episodes of bleeding, perforation or pancreatitis post-ERCP. Four patients developed self-resolving fever post-procedure. The technical success rate was 75.8% (50 patients) while the clinical success rate was 71.2% (47 patients). CONCLUSION: ERCP post-PD can be challenging due to the surgical anatomy and inability to use common endoscopes and instruments. Our study demonstrates that nevertheless, endoscopic biliary decompression can still be successful by experienced endoscopists in the majority of patients post-PD, with minimal adverse events.

885 Outcomes of ERCP in Patients With Acute Myocardial Infarction: A National Study

INTRODUCTION: There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction. The objective of this study is to better assess safety and outcomes in patients with admission for acute myocardial infarction (MI) that undergo ERCP for a variety of reasons during the same admission in a national inpatient database. METHODS: 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 myocardial infarction and who underwent ERCP were included (n = 259). Case-control matching (3:1) based on age and race were selected (n = 762). Mortality, length of stay, cost of hospitalization, and complications were measured against case controls. RESULTS: Between 2008 and 2014, there were 259 patients older than 18 years with acute myocardial infarction who underwent inpatient ERCP. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP were infrequent though the rate of post-ERCP bleeding was higher in patients with recent MI compared to controls (4.2% vs. 1.6%; P = 0.012). Rates of cholecystitis, post-ERCP pancreatitis and perforation were not different between groups. There was no significant difference in mortality between patients that had recent MI vs those who did not (4.6% vs. 2.5%, P = 0.083). Length of stay was higher in patients with recent MI (median 9 days vs. 5 days, P < 0.001). Cost of hospitalization was also significantly higher in the MI group ($22,197.86 vs. $25,937, P < 0.001). The primary indication for ERCP in patients with acute MI was choledocholithiasis while that in the control group was cholangitis. Furthermore, the time to ERCP (emergent, urgent or delayed) did not significantly affect the risk of mortality and post-ERCP hemorrhage. CONCLUSION: Patients with acute MI that undergo ERCP during the same admission have a higher risk of post-ERCP hemorrhage with longer LOS and cost of hospitalization. However, the mortality and other ERCP-related complications are not significantly different when compared to patients undergoing ERCP without recent MI. Therefore, in general it would be considered safe to perform ERCP in patients with recent MI with precautions to monitor or prevent post-ERCP bleeding.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in pregnancy: A high-volume study with long-term follow-up.

Pancreaticobiliary diseases are observed more frequently in pregnancy due to increased biliary stone formation. There are some concerns about the use of endoscopic retrograde cholangiopancreatography (ERCP) because of potential fetal exposure to radiation and serious adverse events, such as post-ERCP pancreatitis, which increases fetal or maternal morbidity and mortality. The aim of this study was to evaluate the efficacy and safety of ERCP during pregnancy and to present our experience. This study included 25 pregnant patients who underwent ERCP due to biliopancreatic pathologies between 2010 and 2017. Indications for ERCP were choledocholithiasis (n=12), biliary pancreatitis (n=9), and acute cholangitis (n=4). ERCP procedures were performed using fluoroscopy (n=18) and the non-radiation technique (n=7). The duration of fluoroscopy was recorded in all cases. Fetal and maternal complications were both assessed. The mean age of patients was 29.4 (range, 21-40) years, and the mean duration of pregnancy was 19.9 weeks. All the 25 ERCP procedures were performed successfully. Biliary sphincterotomy was performed in all patients, and 18 patients with choledocholithiasis underwent stone extraction. The average procedure duration was 11 min, and the average duration of fluoroscopy was 6 s. There were no major complications in any patient. After the deliveries, the newborns were apparently healthy during the follow-up period of 1-7 years. Either conventional or non-radiation ERCP procedures can be performed successfully in pregnancy, with no increase in the number of feto-maternal complications when performed by experienced endoscopists.

Endoscopic treatment of biliary complications after duct-to-duct biliary anastomosis in pediatric liver transplantation.

Studies reporting outcomes of endoscopic treatment methods in children who underwent liver transplantation (LT) is very limited. We present our outcomes, as a high-volume transplant center where endoscopic methods are preferred as the first choice in the treatment of biliary complications in children. Patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) as the first treatment approach for biliary complications after LT between 2005 and 2017 were included. Clinical data included patient demographics, ERCP indications (stricture or leak), and treatment outcomes, including the need for percutaneous and surgical intervention. ERCP was performed in 49 patients who had a duct-to-duct anastomosis (38 living donor liver transplantation (LDLT), 11 deceased donor liver transplantation (DDLT)). The most common biliary complication was stricture. Our endoscopic success rate was 66.7% (18/27) and 75% (6/8) in LDLT and DDLT patients with stricture (p > 0.05), respectively. While our endoscopic success rate was 75% (3/4) in patients with leak alone after LDLT, it was 25% (1/4) in patients with leak and stricture in this group. The endoscopic success rate was 50% in two patients who had leak alone after DDLT. ERCP should be considered as a preferential treatment option for the management of biliary complications in pediatric liver transplant patients with duct-to-duct anastomosis, as in adults.

713 THE USE OF ERCP IN THE LAST DECADE

With the advent of newer imaging modalities, the indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed within the last decade. Data has shown that the use of ERCP continues to increase. Common bile duct stones and biliary strictures are among the most common indications for ERCP. However, these studies are older and may exhibit trends prior to many recent advances in the world of therapeutic and diagnostic endoscopy. Thus, the aim of this study is to assess the inpatient prevalence of ERCP, outcomes, and the most common indications.

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUNDPancreaticobiliary maljunction (PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct (CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum (PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition. Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARYA boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSIONWe consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases, especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BackgroundIndication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging. AimsIn this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers. MethodsClinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed. ResultsThere were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)]. ConclusionOptimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.

Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation

This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy-related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27-79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups (P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2-6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group (P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.

ERCP-related perforation: an analysis of operative outcomes in a large series over 12years.

Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24h of ERCP. Twenty patients underwent delayed surgery (after 24h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.

Endoscopic Retrograde Cholangiopancreaticography in Children: A Single-center Experience From Northern India

To evaluate spectrum, efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) in pediatric population. Retrospective case record review of pediatric patients (age ≤15 y) undergoing ERCP between January 2011 to June 2015 at a tertiary care referral hospital in New Delhi, India. The Indications for ERCP, cannulation success rate, procedure success rate and complications were recorded. The mean (SD) age of the participants were 11.5 (3) years. 164 ERCP procedures were done in 126 patients (67 males). All procedures were done under conscious sedation. The common indications for ERCP were choledocholithiasis (50, 30.5%), chronic calcific pancreatitis (38,23.2%), main pancreatic duct injury with leak (21,12.8%), and bile leak (12,7.3%). The cannulation success rate was 90.4% (114 out of 126), while procedural success rate was 86% (141 out of 164). Overall 8 complications were encountered; all were successfully managed conservatively. ERCP in children can be successfully performed at centers with such expertise.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement.

To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals. We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate. Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5days vs. 140.5days, p < .0001). Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

ERCP in infants, children, and adolescents-Different roles of the methods in different age groups.

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children.MethodsData were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records.ResultsWe performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations.ConclusionsOur study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.

Prospective evaluation of ERCP performance in an Italian regional database study

BackgroundProspective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare. AimTo assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice. MethodsProspective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered. Results38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed. ConclusionsThe procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting.

Endoscopic retrograde cholangiopancreatography in the management of biliary complications after orthotopic liver transplantation.

biliary complications are frequent after orthotopic liver transplantation and the management of these complications with endoscopic retrograde cholangiopancreatography (ERCP) is available. The aims of the study were to analyze the experience in the endoscopic management of biliary complications after liver transplantation in a third level center. Furthermore, the factors associated with higher rates of technical and clinical success were determined. this was an observational retrospective study of ERCPs performed in patients with biliary complications after liver transplantation between February 2012 and January 2017. The factors analyzed were: demographics, time between transplantation and ERCP, indications for ERCP, strategy of stenting (only plastic stents, only self-expandable metallic stents, plastic followed by metallic stents and metallic followed by plastic stents), technical and clinical success and complications. one hundred and sixty-eight endoscopies were performed in 58 patients. Thirty-three patients (56.9%) presented with early complications. The most frequent indication for ERCP was anastomotic stenosis (57.8%). Technical success in the first ERCP was achieved in 43 patients (74.1%). Early onset of biliary complications was associated with higher rates of technical success (OR: 6.49; p: 0.036). Clinical success was obtained in 36 cases (62.1%). Patients with early complications had a higher probability of having good clinical response (OR: 11.16; p: 0.033). The results were worse in patients with only plastic stents (50% of clinical success). Eleven complications were observed among 168 ERCPs (6.54%), including two pancreatitis, five bleeding events, three cholangitis and one micro-perforation. ERCP is safe and useful in the management of biliary complications after liver transplantation. Early onset of complications is associated with better results. Some patients will need repeated procedures to obtain a good clinical response.

The impact of selective serotonin receptor inhibitors on post-endoscopic sphincterotomy bleeding, alone or with concurrent aspirin or nonsteroidal anti-inflammatory drugs.

Background:Observational studies have shown an increased risk of upper gastrointestinal bleeding in users of selective serotonin receptor inhibitors (SSRIs). We retrospectively investigated the impact of SSRIs, alone or combined with aspirin (ASA) or nonsteroidal anti-inflammatory drugs (NSAIDs), on the incidence of post-endoscopic sphincterotomy (post-ES) bleeding.Methods:A total of 3058 patients were included. Of these, 457 patients received SSRIs, alone or plus ASA or NSAIDs, until the day of ES (SSRIs group), while 2659 patients (non SSRIs group) had never been on SSRIs (n=1925), though some had been on ASA (n=613) or NSAIDS (n=121). Patient assessment included indication for endoscopic retrograde cholangiopancreatography (ERCP), comorbid diseases, detailed drug history before and after ES, procedural details, and risk factors for post-ES bleeding. Primary outcome was defined as the incidence, type and severity of post-ES bleeding.Results:There was no statistical difference in age, sex, indication for ERCP, comorbid diseases, technical characteristics or results of therapeutic ERCP between the 2 groups. The incidence of post-ES bleeding was 3.9% in the SSRIs group and 3% in the non SSRIs group, a difference not statistically significant (P=0.754). Likewise, there was no difference in type (P=0.145) or severity of bleeding (P=0.754) between the 2 groups. Multivariate analysis showed the precut technique as the only independent risk factor for post ES hemorrhage (odds ratio 2.56, 95% confidence interval 1.23-3.63; P=0.001).Conclusion:This study found that SSRIs, alone or combined with ASA or NSAIDs, had no influence on the incidence or the severity of post-ES bleeding.

Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events

AIMTo investigate indications and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events.METHODSWe performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017.RESULTSA total of 6,505 patients from 15 studies were analyzed (male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58% (95%CI: 2.77-6.75%, I2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95%CI: 1.83-6.00%, I2 = 89.5%), cholangitis in 1.93% (95%CI: 0.63-3.71%, I2 = 87.1%) and perforation in 0.00% (95%CI: 0.00-0.23%, I2 = 37.8%). Six studies were used for comparison of ERCP-related complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63 (95%CI: 1.27-2.09, I2 = 65%): higher rates of hemorrhage with OR of 2.05 (95%CI: 1.62-2.58, I2 = 2.1%) and PEP with OR of 1.33 (95%CI: 1.04-1.70, I2=65%), but similar cholangitis rates with OR of 1.23 (95%CI: 0.67-2.26, I2 = 44.3%).CONCLUSIONThere is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.

Endoscopicretrograde cholangio-pancreatography management of long-term complications after pancreaticoduodenectomy

Objective: To investigate the feasibility and effectiveness of endoscopicretrograde cholangio-pancreatography(ERCP)in the management of long-term complications after pancreaticoduodenectomy. Methods: From January 2009 to July 2018, the clinical data of 62 patients with biliary or pancreatic long-term complications after pancreatoduodenectomy were reviewed at Department of General Surgery, and the corresponding ERCP were carried out in the multi-disciplinary cooperation.There were 39 males and 24 females.The age was 56.5 years(aging from 13 to 76 years). The time of treatment was 3 months to 20 years after pancreatoduodenectomy.The long-term biliopancreatic complications after pancreatoduodenectomy included 51 cases of biliary calculi, 42 cases of bilioenteric anastomotic stenosis with proximal bile duct dilatation, and 11 cases of pancreaticointestinal anastomosis stenosis with distal pancreatic duct dilatation.All patients received conventional duodenoscopy or single-balloon enteroscopy assisted ERCP under general anesthesia. Results: A total of 95 ERCP were performed in 62 patients, averaging 1.5 times per case.The long-term complications of cholangiopancreatic after pancreatoduodenectomy(ERCP indications) included 56 times of bile duct stones(58.9%), 45 times of bilioenteric anastomatic stricture(47.4%), 11 times of recurrent pancreatitis(11.6%), 6 cases(6.3%) of bilioenteric anastomatic foreign body, 3 times of intrahepatic bile duct stenosis(3.2%). Among the 95 times, 82 times(86.3%) achieved endoscopic endoscopy, 76 times(80.0%) were diagnosed successfully, and 72 times(75.8%) were successfully treated with ERCP.Small intestinal perforation occurred in 1 patient undergoing duodenoscopy, and then healed by surgical repair. Conclusion: Multi-disciplinary collaboration of ERCP is safe and effective in the treatment of long-term complications after pancreaticoduodenectomy, but the long-term effect still needs further clinical follow-up.

Chinese guidelines for ERCP (2018)

Endoscopic retrograde cholangiopancreatography (ERCP) was reported for the first time in 1970s. Since then, ERCP has become an indispensable procedure in the diagnosis and management of a variety of biliary and pancreatic disorders. The main purpose of Chinese ERCP guideline is to precisely define the clinical indications of ERCP. In this guideline, all recommendations were based on reviewed studies and graded on the strength of supporting evidence by GRADE criteria. ERCP is particularly appropriate in the management of patients with biliary obstruction caused by choledocholithiasis and other benign or malignant disorders. Meanwhile, a variety of benign or pancreatic disorders can be diagnosed and treated with ERCP. Plastic or metal biliary and pancreatic stents are primarily used to establish patency of an obstructed bile or pancreatic duct. Last but not least, it is very important to fully understand the potential complications of ERCP. Early recognition and immediate management of adverse events are critical to reduce procedure related morbidity and mortality.