Number Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives.

Background and study aims Therapeutic EUS (t-EUS) is increasingly being adopted in clinical practice in tertiary referral centers; however, little is known about radiation exposure (RE) metrics and diagnostic reference limits for it. Methods Kerma-area product (KAP [Gy·cm 2 ]), Air Kerma and fluoroscopy time were retrospectively evaluated for all consecutive t-EUS procedures performed in San Raffaele Institute between 2019 and 2021. For EUS-guided choledochoduodenostomies (EUS-CDS) and gastroenterostomies (EUS-GE), an equal number of endoscopic retrograde cholangiopancreatographies (ERCPs) plus metal stenting and duodenal stents were included respectively for comparison. Results Data from 141 t-EUS procedures were retrieved (49 % pancreatic cancer, 38 % peripancreatic fluid collections). EUS-CDS (N = 44) were mainly performed fluoroless, while ERCPs required a significantly higher RE (KAP = 25 [17–55], P < 0.0001). Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 [13–45]). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3–21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 [28–88] versus 29 [19–46], P = 0.03). EUS-guided hepaticogastrostomies (EUS-HGS, N = 10) had the highest RE among t-EUS procedures (KAP = 81 [49–123]). Procedure complexity or intervening complications were evaluated and resulted in higher RE within each procedure. Conclusions t-EUS procedures have different RE ( P < 0.000001). EUS-CDS, EUS-GBD, and EUS-FCD with LAMS can be performed with no-to-mild radioscopy, unlike standard alternatives. However, radioscopy remains essential in case of technical difficulties or complications. EUS-GE and EUS-HGS involve a high RE. Endoscopists involved in t-EUS might experience RE higher than category standards, which indicates a need for increased awareness and personalized preventive measures.

Long-term Follow-up of Patients Undergoing Endoscopic Intervention for Abdominal Pain with Minimal Biliary Ductal Dilation, Stone Disease, or Malignancy.

Safety and efficacy of endoscopic methods in management of biliary colic after cholecystectomy in patients with minimal biliary ductal dilation and no evidence of biliary stones or malignancy have not been clearly demonstrated. This study aimed to assess the efficacy of endoscopic management of such patients. The University of Louisville database was queried for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for colicky abdominal pain between 1996 and 2016 who had a common bile duct (CBD) diameter of ≤12mm. All patients had undergone prior cholecystectomy and were free of malignancy. Demographic, serologic, procedural, and outcome variables were assessed. A total of 35 patients underwent a total of 99 ERCPs. Median CBD diameter was 10 (range 4-12) mm. A total of 31 patients (89%) underwent sphincterotomy, 28 (80%) underwent stent placement, and 5 (14%) underwent balloon dilation. The median number of ERCPs performed was 2 (range 1-10). Three of the 35 patients (9%) developed post-ERCP pancreatitis at some point during their treatment. At last follow-up since initial ERCP (median 16 months, range 2.4-184 months), 12 (34%) patients endorsed abdominal pain and 11 (31%) reported experiencing nausea. For select patients with abdominal pain in the setting of minimal CBD dilation and no evidence of stone disease or malignancy, ERCP can safely and effectively be used to manage symptoms. While patients may require multiple interventions, they can derive long-term relief from these procedures.

Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer.

BACKGROUNDBiliary ductal cancer (BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography (ERCP) sessions, etc.] are unknown.AIMTo clarify what constitutes an adequate method for biliary biopsy.METHODSIn total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group (P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group (N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups.RESULTSThe numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions (one/two), P group 72/4 vs N group 15/4, P value = 0.048; number of biliary biopsies, P group 2 (1-6) vs N group 2 (1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies.CONCLUSIONThis study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods (Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.

Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All

Bacteremia due to cholangitis can occur as a complication of biliary instrumentation. Biliary sepsis can result from frequent endoscopic retrograde cholangiopancreatography (ERCP). We hypothesized that routine use of antibiotics in patients who require frequent ERCPs leads to cholangitis resistant to empiric antibiotics used to treat biliary sepsis. We retrospectively reviewed patients with frequent biliary instrumentation and blood stream infection due to cholangitis. Conventional empiric antibiotics were defined as broad-spectrum antibacterial agents predominantly used for community-acquired infections and surgical prophylaxis. Broad-spectrum antibacterial agents used for hospital-onset/multidrug-resistant infections were defined as broad-spectrum MDR antibiotics. Seventy-eight patients had bacteremia secondary to cholangitis from biliary obstruction. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis. Thirty-seven patients did not receive post-procedural antibiotics and forty-one patients did. Of the ones who did, 58% later had a bloodstream infection with bacteria resistant to the antibiotic used for prophylaxis, and 26 patients (63%) required a broad-spectrum MDR antibiotic for treatment. The number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broad-spectrum MDR antibiotics for treatment of cholangitis-associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend toward need for broad-spectrum MDR antibiotics for cholangitis-associated bacteremia, Chi-square 3.7, 0 0.0540. Bacterial resistance to conventional empiric antibiotics is an emerging problem. Blood cultures are needed to guide therapy.

Evaluation of Biliary Bacterial Resistance in Patients With Frequent Biliary Instrumentation: One Size Does Not Fit All

Introduction: Bacteremia due to ascending cholangitis can be encountered as a complication of biliary instrumentation. Patients who undergo frequent endoscopic retrograde cholangiopancreatography (ERCP) usually receive periprocedural prophylactic antibiotics.Table: Demographics and clinical characteristics.Methods: This is a retrospective review of patients with more than one ERCP, and bacteremia due to ascending cholangitis. Conventional empiric antibiotics were defined as ciprofloxacin, penicillins alone or first or second-generation cephalosporin. Antibiotics with broader spectrum were defined as wide spectrum. Results: A total of 140 patients over a period of 6 years were reviewed. Sixty-two patients were excluded due to bacteremia secondary to other source. Patient characteristics are described in table 1. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis (ciprofloxacin or 1st or 2nd generation cephalosporin). Forty-one patients received post procedural antibiotics for one week starting from the day of the procedure, of those 58% grew bacteria resistant to the antibiotic used for prophylaxis and 26 patients (63%) required a wider-spectrum antibiotic for treatment. Number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broader-spectrum antibiotics for treatment of ascending cholangitis associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend towards need for wider-spectrum antibiotics for ascending cholangitis associated bacteremia, chi-square 3.7, P= 0.0540. Conclusion: Biliary bacterial resistance to conventional empiric recommended antibiotics is an emerging problem, and consideration for wider spectrum antibiotics should be made in certain patients, particularly in patients with prior antibiotic exposure. Blood cultures are needed to guide therapy.

The utility and yield of endoscopic ultrasonography for suspected choledocholithiasis in common gastroenterology practice.

Endoscopic ultrasonography (EUS) is an established diagnostic modality for diagnosing common bile duct (CBD) stones. Its use has led to a reduction in the number of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for suspected choledocholithiasis. We aimed to explore the role of EUS in detecting CBD stones and/or sludge in common gastroenterology practice. We reviewed case records of 268 consecutive patients who underwent (EUS) procedures performed to confirm or rule out the presence of CBD stones and/or sludge between November 2006 and January 2011 in the Reinier de Graaf Hospital, Delft, The Netherlands, which is a nonacademic community hospital. On the basis of EUS findings, 169 of 268 (63%) patients did not undergo ERCP and were therefore not exposed to its risk of complications. Patients with positive findings on EUS (n=99) all underwent ERCP and endoscopic sphincterotomy. Only 57 of 99 (58%) had positive findings at ERCP. The main contributing factors to this finding seem to be time interval between EUS and ERCP and the type of CBD content (i.e. sludge, one CBD stone or more than one CBD stone) described. In our common gastroenterology practice, EUS plays an important role in selecting patients suspected to have CBD stones or sludge for ERCP. Much is to be learned about the probability of spontaneous passage of CBD stones and sludge into the duodenum.

Endoscopic papillary large balloon dilation for bile duct stones in elderly patients.

To investigate whether endoscopic papillary large balloon dilation (EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A (< 80 years) and group B (≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies (ERCP), and incidence of complications were examined in both groups. Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent (P < 0.05). The success rate of the initial lithotomy was 88.7 (94/106)%. The final lithotomy rate was 100 (106/106)%. Complications due to treatment procedure occurred in 4.72 (5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B. EPLBD can be safely performed in elderly patients, the same as in younger patients.

Early Postoperative Use of Ursodeoxycholic Acid Does Not Prevent Biliary Complications After Orthotopic Liver Transplantation

Introduction: Biliary complications remain a significant cause of morbidity after liver transplant (LT). Toxic bile acids cause duct injury, and intrahepatic bile stasis contributes to hepatobiliary injury early after LT. Ursodeoxycholic acid (UDCA) has been used to abrogate bile acid toxicity in many chronic cholestatic conditions. While small studies evaluating UDCA use post-LT show reduction in serum bilirubin levels, to date, no large studies have examined the effect of early postoperative UDCA on the prevention of biliary complications post-LT. Aim: To evaluate the effect of immediate postoperative UDCA use on incidence and severity of biliary complications after LT. Methods: A retrospective, unmatched cohort study identifying consecutive LT recipients over a 4-year period (2009-2013) with 1-year follow-up. Subjects with hepatic artery thrombosis or Roux-en-Y biliary reconstruction were excluded. Biliary complications were defined as obstruction, stricture, leak, and cholangitis. “UDCA group” was defined as subjects with uninterrupted usage of UDCA (300 mg PO TID) for a minimum of 1 month post-LT. “Non-UDCA group” had no recorded exposure. Baseline demographics included: age, gender, indication for LT, Model for End Stage Liver Disease (MELD) score at LT, blood type, BMI, and Cytomegalovirus donor status. Outcomes compared between UDCA and non-UDCA groups included: 1-year survival, number of biliary complications, number of endoscopic retrograde cholangiopancreatographies (ERCPs), number of stents placed, and serum bilirubin at hospital discharge post-LT, first ERCP, 3, 6, 9, and 12 months. Categorical variables were analyzed using Fisher’s exact tests. Continuous variables were compared with Levene’s test for equal variances and student’s t test with p<0.05 considered statistically significant. Results: A total of 199 patients met inclusion criteria. No significant differences in demographics existed between UDCA and non-UDCA groups. The overall biliary complication rate was 21.6% with no difference in incidence of biliary complications between UDCA (20.8%) and non-UDCA groups, (25.0%; p=0.528). Early use of UDCA post-LT did not influence the severity of biliary complications with no significant differences in the number of ERCPs performed (3.0 vs. 3.0; p=0.999) or stents placed (2.66 vs. 3.70; p=0.796). There were no significant differences in 1-year survival or serum bilirubin levels at any time point. Conclusion: The early use of UDCA does not prevent the development or reduce the severity of biliary complications post-LT. Further research is needed to identify other pharmacologic agents that may be a useful adjunct to the endoscopic management of biliary complications after LT.

Clinical usefulness of a short‐type, prototype single‐balloon enteroscope for endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy: Preliminary experiences

A limited number of endoscopic retrograde cholangiopancreatography (ERCP) accessories are compatible with the conventional single-balloon enteroscope (SBE) because of the latter's dimensions. The aim of the present study was to assess the utility of a prototype SBE that has a shorter working length and a wider channel than the conventional SBE. ERCP procedures carried out between January 2012 and July 2013 using the short SBE prototype were reconstructions such as Billroth II (B-II), post-gastrectomy with Roux-en-Y (RY-G), and post-choledochojejunostomy with Roux-en-Y (RY-CJ). We retrospectively analyzed the rate of reaching the blind end of the intestine, the diagnostic success rate, the interventional success rate, and the frequency of related complications. Twenty-seven ERCP procedures on 18 patients analyzed comprised two B-II, 15 RY-G, and 10 RY-CJ reconstructions. With a mean procedure time of 56 min (range 40-150 min), the rate of reaching the blind end, the diagnostic success rate, and the interventional success rate were 24/27 (89%), 20/27 (74%), and 19/27 (70%), respectively. There were no major ERCP-related complications in any patient. The prototype short-type SBE appears safe and effective for use in ERCP, and is compatible with conventional endoscopy accessories.

Covered Self-expanding Metal Stents May be Preferable to Plastic Stents in the Treatment of Chronic Pancreatitis-related Biliary Strictures

Covered self-expanding metal stents (CSEMS) are being increasingly used in the endoscopic treatment of benign biliary strictures (BBS). There is no solid evidence yet to support their routine use. To evaluate feasibility, success rate, and complications of CSEMS compared with multiple plastic stents (PS) in BBS in a systematic review. A systematic search of electronic databases (Medline, Scopus, and Embase) for studies published from 2000 to 2012 combined to hand-search of reference lists resulted 4977 articles. Out of 99 potentially relevant studies selected for full-text review, 12 CSEMS (376 patients) and 13 PS studies (570 patients) met the final inclusion criteria. A systematic review comparing the 2 methods was made using proportion meta-analysis. A tendency to successful use of CSEMS in strictures related to chronic pancreatitis (CP) was shown: clinical success of 77% and 33% [95% confidence interval (CI), 61%-94% vs. 4%-63%, P=0.06] was achieved with CSEMS and PS at 12 months follow-up, respectively. There were no differences in the success rates of other etiologies except CP or in the early complications. In CSEMS, incidence of late adverse events was lower in CP-related strictures (3% vs. 67%, 95% CI, 0%-13% vs. 17%-99%, P=0.02). The median number of endoscopic retrograde cholangiopancreatographies was lower with CSEMSs: 1.5 versus 3.9 (P=0.002). Improved clinical success with fewer endoscopic sessions and corresponding complication rate may be achieved with CSEMS treatment compared with PS in BBS secondary to CP. In other BBS etiologies, this systematic review remains inconclusive.

Sedative techniques for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia.A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide. The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings. We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid)versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation. We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel.Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems.Secondary outcomes encompassed sedation efficacy and recovery. No immediate mortality was reported.There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures.Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias. Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.

ENDOSCOPIC TREATMENT FOR BILIARY STRICTURE SECONDARY TO CHRONIC PANCREATITIS

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources

Background & Aims Walled-off pancreatic necrosis (WOPN), a complication of severe acute pancreatitis (SAP), can become infected, obstruct adjacent structures, and result in clinical deterioration of patients. Patients with WOPN have prolonged hospitalizations, needing multiple radiologic and medical interventions. We compared an established treatment of WOPN, standard percutaneous drainage (SPD), with combined modality therapy (CMT), in which endoscopic transenteric stents were added to a regimen of percutaneous drains. Methods Symptomatic patients with WOPN between January 2006 and August 2009 were treated with SPD (n = 43, 28 male) or CMT (n = 23, 17 male) and compared by disease severity, length of hospitalization, duration of drainage, complications, and number of radiologic and endoscopic procedures. Results Patient age (59 vs 54 years), sex (77% vs 58% male), computed tomography severity index (8.0 vs 7.2), number of endoscopic retrograde cholangiopancreatographies (2.0 vs 2.6), and percentage with disconnected pancreatic ducts (50% vs 46%) were equivalent in the CMT and SPD arms, respectively. Patients undergoing CMT had significantly decreased length of hospitalization (26 vs 55 days, P Conclusions For patients with symptomatic WOPN, CMT provided a more effective and safer management technique, resulting in shorter hospitalizations and fewer radiologic procedures than SPD.

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources

Walled-off pancreatic necrosis (WOPN), a complication of severe acute pancreatitis (SAP), can become infected, obstruct adjacent structures, and result in clinical deterioration of patients. Patients with WOPN have prolonged hospitalizations, needing multiple radiologic and medical interventions. We compared an established treatment of WOPN, standard percutaneous drainage (SPD), with combined modality therapy (CMT), in which endoscopic transenteric stents were added to a regimen of percutaneous drains. Symptomatic patients with WOPN between January 2006 and August 2009 were treated with SPD (n = 43, 28 male) or CMT (n = 23, 17 male) and compared by disease severity, length of hospitalization, duration of drainage, complications, and number of radiologic and endoscopic procedures. Patient age (59 vs 54 years), sex (77% vs 58% male), computed tomography severity index (8.0 vs 7.2), number of endoscopic retrograde cholangiopancreatographies (2.0 vs 2.6), and percentage with disconnected pancreatic ducts (50% vs 46%) were equivalent in the CMT and SPD arms, respectively. Patients undergoing CMT had significantly decreased length of hospitalization (26 vs 55 days, P < .0026), duration of external drainage (83.9 vs 189 days, P < .002), number of computed tomography scans (8.95 vs 14.3, P < .002), and drain studies (6.5 vs 13, P < .0001). Patients in the SPD arm had more complications. For patients with symptomatic WOPN, CMT provided a more effective and safer management technique, resulting in shorter hospitalizations and fewer radiologic procedures than SPD.

PROSPECTIVE STUDY TO DEVELOP AN ALGORITHM FOR INVESTIGATION BY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY OR MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY*

Identifying cost-efficient and patient-friendly pathways for those who present with suspected pancreatico-biliary disease remains a challenge. Algorithms must be tailored to improve decision-making. We assessed suitable criteria from which an algorithm for selection for endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography could be developed. Data on clinical, ultrasound and liver function test findings and outcome were recorded for consecutive patients undergoing ERCP and patients were stratified into different indications and a therapeutic ratio (TR) obtained for each (TR = number of therapeutic ERCP/total number of ERCP). One hundred and twenty ERCP were attempted with 112 cannulations (93.3%). Seventy-one therapeutic procedures were attempted with 64 (90.1%) successes. Forty-two (35%) investigations were normal. Seven (6%) patients suffered complications. Thirteen indications were used. The TR varied according to the indication. The TR for jaundice with biliary dilatation was 0.85. In contrast, asymptomatic patients with deranged liver function test and normal gall bladder on USS had a TR of 0.17. Gallstones with cholestatic liver function test yielded a TR of 0.54. A TR of 0.7 was considered an appropriate 'cut-off' for triage to ERCP or magnetic resonance cholangiopancreatography. An algorithm was generated based on these data. From this cohort, 50 (42%) patients would have been more appropriately investigated by magnetic resonance cholangiopancreatography, although 20 (40%) would have required therapy afterwards. An algorithm that separates indications by TR (TR > 0.7) may provide a cost-efficient, patient-friendly pathway for investigation and improve the use of resources.

Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series

Increasing reports suggest that endoscopic removal of benign ampullary and duodenal polyps is safe and frequently definitive; however, most reported polyps have been small in size (<3 cm). We have developed experience with endoscopic removal of increasingly large and complex polyps. Fifty-one cases of endoscopic removal were attempted and grouped according to size: group A (n = 22) polyps 1 to 3 cm and group B (n = 29) polyps 3 cm or larger, including 7 cases larger than 5 cm. When the ampulla was involved, biductal sphincterotomy and prophylactic pancreatic duct stent placement was performed first, followed by saline solution-assisted piecemeal polypectomy, argon plasma coagulation, selective endoclip placement, and recovery of all polyp fragments. Endoscopic removal of duodenal and ampullary adenomas. The outcomes of small and large adenoma removal include mean number of endoscopic retrograde cholangiopancreatographies required for complete removal (2.09 vs 2.56, P = .392), number of complications (4.5% vs 13.9%, P = .375), discovery of unsuspected cancer (0% vs 10.3%, P = .242), and final definitive resolution (100% vs 86.2%, P = .124). Complete removal was achieved in 92.2% of all patients. This was a single center retrospective study. Large (>/=3 cm) ampullary and duodenal polyps comprised 56.9% of our endoscopically treated cases and present special challenges to definitive endoscopic removal. Successful removal of even very large sessile lesions is possible with minimal increase in risk.

Does the Advent of Endoscopic Ultrasound (EUS) Sound the Death Knell for Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Endoscopic retrograde cholangiopancreatography (ERCP) has been the premier diagnostic and therapeutic endoscopic procedure in the management of pancreatic and biliary diseases (PBD). The use of endoscopic ultrasound (EUS), including EUS-guided fine needle aspiration (FNA), of pancreatic and biliary tumours has become more widely available in the last decade and has gradually replaced diagnostic ERCP. Together with EUS, other imaging modalities like magnetic resonance cholangiopancreatography (MRCP) have resulted in a decrease in the number of ERCPs. With the advent of interventional EUS, ERCP is at risk of being completely eclipsed. A search of all relevant articles on EUS and ERCP from Medline and peer-reviewed journals. This review article examines the exact place of ERCP and EUS and their relative contributions in the management algorithm of PBD. Although diagnostic EUS, including EUS-guided FNA, is well established in the evaluation of PBD, interventional EUS is still in its infancy and its true potential is unknown. Therefore, therapeutic ERCP still has a vital, albeit smaller role to play in the treatment of pancreatic and biliary diseases.

Indications, Findings and Complications of ERCP in Children

Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is an effective and widely employed endoscopic procedure in adult populations with pancreaticobiliary disease; however less is known about the usefulness and safety of this procedure in children. The goal of this study is to describe our clinical experience in performing ERCP in the pediatric population. Methods: Retrospective chart review was performed on pediatric patients undergoing ERCP between May 1991 and March 2005. The following data were recorded: 1) Patient age, 2) Indication for procedure, 3) Method of anesthesia used, 4) Any therapeutic or diagnostic procedure performed, and 5) Intraoperative complications. Results: Eighty pediatric ERCPs were performed during the study period. The average patient age was 11.8 years (range 5 months to 18 years). Table 1 shows the number of procedures performed for each indication with recurrent pancreatitis and suspected biliary obstruction being the most common. Fifteen patients who underwent ERCP for acute recurrent pancreatitis had a normal study, 5 had pancreas divisum and 3 had chronic pancreatitis. The majority of those with suspected biliary obstruction had choledocholithiasis (n = 15). Other diagnoses in this category included sclerosing cholangitis (n = 2) and choledochal cyst (n = 2)Table: Number of ERCPs by IndicationTable 2 Shows the Number of Each Type of Therapeutic or Diagnostic Intervention with Sphincterotomy being the Most CommonTable: Number of Each Therapeutic InterventionIn contrast to adult ERCPs, which are usually performed under conscious sedation, most pediatric ERCPs in this study were carried out under general endotracheal anesthesia (n = 46) administered by an anesthesiologist, with only 9 procedures performed under conscious sedation managed by the endoscopist. The success rate of ERCP, as defined by imaging of ducts of interest or success of intended therapy, was 98.8% (in one procedure duodenal intubation could not be achieved). There were no intraoperative complications noted in any of the 80 procedures. Conclusions: ERCP is a valuable tool in the evaluation of suspected pancreaticobiliary disorders in children. ERCP in the pediatric population was highly successful (98.8%), intraoperatively safe, and associated with a high rate of therapeutic interventions.

Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that can cause substantial complications. Competence in performing ERCP and the learning curve for achieving competence are poorly understood. To evaluate the number of supervised ERCPs that physicians must do to achieve procedural competence. Competence was defined as a 0.8 probability of successfully completing specific technical components of ERCP and an overall grading of competence as judged by the attending physician. Prospective study. University training program for gastroenterologists. 17 gastroenterology fellows at various stages of training. Experienced therapeutic endoscopists prospectively graded gastroenterology fellows during 1796 consecutive ERCPs. Fellows were graded on their overall level of competence for the procedure and on specific technical components of ERCP. Grading data were available for 1450 ERCPs (81%). The number of ERCPs done before adequate skill was achieved was 160 for cholangiography, 140 for pancreatography, 160 for deep cannulation of the pancreatic duct, 120 for stone extraction, and 60 for stent insertion. Fellows achieved overall competence after completing 180 to 200 ERCPs. The predicted probability of overall competence was 0.8 after 137 ERCPs and 0.9 after 185 ERCPs. At least 180 ERCPs were required before these gastroenterology fellows could be considered competent in ERCP. This number is much greater than that previously recommended, and these findings have substantial implications for training guidelines and issues of competence and certification in ERCP. The methods used to define and evaluate competence in ERCP could also be used to assess competence in other medical procedures.

Gastroenterology in the Trent Region in 1992 and a review of changes since 1975.

A survey of all gastroenterologists in the Trent Region (population 4.7 million) showed that in 1992 the number of upper gastrointestinal endoscopies had continued to rise considerably. There were 8.6 per thousand of the population. Colonoscopies had also increased to 1.4 per thousand. There had been a large fall in barium meal examinations to 4.8 per thousand. Barium enema examinations had increased slightly to 5.3 per thousand. The number of endoscopic retrograde cholangiopancreatographies (ERCPs) and variceal sclerotherapies had also increased by 54% and 21% respectively since 1986 and were available in most of the 20 hospitals. Percutaneous endoscopic gastrostomy had been introduced at most hospitals. Emergency endoscopy was readily available at night in only half the hospitals. Fourteen hospitals offered formal open access endoscopy. Intravenous sedation was used routinely in 12 hospitals. The rate for perforation at routine upper gastrointestinal endoscopy was 1 in 4500 and for death was 1 in 20,000. There were serious deficiencies in provision of facilities or staff, or both at 14 hospitals. The total number of gastroenterologists had only increased from 25 to 26 since 1986. Thus endoscopy workload continues to increase and diversify often without adequate staffing, facilities, and funding.