Pancreaticobiliary Disease Research Articles

MOY 2 MicroRNAs as Bile Based Biomarkers for Pancreaticobiliary Cancers (MIRABILE)

Abstract Aims MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression at the post-transcriptional level. They are commonly deregulated in cancer and are incredibly stable molecules in tissues and biofluids. Accurate identification of a malignant biliary stricture can sometimes be challenging. We aimed to identify miRNAs in the bile that are able to differentiate between malignant (pancreatic ductal adenocarcinoma (PDAC) and cholangiocarcinoma (CCA)) and benign pancreaticobiliary disease. Methods There were 111 patients recruited prospectively at initial endoscopic retrograde cholangiopancreatography (ERCP) for obstructive jaundice and bile aspirated for analysis. Total cell-free RNA was extracted from the bile from a discovery cohort of patients (n=78: 27 PDAC, 14 CCA, and 37 benign disease) and small RNA sequencing was performed. LASSO regression analysis was used to define bile miRNA signatures, and NormFinder used to identify endogenous controls. A validation cohort was used (n=87: 34 PDAC, 14 CCA, and 39 benign disease) to confirm candidate miRNAs using TaqMan RT-qPCR. Results We identified 6 potential bile miRNAs, of which 4 were suitable for RT-qPCR validation. We found miR-340 and miR-182 were significantly differentially expressed (p=0.0268 and p=0.0004 respectively) in malignant vs. benign bile, with combined AUC of 0.80 (sensitivity 64.6%; specificity 82.1%) for predicting malignant pancreaticobiliary disease. Adding serum CA 19-9 to this bile miRNA model improved the diagnostic potential (AUC 0.85: sensitivity of 86.4%; specificity of 71.4%). Conclusions Bile obtained at ERCP contains miRNAs able to differentiate benign from malignant pancreaticobiliary disease. Our novel bile miRNAs can be used with serum CA 19-9 to rapidly detect CCA and PDAC in patients presenting with obstructive jaundice.

Endoscopic Retrograde Cholangiopancreatography in Children: Nine Years' Experience at Santa Fe Foundation in Bogota, Colombia.

Experience in the use of diagnostic and/or therapy of endoscopic retrograde cholangiopancreatography (ERCP) in children is limited. This is due to the underdiagnosis of pancreaticobiliary disease in the pediatric population and specialist personnel in this procedure. To determine the safety and success rate of ERCP in children at Hospital Fundación Santa Fe de Bogotá between January 2007 and June 2015. This was an observational, descriptive, retrospective case series study of patients under 18 years, who underwent ERCP between January 2007 and June 2015. The following variables were analyzed: indication, duration, type of procedure, rate of success, and complications. A total of 30 patients were included, in whom 65 ERCP procedures were performed. Successful cannulation was achieved in 52 of the 65 procedures (80%). Among the complications that occurred, there were four cases of pancreatitis (6.2%), two cases of bleeding (3.1%), and one case of bacteremia (1.5%), and in most cases (58 in total, 89.2%), there were no complications. The pediatric gastroenterology group of the Fundación Santa Fe de Bogotá has obtained good results in performing ERCP in the pediatric population with a success rate of 80% associated with a null mortality rate. There is enough literature available to conclude that performing ERCP in the pediatric population maintains an adequate success rate and a low complication rate. In all the studies evaluated, a null mortality rate was found, so it is considered that this procedure is safe in patients under 18 years of age.

Current status of artificial intelligence analysis for the treatment of pancreaticobiliary diseases using endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography.

Pancreatic and biliary diseases encompass a range of conditions requiring accurate diagnosis for appropriate treatment strategies. This diagnosis relies heavily on imaging techniques like endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Artificial intelligence (AI), including machine learning and deep learning, is becoming integral in medical imaging and diagnostics, such as the detection of colorectal polyps. AI shows great potential in diagnosing pancreatobiliary diseases. Unlike machine learning, which requires feature extraction and selection, deep learning can utilize images directly as input. Accurate evaluation of AI performance is a complex task due to varied terminologies, evaluation methods, and development stages. Essential aspects of AI evaluation involve defining the AI's purpose, choosing appropriate gold standards, deciding on the validation phase, and selecting reliable validation methods. AI, particularly deep learning, is increasingly employed in endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography diagnostics, achieving high accuracy levels in detecting and classifying various pancreatobiliary diseases. The AI often performs better than doctors, even in tasks like differentiating benign from malignant pancreatic tumors, cysts, and subepithelial lesions, identifying gallbladder lesions, assessing endoscopic retrograde cholangiopancreatography difficulty, and evaluating the biliary strictures. The potential for AI in diagnosing pancreatobiliary diseases, especially where other modalities have limitations, is considerable. However, a crucial constraint is the need for extensive, high-quality annotated data for AI training. Future advances in AI, such as large language models, promise further applications in the medical field.

Influence of Frailty in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Biliary Stone Disease: A Nationwide Study.

Pancreaticobiliary diseases are common in the elderly. To this end, frailty represents a state of vulnerability that should be considered when assessing the risks and benefits of therapeutic endoscopic procedures. We aim to determine the rate of readmissions and clinical outcomes using the validated Hospital Frailty Risk Score in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Using the National Readmissions Database, we identified patients with an admission diagnosis of cholangitis with obstructive stone from 2016 to 2019. Patients were determined to be of low frailty risk with a score of < 5, while patients of medium to high frailty risk had a score of > 5. During the study period, 5751 patients were identified with acute cholangitis with obstructing stone. Mean age of index admissions was 69.4years and 51.8% were female. From the total cohort, 5119 (89.2%) patients underwent therapeutic ERCP, 38.0% (n = 1947) of whom were regarded as frail (risk score > 5). Following ERCP, frail patients had a less but statistically insignificant readmission rate compared to non-frail patients (2.76% vs 4.05%, p = 0.450). However, compared to non-frail patients, frail patients experienced higher post-ERCP complications (6.20% vs 14.63%, p < 0.001). Frail patients were more likely to have longer lengths of stay, higher hospital cost, and mortality risk. ERCP is not a risk factor for readmission among frail patients. However, frail patients are at higher risk for procedure-related complications, healthcare utilization, and mortality.

Horizontal duodenal papilla is associated with a special spectrum of pancreaticobiliary diseases: a retrospective magnetic resonance cholangiopancreatography-based study.

Horizontal duodenal papilla (HDP) is not an uncommon ectopic major papilla. The impact of HDP on the occurrence of pancreaticobiliary diseases remains unclear. Here, we explored the associations in patients who underwent magnetic resonance cholangiopancreatography (MRCP). Consecutive patients who underwent MRCP at Xijing Hospital (Xi'an, China) between January 2020 and December 2021 were eligible. Patients were divided into HDP and regular papilla (RP) according to the position of the major papilla. The primary outcome was the proportion of congenital pancreaticobiliary diseases. A total of 2,194 patients were included, of whom 72 (3.3%) had HDP. Compared with the RP group (n = 2,122), the HDP group had a higher proportion of congenital pancreaticobiliary diseases, especially choledochal cyst (CC) or anomalous pancreaticobiliary junction (APBJ) (6.9% vs 1.4%, P = 0.001). More gallbladder cancer (6.9% vs 1.2%, P < 0.001) and pancreatic cysts (27.8% vs 16.3%, P = 0.01) were also identified in the HDP group. Morphologically, the HDP group had a longer extrahepatic bile duct (8.4 [7.6-9.3] cm vs 7.2 [6.5-8.1] cm, P < 0.001), and larger angles between the common bile duct-duodenum and pancreatic duct-duodenum. Multivariate analysis showed that the presence of HDP was an independent risk factor for gallbladder cancer. This study confirmed that HDP was not rare in patients underwent MRCP. A higher prevalence of congenital pancreaticobiliary malformations (especially CC or APBJ), gallbladder cancer and pancreatic cysts was observed in patients with HDP, as well as distinctive morphologic features.

Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure.

Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change. Patients and methods Information about patients with Roux-en-Y gastric bypass anatomy who underwent EDGE between 2015 and 2021 from 10 institutions was captured in a registry. Patient demographics, procedural details, and clinical outcomes were analyzed. Results One hundred seventy-two patients were included in the study (mean age 60, 25 % male). Technical success of lumen-apposing metal stent (LAMS) placement was 171 of 172 (99.4 %) while clinical success of intervention was 95%. The mean procedure time was 65 minutes. The most commonly reported complication was stent dislodgement/migration (n = 29, 17). Mean length of time of LAMS duration was 69 days. Mean follow-up time was 6 months. Endoscopic fistula closure was performed in 40 % of patients (69/172) at the time of LAMS removal. Persistence of fistula was observed in 19 of 62 patients (31 %) assessed. Length of LAMS indwell time (days) was a predictor of persistent fistula. The average weight gain while the LAMS was in place was 12 lb in 63 patients (36.6 %); 59.4 % of patients gained < 5 lb. Conclusions EDGE is a safe and efficacious procedure for RYGB patients requiring ERCP. Post-procedure evaluation and management of the enteral fistula varies widely among centers currently and would benefit from further standardization. Fistula persistence appears to be uncommon and can be managed endoscopically but may be related to length of indwell times of the LAMS.

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part II (Technical Aspects)

AbstractEndoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Microbiomic profiles of bile in patients with benign and malignant pancreaticobiliary disease.

The prognostic and pathophysiologic significance of the biliary microbiota in pancreaticobiliary malignancies is little understood. Our goal was to find malignancy-related microbiomic fingerprints in bile samples taken from patients with benign and malignant pancreaticobiliary diseases. Bile specimens were collected from consenting patients during routine endoscopic retrograde cholangiopancreatography. We used PowerViral RNA/DNA Isolation kit to extract DNA from bile specimens. The Illumina 16S Metagenomic Sequencing Library Preparation guide was used to amplify the bacterial 16S rRNA gene and create libraries. QIIME (Quantitative Insights Into Microbial Ecology), Bioconductor phyloseq, microbiomeSeq, and mixMC packages were used for post-sequencing analysis. Of 46 enrolled patients, 32 patients had pancreatic cancers, 6 had cholangiocarcinoma and 1 had gallbladder cancer. Rest of the patients had benign diseases including gallstones, and acute and chronic pancreatitis. We used multivariate approach in mixMC to classify Operational Taxonomic Units (OTUs). Doing this, we found a predominance of genera Dickeya (p = 0.00008), [Eubacterium] hallii group (p = 0.0004), Bacteroides (p = 0.0006), Faecalibacterium (p = 0.006), Escherichia-Shigella (p = 0.008), and Ruminococcus 1 (p = 0.008) in bile samples from pancreaticobiliary cancers as compared to benign diseases. Additionally, bile samples from patients with pancreatic cancer exhibited a predominance of genus Rothia (p = 0.008) as compared to those with cholangiocarcinoma, whereas bile samples from patients with cholangiocarcinoma exhibited a predominance of genera Akkermansia (p = 0.031) and Achromobacter (p = 0.031) as compared to those with pancreatic cancers. Both benign and malignant pancreaticobiliary diseases have distinct microbiomic fingerprints. The relative abundance of OTUs in bile samples varies between patients with benign and malignant pancreaticobiliary diseases, as well as between cholangiocarcinoma and pancreatic cancer. Our data suggest that either these OTUs play a role in carcinogenesis or that benign disease-specific microenvironmental changes differ from cancer-specific microenvironmental changes, resulting to a clear separation of OTU clusters. We need more research to confirm and expand on our findings.

Retrospective Analysis of Characteristics, Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Tertiary Referral Center in Saudi Arabia.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia. Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database. Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Board-certified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563(96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22(3.1%) followed by post-sphincterotomy bleeding in 16(2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patienthad procedure-related mortalitysecondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in theinternational literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

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

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

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)

AbstractEndoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Abnormal Anatomic Variation of Pancreaticobiliary Union in Magnetic Resonance Cholangiopancreatography Department of Radiology and Imaging in a Tertiary Care Centre: A Descriptive Cross-sectional Study

The knowledge of the variations of the abnormal anatomy of pancreaticobiliary union is of great importance for understanding various pathologies of the biliary tract, gall bladder, and pancreas as well as to avoid surgical complications and morbidity which may arise from pancreaticobiliary maljunction. Moreover, it helps in the early diagnosis and preventive treatment of pancreaticobiliary disease. The objective of this study was to find out the prevalence of abnormal anatomic variations of the pancreaticobiliary union in magnetic resonance cholangiopancreatography examinations. This descriptive cross-sectional study was done in patients referred for Magnetic resonance cholangiopancreatography examinations for various clinical indications from 1 February 2021 to 30 May 2021. Ethical approval was obtained from the Institutional Review Committee [Reference number: 306 (6-11)E 2 077/078]. The variations in the pancreaticobiliary union, length of the common channel, and angle between the common bile duct and major pancreatic duct were obtained from the 1.5T magnetic resonance scanner in 90 patients. The three‑dimensional magnetic resonance cholangiopancreaticography images were visually analyzed and classified into four categories. Convenience sampling method was used. Point estimate and 90% Confidence Interval were calculated. Out of 90 patients, 73 (81.11%) (74.34-87.88, 90% Confidence Interval) patients had abnormal pancreaticobiliary union with pancreaticobiliary type as the most common occurrence seen in 33 (36.67%) patients. The prevalence of abnormal anatomic variation of pancreaticobiliary union was found to be higher than other studies done in similar settings. common bile duct; main pancreatic duct; magnetic resonance cholangiopancreatography.

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

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

Clinical impact of serum prealbumin in pancreaticobiliary disease.

Although there are many studies on prealbumin in individual diseases such as malignant or inflammatory diseases, there are few comparative studies. This study aimed to compare the clinical differences between prealbumin levels in cholecystitis and pancreaticobiliary malignancies and investigate the clinical impact of low prealbumin levels in pancreaticobiliary malignancies. From June 2021 to September 2021, 61 patients who had undergone surgery for various pancreaticobiliary diseases were enrolled in this study, and their clinicopathological data were retrospectively analyzed. Many elderly patients with malignant diseases had poor American Society of Anesthesiologists (ASA) scores, significantly lower albumin and prealbumin levels, and higher systemic immune inflammation indices. The low prealbumin group was older; had poorer ASA scores; and had significantly lower body mass index and hemoglobin and albumin levels and higher systemic immune inflammation indices than the normal prealbumin group. In malignant diseases, the low prealbumin group had significantly lower body mass index and hemoglobin levels and a tendency toward more advanced disease (lymph node and distant metastasis). Preoperative low prealbumin levels had an area under the receiver operator characteristic curve of 0.69, suggesting that it may be useful for predicting pancreaticobiliary malignancies. Prealbumin levels were lower in malignant diseases, possibly related to poor nutritional status and systemic immune inflammation. Low prealbumin levels may predict the risk of more advanced disease.

ERCP in patients with prior sphincterotomy has a 50% lower rate of post-ERCP pancreatitis and fewer unplanned hospital admissions

Objectives ERCP is essential in managing pancreaticobiliary disease, with well-documented complications. Rates of clinically significant complications are about 10%, approximately half of which is related to post-ERCP pancreatitis (PEP). We aimed to quantify the effect of previous sphincterotomy on post-endoiscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Materials and methods Data were collated from a contemporaneously collected database of 2876 consecutive ERCP procedures of a single operator in a tertiary referral centre. Analysis was conducted using R software, and logistic regression models. Results Of 2876 procedures (mean age 63 years, 56% female), 120 (4.2%) developed PEP and 268 (9.3%) had prolonged/unplanned hospital admission. Univariate analysis showed patients with previous sphincterotomy 28/1054 (2.7%) had decreased risk of PEP compared with those without sphincterotomy 92/1822 (5.0%) (OR 0.52, p = .0021). This difference was not evident when multivariate analysis for age, sex and indication was undertaken due to a particularly low risk of PEP in stent change patients (1.4%), which were disproportionately represented in the previous sphincterotomy group. The rate of prolonged/unplanned hospital admission was recorded for a total of 2876 patients, occurring in 184/1802 (10.1%) in the native ampulla group, versus 84/1045 (8.0%) in the previous sphincterotomy group. Conclusions The risk of PEP is halved by prior sphincterotomy. The presence of a biliary stent conferred an even lower risk of PEP (1.4%), but those without an in situ stent at the time of ERCP had a similar risk of PEP (4.6%) of prolonged/unplanned hospitalisation to those with a native ampulla.

IMPACT OF DIAGNOSTIC AND INTERVENTIONAL ENDOSCOPIC ULTRASONOGRAPHY IN CHILDREN.

Endoscopic ultrasonography is used in the diagnosis and treatment of digestive diseases in adults. In children, its use is limited due to a lack of available expertise. This study aimed to evaluate the clinical impact of endoscopic ultrasonography on diagnostic and therapeutic strategy changes in pediatric patients. Over ten years, this study retrospectively and consecutively analyzed children aged ≤18 years who underwent endoscopic ultrasonography because of inconclusive imaging or laboratory tests. The indications, results, occurrence of adverse events, and clinical impact of the procedures were analyzed. The clinical impact was classified as major (when the findings led to changes in diagnosis and management), minor (change in diagnosis but not in management), or none (no change in diagnosis or management). Overall, 107 children [77 (72%) of whom were female; mean age: 11.7 ± 4 years] underwent upper [102 (95.3%)] and lower [5 (4.7%)] endoscopic ultrasonography; 64 (58%) patients underwent diagnostic endoscopic ultrasonography, and 43 (42%) underwent interventional endoscopic ultrasonography. Endoscopic ultrasonography was used to investigate pancreaticobiliary, gastric, rectal, esophageal, duodenal, and mediastinal diseases in 81 (76%), 14 (13%), 5 (4.6%), 3 (2.8%), 2 (1.8%), and 2 (1.8%) patients, respectively. The clinical impact was significant in 81% of the children. Major and no clinical impact on pancreaticobiliary, gastrointestinal diseases, and mediastinal masses occurred in 50 (62%) and 13 (16%), 13 (54%) and 9 (37%), and 2 (100%) and 0 (0%) of the patients, respectively. This study evaluated the impact of diagnostic and interventional endoscopic ultrasonography in pediatric patients. When clinically and appropriately indicated, these procedures are safe and effective diagnostic or therapeutic interventions in pediatric patients with gastrointestinal or pancreaticobiliary disorders.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for BillrothII patients).Strong recommendation, moderate quality evidence.

Evaluation of the success and complication rates of endoscopic retrograde cholangiography according to the difficulty of the procedure

AbstractEndoscopic retrograde cholangiopancreatography (ERCP), is an invasive procedure with a high complication rate used in the diagnosis and treatment of pancreaticobiliary system diseases. A system that grading the difficulty and complexity of the ERCP procedure has been developed by the American Society of Gastrointestinal Endoscopy (ASGE). The aim of the study is to evaluate the degree of difficulty of ERCP procedures according to the ASGE grading system and its effectiveness in predicting the success and complications of the procedure. A total of 600 patients who underwent ERCP were evaluated retrospectively. Of all ERCP procedures, 5.5% were classified as ASGE 1, 46.8% as ASGE 2, 39% as ASGE 3, and 8.6% as ASGE 4. In all procedures, the successful cannulation rate was 96.3%, the technical success rate was 96%, and the clinical success rate was 94.8%. The procedure's success decreased linearly and the need for repetition increased linearly as the ASGE grade increased (p &gt; .05). In terms of complications, there was no statistical difference between ASGE 1–3 and 4. We believe that the ASGE grading system will be useful in clinical practice, particularly for less experienced endoscopists in ERCP procedures.

Mortality Trends of Gastrointestinal, Liver, and Pancreaticobiliary Diseases: A Hospital-Based Prospective Study in the Southeast of Iran.

Background: Gastrointestinal (GI), liver, and pancreaticobiliary diseases, in addition to the high health care utilization, account for a significant proportion of disability and death in Iran. We aimed to assess the incidence of in-hospital mortality for the total GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman, Iran. Methods: In a cross-sectional study from May 2017 to April 2018, we collected the data of in-hospital death records due to GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman city. GI and liver diseases were classified into three main categories: 1. Non-malignant GI diseases, 2. Non-malignant liver and pancreaticobiliary diseases, and 3. GI, liver, and pancreaticobiliary malignancies. All data were analyzed using SPSS software, version 22 (IBM). Results: Of 3427 in-hospital mortality, 269 (7.84%) deaths were due to GI, liver, and pancreaticobiliary diseases, of which 82 (30.48%) were related to non-malignant GI disorders, 92 (34.20%) to the non-malignant liver and pancreaticobiliary diseases, and 95 (35.31%) were associated with GI, liver and pancreaticobiliary malignancies. Most patients were male (62.08%), and the most common age was between 60-80 years (40.5%). GI bleeding occurred in 158 (58.73%) patients, and variceal bleeding was the most common cause (28.48%). Additionally, cirrhosis was reported in 41 out of 92 (44.56%), and hepatitis B virus (HBV) was the most common cause of cirrhosis among 17 out of 41 (41.46%). Conclusion: Our results show that gastric, colorectal, and pancreatic cancers and cirrhosis due to HBV were the most common causes of mortality associated with GI, liver, and pancreaticobiliary diseases in the hospitals of Kerman.

Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database.

Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients.Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management.Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.