Risk Of post-ERCP Pancreatitis Research Articles

Low-dose rectal diclofenac does not prevent post-ERCP pancreatitis in low- or high-risk patients.

The most common adverse event following an endoscopic retrograde cholangiopancreatography (ERCP) procedure is post-ERCP pancreatitis (PEP). Rectal nonsteroidal anti-inflammatory drug (NSAID) administration has shown promise to reduce the risk of PEP in high-risk patients. However, in contrast to high-risk patients, the role of NSAID administration in patients with low risk remains controversial. We performed a prospective, single-center, single-blinded, two-arm parallel group, randomized controlled trial to clarify the efficacy of low dose (50mg) rectal NSAID administration for preventing PEP in at-risk patients. Patients scheduled to undergo ERCP were randomized into two groups, those with and without rectal administration of diclofenac. Patients in the diclofenac group received 50mg of rectal diclofenac 30min before undergoing ERCP. The primary endpoint was rate of PEP. A total of 303 were randomized into the study groups. Four patients declined participation following randomization, and another two were withdrawn. As a result, a total of 147 patients were assigned to the diclofenac group and 150 to the control group. The baseline and procedural characteristics were similar in both groups. The primary endpoint of PEP occurrence was seen in 13 of 297 patients (4.4%), including eight (5.4%) in the diclofenac group and five (3.3%) in the control group (P=0.286). Additionally, those results were not significantly different when patients were classified as low or high risk. Prophylactic low-dose rectal diclofenac did not reduce the incidence of PEP following ERCP in patients classified as low or high risk.

Practice patterns of post-ERCP pancreatitis prophylaxis techniques in the United States: a survey of advanced endoscopists

The American Society for Gastrointestinal Endoscopy recommends prophylactic pancreatic duct stent placement (PPS) and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals and suggests that rectal indomethacin may decrease the risk and severity of PEP in average-risk individuals. The European Society for Gastrointestinal Endoscopy recommends rectal indomethacin for all patients undergoing ERCP. Previous surveys of European endoscopists revealed low adoption of PPS or rectal NSAIDs to prevent PEP. We sought to capture current practice in the prevention of PEP among endoscopists in the United States involved in advanced endoscopy fellowship programs. An anonymous online 16-item survey was e-mailed to 233 advanced endoscopists involved in advanced endoscopy fellowship programs. Of the 233 endoscopists who were invited to participate, 62 responded (26.7%). Most respondents reported working in tertiary referral centers (57; 95.0%) and performing ERCP for greater than 5 years (44; 74.6%). All respondents (60; 100.0%) reported working with fellows. Most PPS users (41; 72.0%) reported use of PPS in high-risk patients only and using PPS for PEP in≤25% of ERCPs (38; 64.4%). Most respondents reported using rectal NSAIDs for high-risk patients only (34; 59.7%) compared with respondents (23; 40.1%) who reported using rectal NSAIDs for prevention of PEP in average-risk patients undergoing ERCP. Most respondents (49; 83.0%) also reported using rapid intravenous fluids to prevent PEP. Among endoscopists involved in advanced endoscopy fellowships in the United States, rectal NSAIDs are used more frequently than PPS in the prevention of PEP. Despite mounting evidence supporting the use of rectal NSAIDs to prevent PEP in average-risk patients, less than half of the respondents in this survey reported such practice.

35 Is Weekend Admission Associated With Increased Risk of Post-ERCP Pancreatitis?

INTRODUCTION: Pancreatitis is one of the most common complications of Endoscopic Retrograde Cholangiopancreatography (ERCP). There are endoscopist related factors and patient related factors that increase the risk of post-ERCP pancreatitis. However, epidemiologic factors that increase the risk of same are not well known. We aim to study the association between various epidemiologic factors especially weekend admission and post- ERCP pancreatitis. METHODS: National Inpatient Sample for years 2009–2013 was used for this study. It is the largest ICD-9 code based inpatient database in the US. ICD-9-CM procedure code 51.10 was used to identify all adults who underwent ERCP. Post-ERCP pancreatitis was identified with ICD-9-CM code 577.0 listed as secondary diagnosis. All hospitalizations with missing age & gender information, or primary diagnosis of pancreatitis were excluded. Mean and percentages were used to summarize continuous and categorical variables respectively. Multivariate logistic regression was used to identify the predictors of post-ERCP pancreatitis. Demographic & hospital characteristics, clinically relevant Elixhauser co-morbidites, pancreatic stent placement, and sphincterotomy were used as covariates for regression model. RESULTS: Total of 140859 ERCP(s) were performed during five years. Of these 18870 (13.4%) patients developed post-ERCP pancreatitis and 430 (2.3%) of these died during the hospitalization. Pancreatic duct stent was placed in 4356 patients and 943 (21.6%) of these patients developed post-ERCP pancreatitis. Demographic, hospital characteristics, and outcomes of patients who developed post-ERCP pancreatitis compared to those who didn't are shown in Table 1. On multivariate regression weekend admission (OR = 1.12, P = 0.01), sphincterotomy (OR = 1.48, P < 0.001), pancreatic stent placement (OR = 1.47, P = 0.01), obesity (OR = 1.45, P < 0.001) were some of the factors associated with increased risk of post-ERCP pancreatitis. Teaching hospitals (OR = 0.81, P < 0.001) were associated with lower risk of pancreatitis. CONCLUSION: Pancreatic stent placement has been shown to be protective for post-ERCP pancreatitis, however, in our study there were higher odds of pancreatitis in patients receiving pancreatic. This was likely because of pancreatic stents being placed in patients felt to be at higher risk of post ERCP pancreatitis. In conclusion, weekend admission was associated with higher risk, and teaching hospitals with lower risk of developing post-ERCP pancreatitis.

78 What Is the Impact of a Delayed Presentation on Outpatients With Post-ERCP Pancreatitis? An Analysis of Clinical Predictors and Outcomes

INTRODUCTION: Post-ERCP pancreatitis (PEP) occurs in up to 15% of high risk patients. Symptoms after ERCP are common and usually determine admission. However, discharge of outpatients at risk for PEP is frequent after ERCP. In retrospective studies, discharged PEP patients are at increased risk for severity, possibly due to delays in IV fluid therapy. The aim of this study is to evaluate clinical predictors and outcomes in patients discharged and later admitted with delayed presentation of PEP. METHODS: We identified consecutive outpatients with PEP enrolled in a prospective study designed to evaluate the optimal rectal Indomethacin dose for prevention of PEP in high-risk patients. All patients received Indomethacin and were observed for at least 4 hours post-ERCP per protocol. All clinical data except IV fluids, recovery medications, and pain scores were collected prospectively. Diagnosis and severity of PEP was defined by Cotton criteria. RESULTS: 107/720 (14.9%) developed PEP. 135/720 (18.8%) were directly admitted after ERCP. While the direct admission rate in patients that developed PEP was higher (P < 0.001), 58/107 (54.2%) were discharged and had a delayed presentation of PEP. Median time to presentation was 24 hours (IQR 15–31.75 h). Discharged patients were older (age 47.7 vs 41.1, P = 0.026), more often had a morning procedure (59.2% vs 39.7%, P = 0.044), less often had pancreatic stent placement (82.8% vs 95.9%, P = 0.032), spent less time in recovery (261 vs 312 minutes, P = 0.004), required less IV opioids (6.4 vs 17.3 MME, P < 0.001) and had lower pain scores (2.8 vs 6.5, P < 0.001) (Table 1). On multivariable analysis, an afternoon procedure (OR 4.00, P = 0.016) and pain score >3 (OR 1.37, P = 0.001) were associated with admission. While discharged patients were more likely to present with SIRS on admission (43.1% vs 10.2%, P < 0.001), a delayed presentation was not associated with severe PEP (Table 2). CONCLUSION: Delayed presentation of PEP after discharge of high-risk patients is frequent, but not associated with adverse outcomes or severe PEP. Systematic deployment of PEP prophylaxis with rectal Indomethacin, pancreatic stents, and IV fluids may attenuate the impact of delayed presentation on outcomes. Afternoon procedure time and increased pain appear to influence decisions to admit. However, given the frequency of delayed presentation of PEP, accurate and early diagnostic tests for PEP may be of clinical value.

2940 Favorable Rates of Post-ERCP Pancreatitis With Endoscopic Sphincterotomy With Delayed Sphincteroplasty Approach

INTRODUCTION: There are multiple modalities for the management of large bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP). Large bile duct stones, defined as size greater than 15 mm, are a subset of multiple clinical situations associated with difficult bile duct stone extraction. The successful extraction of common bile duct stones typically requires either a sphincterotomy or papillary balloon dilation. Multiple prior studies have shown that endoscopic papillary balloon dilation (EPBD) has less success in stone clearance with more frequent requirement for lithotripsy in addition to carrying a higher risk of post-ERCP pancreatitis. We report the technique of delayed sphincteroplasty to be effective and safe in the management of large bile duct stones. METHODS: A retrospective analysis from 2012 to 2018 was obtained from our endoscopy software of all patients who underwent a two-step ERCP with balloon dilation and analyzed in terms of patient demographics, stone size, success of stone extraction, number or procedures required for duct clearance and procedure-related complications. Patients with bile duct strictures, periampullary malignancy or coagulopathy were excluded. RESULTS: Seventy five patients had ERCP performed with balloon sphincterotomy at least 30 days after initial ERCP. Twenty seven of them were men. Age ranged from 26 to 101 with an average age of 73. 37.3% of the patients were Caucasian, 33.3% African American, 6.6% Asian, 5.3% Hispanic and 17.3% unknown. The average common bile duct size on imaging prior to ERCP was 14.2 mm. The initial ERCP was performed within an average of 4 days of admission. Total bilirubin was 3.9 on average. Most common indication was proven bile duct stone on imaging, 60.8%. 84% of patients had a plastic stent placed during initial ERCP. 13% had more than 5 stones. Balloon was dilated to an average of 14.6 mm. 97% (73/75) had no immediate complications post procedure. Three patients needed additional lithotripsy. CONCLUSION: We present our center's experience with the management of large bile duct stones with the technique using endoscopic sphincterotomy with stent placement for initial drainage and a delayed sphincteroplasty reported decreased rates of post-ERCP pancreatitis and encouraging success rates for stone extraction.

77 Post-ERCP Pancreatitis Rates and NSAID Use in a Community Hospital

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) has been consistently used for more than 50 years as a diagnostic and therapeutic procedure in pancreaticobiliary diseases. However, its use is associated with several adverse effects including bleeding, cholangitis, pancreatitis, intestinal perforation, and death. Of these, post-ERCP pancreatitis (PEP) is the leading cause of morbidity and mortality with an estimated incidence of 1.6–15%. Endoscopic techniques, patient characteristics, and the hospital setting have been noted to put patients at higher risk of developing PEP. Williams et al. reported a significantly increased risk of PEP in community hospitals compared to university hospitals. Rectal NSAIDs, including diclofenac and indomethacin, have shown promising results in several high-quality clinical trials and meta-analysis, especially in high-risk patients. More recent trials failed to show a significant reduction of PEP after NSAID use. There is scant data on the efficacy of rectal NSAIDs in higher risk patients in community hospitals. The aim of this study is to determine if there is an increased risk of PEP in a community hospital and if the use of rectal NSAIDs for high-risk patients is beneficial within a community hospital. METHODS: After obtaining IRB approval, the charts of every adult patient admitted to a Wichita, KS community hospital for ERCP in a 2-year time period were reviewed. Primary endpoint was percentage of patients developing PEP. Secondary endpoints included NSAID use in high-risk individuals (Table 1) and the change in incidence of PEP in this group with the use of rectal NSAID. RESULTS: 422 patients underwent ERCP during the study period. Of these, about 212 (50.2%) were noted to have at least 1 high risk factor to develop PEP. 24 (5.6%) of the patients received rectal NSAIDs, of which 10 patients were noted to be high-risk for PEP. 9 patients (2.1%) developed PEP during the study time period. Of the nine patients, 3 patients were high risk and did not receive any NSAIDs. The use of NSAIDs did not cause a significant reduction in PEP in the high-risk group (p-value 0.7) or overall (P-value 0.66). CONCLUSION: PEP rates in a community hospital setting have not been well established. Our study reports an incidence of 2.1%, comparable to the PEP incidence described in academic trials. Despite the unstandardized use of rectal NSAIDs noted in the study population, there appears to be no significant benefit in their use overall or in the high-risk population.

Risk Factors for Post-Endoscopic Retrograde Pancreatography Pancreatitis: A Retrospective Chart Review in a Regional Hospital in Japan

Background: Endoscopic retrograde pancreatography (ERCP) is sometimes complicated by post-ERCP pancreatitis (PEP), which is a severe adverse effect. Objective: The present study was performed to (i) evaluate the risk factors for PEP and (ii) compare the risk of PEP after ERCP performed in the off hours versus regular hours. Methods: This retrospective study included 374 patients who underwent ERCP from January 2013 to December 2017. Among these patients, 38 (10.2%) developed PEP. The potential risk factors for PEP were evaluated by multivariate regression analysis, and the risk of PEP was compared between ERCP performed during regular hours and off hours. Results: The independent risk factors for PEP were a relatively younger age (<75 years; p = 0.024), female sex (p = 0.002), a history of pancreatitis (p = 0.044), and performance of pancreatography (p = 0.010). Use of a diclofenac suppository and performance of pancreatic stenting were not preventive for PEP after ERCP. The complication rate of PEP did not differ between ERCP performed during the off hours versus regular hours. Conclusions: A relatively younger age (<75 years), female sex, a history of pancreatitis, and performance of pancreatography were potential risk factors for PEP, whereas the risk of PEP was not different between ERCP performed during the off hours versus regular hours.

Does rectal ketoprofen prevent post ERCP pancreatitis?

Background and study aimsEndoscopic retrograde cholangiopancreatography (ERCP) is a commonly used procedure in the management of pancreatic and biliary diseases. Acute pancreatitis is the most common complication following ERCP. Among many medications, nonsteroidal anti-inflammatory drugs (NSAIDs) were subject of numerous trials concerning post ERCP pancreatitis (PEP) prophylaxis. By inhibiting phospholipase A2, these drugs could intervene in the pathogenesis of the disease therefore limiting its occurrence. The use of some rectal NSAIDs agents was shown, to be advantageous in preventing this complication but there were not enough data on ketoprofen. The aim of this study was to assess the efficacy of rectal ketoprofen prophylactic administration in reducing the risk of PEP. Patients and methodsThe study was a non randomized retrospective single center study conducted between 2014 and 2018 on 242 patients divided into control and trial group receiving 100 mg of rectal Ketoprofen 30 mins before ERCP.PEP was defined as a new or exacerbated abdominal pain, in association with an elevation of serum lipase at least three times higher than the normal upper limit within and lasting more than 24 h after the procedure requiring a re-admission or a prolongation of the hospital stay.This endpoint was determined by comparing the number of patients presenting PEP in the NSAIDs group vs. the control group using Fisher exact test, with p < 0.05 representing a significant statistical value. ResultsPancreatitis developed in 6% after ERCP, 5 of them being in the trial group and 9 in the control group. Additionally, statistical calculations showed a non significant difference between the two groups in the prevalence of PEP. ConclusionRectal ketoprofen administration before ERCP does not have any effect in preventing pancreatitis post ERCP.

Peri-Procedural Aggressive Hydration for Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis Prophylaxsis: Meta-analysis of Randomized Controlled Trials

BackgroundPeriprocedural intravenous hydration is suggested to decrease the risk of post-ERCP pancreatitis (PEP). However, quality of evidence supporting this suggestion remains poor. Here we hypothesized that aggressive hydration(AH) could be an effective preventive measure. MethodsPubmed, EMBASE, CINAHL, Google Scholar, Clinical Trials. gov, Clinical Key, International Standard Randomized Trial Number registry as well as secondary sources were searched through January 2019 to identify randomized controlled studies comparing AH to standard hydration (SH) for prevention of PEP. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random-effects model. RevMan 5.3 was used for analysis. ResultsA total of 9 RCTs, with 2094 patients, were included in the meta-analysis. AH reduced incidence of PEP by 56% compared to SH (OR = 0.44, CI:0.28–0.69; p = 0.0004). The incidence of post-ERCP hyperamylasemia also decreased with AH compared to SH (OR = 0.51; p = 0.001). Length of stay decreased by 1 day with AH (Mean Difference (MD): −0.89 d; p = 0.00002). There was no significant difference in adverse events related to fluid overload between two groups (OR:1.29; p = 0.81) and post-ERCP abdominal pain (OR:0.35; p = 0.17). Numbers of patient to be treated with AH to prevent one episode of PEP was 17. Final results of the meta-analysis were not affected by alternative effect measures or statistical models of heterogeneity. ConclusionAggressive hydration is associated with a significantly lower incidence of PEP and it appears to be an effective and safe strategy for the prevention of Post ERCP pancreatitis.

Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial

Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 – 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.

Sa1416 EARLY IMPLEMENTATION OF NEEDLE KNIFE PRECUTTING PAPILLOTOMY SEEMS TO BE PREVENTION OF POST-ERCP PANCREATITIS IN DIFFICULT CASES

Needle knife precutting papillotomy (NKPP) is a powerful tool to make a successful selective deep biliary cannulation in difficult cases. However, this procedure is thought to increase a risk of post-ERCP pancreatitis (PEP). This retrospective study validates that early implementation of NKPP reduces PEP rate in difficult cases. Furthermore, we evaluate preventive effect of PEP in an endoscopic pancreatic stent (EPS).

593 – Development, Validation of a Post-Ercp Pancreatitis Risk Calculator and Machine Learning Based Decision Making Tool for Prophylaxis Selection

593 – Development, Validation of a Post-Ercp Pancreatitis Risk Calculator and Machine Learning Based Decision Making Tool for Prophylaxis Selection

Safety and Efficacy of a Small J-Tipped Guidewire for Pancreatic Duct Endoscopic Intervention.

Background and Aims The insertion of the guidewires (GWs) into the pancreatic duct is technically difficult, and there is a risk of post-ERCP pancreatitis (PEP). The aim of this study was to evaluate the safety and efficacy of a small J-tipped guidewire for pancreatic duct endoscopic intervention. Methods This single-site retrospective study was conducted to assess the procedural success rate and adverse events of endoscopic transpapillary interventions to the pancreatic duct in 114 cases using the small J-tipped GW and 180 cases using the angle-tipped GW. Results The procedural success rate was significantly higher in the small J-tipped GW group compared with that in the angle-tipped GW group (76% versus 47%, P < 0.001). The procedural success-related factors were chronic pancreatitis (OR 0.43, 95% CI 0.22–0.82, P = 0.01), flexion angle of the pancreatic duct < 90° (OR 0.50, 95% CI 0.30–0.80, P = 0.01), and use of the small J-tipped GW (OR 4.63, 95% CI 2.61–8.20, P < 0.001). The rates of total post-ERCP pancreatitis were significantly lower in the small J-tipped GW group compared with that in the angle-tipped GW group (3.5% versus 12.2%, P = 0.01). Multivariate analysis of pancreatitis risk factors indicated that only the use of the small J-tipped GW was a factor in decreasing the risk of developing pancreatitis (OR 0.12, 95% CI 0.09–0.85, P = 0.02). Conclusions Small J-tipped GWs increase the success rate of the pancreatic duct endoscopic intervention as well as a reduced risk of developing postoperative pancreatitis.

Primary Needle-Knife Fistulotomy versus Conventional Cannulation Method in High Risk Cohort of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Randomized Controlled Trial

Background: Successful biliary cannulation is a prerequisite and important component of endoscopic retrograde cholangiopancreatography (ERCP), but conventional cannulation methods (CCMs) have a post-ERCP pancreatitis (PEP) rate of 14.1% in patients at high risk for PEP. The aims of this study were to evaluate the effectiveness and safety of needle-knife fistulotomy (NKF), compared with a CCM, when used for primary biliary access in patients at high risk for developing PEP. Methods: A total of 207 patients with one or more risk factors for PEP were prospectively enrolled. The patients were randomly allocated to one of two groups according to the primary biliary cannulation technique (NKF or CCM). We compared biliary cannulation success rates, cannulation and procedure times, and the incidence of adverse events, including PEP, between the groups. Findings: The mean number of PEP risk factors was similar between the groups (NKF, 2.2 ± 1.0; CCM, 2.2 ± 0.9). PEP occurred in eight patients in the CCM group and in no patients in the NKF group (9.2% vs. 0%, p < 0.001). The rates of other complications did not differ between the groups. The biliary cannulation success rate was higher in the NKF group than in the CCM group (97.9% vs. 89.7%, p = 0.005). The mean cannulation time and total procedure time were longer in the NKF group than in the CCM group. Interpretation: NKF is an effective and safe procedure to gain primary biliary access in patients at high risk for developing PEP. Trial registration number: ClinicalTrials.gov, NCT02916199. Funding Statement: The authors state: None. Declaration of Interests: The authors state: None. Ethics Approval Statement: The study was approved by the institutional review boards of each institution (Approval number: 3-2017-0092).

A Randomized Trial of Topical Epinephrine and Rectal Indomethacin for Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients.

Rectal indomethacin and topical spray of epinephrine have separately shown efficacy in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in randomized controlled trials. We hypothesized that the combination of indomethacin and topical spray of epinephrine on the duodenal papillae would further reduce PEP than when indomethacin was used alone. We conducted a comparative effectiveness, multicenter, double-blinded, randomized trial of rectal indomethacin alone vs a combination of rectal indomethacin and topical spray of epinephrine for the prevention of PEP in high-risk patients. The primary outcome was the incidence of PEP and the secondary outcome was the severity of PEP. A 2-tailed Fisher's exact test was used to analyze the difference in the proportion of patients with PEP in the indomethacin alone vs the combination group. A total of 960 patients (mean age 52.33 ± 14.96 years; 551 [57.4%] females) were randomized and 959 completed follow-up. The baseline demographic and clinical characteristics were similar between the 2 groups. Women <50 years of age (25.4%) and difficult cannulation (84.9%) were the most common PEP risk factors. The incidence of PEP was 6.4% in the indomethacin alone group (n = 482) compared to 6.7% in the combination group (n = 477; P = 0.87). Severe PEP was found in 5 (12%) and 7 (16%) patients in the indomethacin alone and combination groups, respectively (P = 0.88). The overall mortality was 0.6%, which was unrelated to the primary outcome. The combination of rectal indomethacin and topical spray of epinephrine does not reduce the incidence of PEP compared to rectal indomethacin alone in high-risk patients; https://clinicaltrials.gov/ct2/show/NCT02116309.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist.

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

The risk of post-ERCP pancreatitis after single operator peroral spyglass cholangioscopy is highest in the beginning of practice

The risk of post-ERCP pancreatitis after single operator peroral spyglass cholangioscopy is highest in the beginning of practice

EUS-guided antegrade procedures.

Endoscopic transpapillary procedure, so-called ERCP-related procedure, should be considered as the first-line treatment method for biliary disorders such as acute cholangitis, obstructive jaundice, or choledocholithiasis because of its less invasiveness and lower risk of adverse events than other techniques despite the risk of post-ERCP pancreatitis.[1,2,3,4,5] However, ERCP-related procedure is not always successfully accomplished, even when performed by skilled endoscopists, in cases of inability of selective biliary cannulation because of the presence of intradiverticular papillae, a long narrow distal segment of the distal bile duct, or inaccessible papilla because of gastric outlet obstruction or surgically altered anatomy (SAA) even using balloon enteroscope.[6,7] Recently, in such cases, EUS-guided biliary drainage (EUS-BD) approach has been developed and reported as a novel useful alternative technique when standard ERCP-related procedure has failed.[8,9,10,11,12,13,14] As regards EUS-BD for obstructive jaundice due to malignant biliary stricture, EUS-BD is divided into several techniques depending on the approach route.[15] At present, there is no universal consensus on the optimal strategy for which the EUS-BD technique should be selected. Thus far, the selection of the EUS-BD approach depends on the patient's condition, which may involve the presence of gastric outlet obstruction, the site of biliary obstruction, the anastomosis after surgical intervention, or the preference of the endoscopist.[16] In several EUS-BD techniques, EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are common mostly in patients with malignant diseases at the end stage of disease because these techniques are simple. However, bile flow in EUS-CDS or EUS-HGS is not physiological, resulting in short stent patency rather than retrograde biliary metal stent placement across the stricture site by ERCP. Furthermore, as there are as yet no commercially available dedicated metal stents for EUS-CDS or EUS-HGS around the world, a braided-type covered metal stent is conventionally used on EUS-CDS or EUS-HGS, which has some concern about stent misplacement or migration due to its high shortening rate.[17] Therefore, EUS-guided antegrade stenting (EUS-AGS) has been developed and reported as a useful option of EUS-BD because of the theoretical physiological bile flow in patients with inaccessible ampulla.[18] Moreover, EUS-antegrade intervention (EUS-AI) for benign biliary diseases in patients with surgically altered anatomy that is an antegrade treatment via the approach route created by EUS-HGS has been developed by application of EUS-AGS.[19] Herein, we describe technical details regarding such EUS-guided antegrade procedure for malignant and benign biliary diseases.

The risk of post-ERCP pancreatitis after single operator peroral SpyGlass cholangioscopy is highest in the beginning of practice

Background: SpyGlass cholangioscopy (SOC) with intra-ductal visualisation and biopsies is an adjunct to endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnostics of indeterminate biliary strictures. The rate of complications during the learning curve and after establishment of a routine in SOC practice was studied. Methods: All consecutive SOC performed in a tertiary referral center 2012 – 2015 were included. Data was collected prospectively for indications, procedure details and complications and supplemented from records for clinical outcome. Results: 1920 ERCP were performed during the study period. Of those 113 patients (5.9%; mean age 58 y, 57% male) underwent SOC ERCP. Median follow-up was 19 months (range 1 – 48). The indication for SOC was primary sclerosing cholangitis in 43%, indeterminate stricture in 30% and stone disease in 24%. 92% of SOCs were performed in outpatient setting. In the very first 25 SOC, the rate of adverse events was 20%: all 5 patients had a severe post-ERCP pancreatitis (PEP), one of which had fatal outcome In the next 88 SOCs rate of adverse events was 8% (PEP 3%, cholangitis 3%, bleeding 1%, mortality 0%, none severe). The sensitivity and specificity of SOC biopsies were 75% and 87% for detecting cancer, respectively. Conclusion: The risk of pancreatitis after SOC decreases to the level seen in standard ERCP as experience accumulates. SOC may be considered a safe diagnostic aid in unclear biliary strictures even in outpatient setting.

Prolonged retention of prophylactic pancreatic stents is not associated with increased complications

ObjectivesThe risk of post-ERCP pancreatitis (PEP) can be reduced effectively by the placement of a self dislodging pancreatic stent. The present study analyzed whether a prolonged interval until stent passage evaluation and removal of retained stents is associated with an increased risk for clinically relevant complications. MethodsIn the retrospective study 182 patients receiving a pancreatic stent for PEP prophylaxis were included and clinical data and complications until documented spontaneous stent dislodgement or removal were analyzed. ResultsThe main indication for ERCP was choledocholithiasis (40.1%) followed by malignant stenosis (30.8%). Stent passage evaluation was performed in 34.1% at day 1–4, 23.6% at day 5–10, 17.6% at day 11–28 and 24.7% at day >28. PEP occurred in 13.1% of patients with no case of severe PEP. No association between PEP and day of stent passage evaluation (p = 0.719), retention of the pancreatic stent at time of evaluation (0.867) or prolonged stent retention >10 days (0.234) was observed. Only the duration of the procedure was associated with risk for PEP (p = 0.037). Besides PEP only one clinically relevant complication was observed in the cohort (0.5%) which was a late possibly stent related pancreatitis at day 9 after the procedure that resolved completely. ConclusionsA prolonged interval for stent passage evaluation and stent retention is not associated with an increase of clinically relevant complications. A later evaluation and extraction of retained stents might be acceptable in selected cases where an additional endoscopic procedure can be saved due to a planned follow-up endoscopy.