Retrograde Cholangiopancreatography Complications Research Articles

Management of Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Complications

AbstractBackground: Endoscopic retrograde cholangiopancrea-tography (ERCP) is considered as a diagnostic and therapeutic procedure used to treat problems associated with biliary and pancreatic diseases. The benefits of ERCP over surgical treatment are well documented; however, there is complications including infection, pancreatitis, hemorrhage, and perforation can occur even in expert hands. Several factors may affect, such as patient selection, skills of the operator, and the how complex the procedure was. This work studies ERCP compli-cation rates, predictive factors for incidence and management plans to improve outcomes.Aim of Study: To spot complications that happened post-ERCP and how to manage it.Patients and Methods: In a prospective, 2-years study from September 2017 to September 2019 of 50 patients underwent ERCP and notice if complications happened and the risk factors for that complication.Results: 20% had post-ERCP complications, with pancre-atitis (8%), perforation (8%) and infection (cholangitis and cholecystitis) (4%). Perforation was considered the most serious complication of ERCP. It demands early diagnosis and good management. Surgical intervention the urgent solu-tion to manage post-ERCP perforation (3 of the 4 perforated patients underwent surgical intervention.Conclusion: ERCP is a safe and widely used all over the world. To overcome its complications it demands good prep-aration for patients, increase our experience, short procedure especially in risky patients, and close observation post-ERCP patients aiming at early diagnosis of complications and early management if happened.

Safety of endoscopic retrograde cholangiopancreatography in liver transplanted patients: A single‐center retrospective study

AbstractThe incidence rate of endoscopic retrograde cholangiopancreatography complication in liver transplanted patient has not been well studied. Some studies believed such patients inherit higher complication risk in ERCP procedure owing to innate structure deformity and coagulopathy condition. Our aim of this study is to evaluate the post‐ERCP complications incidence in liver transplanted patients. All liver transplant patients (deceased donor and living‐related donor) from January 2010 to December 2015 who underwent ERCP procedure alone in Changhua Christian medical center hospital were retrospective evaluated. Data regarding post‐ERCP complications, including pancreatitis, hemorrhage, perforation, and infection, are collected and analyzed. A total of 98 ERCP procedures were performed in 43 liver transplanted patients during 5‐year period. The overall incidence rate of post ERCP complications was 13.27%. The most common complication was bleeding 6.12%, followed by pancreatitis 5.10%, perforation 2.04%, and cholangitis 1.02%. Among patients with post‐ERCP hemorrhage, more than half of the patients had delay bleeding and required more than two times of endoscopic procedure. Differ from general ERCP complications, all of the perforation events were related to bile duct injury.

A simple and novel marking method for correctly identifying the precutting direction to achieve safe and efficacious precut sphincterotomy (with video).

Background and study aims Failure to recognize the right direction and precise incision length during precutting has been reported. To address these concerns, we developed a marking method that places a marking on the cutting endpoint before starting precutting. This preliminary study aimed to assess the effectiveness and safety of precut sphincterotomy using our new marking method. Patients and methods Between April 2015 and May 2017, 21 patients from our tertiary referral center were included in this study. Precut sphincterotomy using our marking method was employed for difficult common bile duct cannulation cases. Before starting precutting, a marking was placed slightly before the upper margin of the bulge of the papilla in the 11- to 12-o’clock direction as a cutting endpoint by cauterization with a needle knife. Results Technical success was obtained in all 21 procedures. There were no post-endoscopic retrograde cholangiopancreatography (ERCP) complications except for one mild case of post-ERCP pancreatitis. Conclusion Our new marking method before precutting enabled precise incision and quick bile duct cannulation without causing severe complications.

Pediatric Endoscopic Procedure Complications.

This review summarizes the current body of research, define high-risk patients and endoscopic processes, and outline evidence-based countermeasures aimed at minimizing the incidence of complications during endoscopy in children. Significant complications of endoscopy requiring emergency department or inpatient admission in otherwise healthy children are unusual, but more common with therapeutic procedures; risk from procedures increases incrementally with preoperative coexisting conditions. Duodenal hematoma is predominantly a pediatric endoscopic complication and is more likely in hematology-oncology patients. Air embolism is a well-defined endoscopic retrograde cholangiopancreatography (ERCP) complication in adults and is likely to increase in children with increased performance of pediatric ERCP. Increased physician expertise is the most often proposed countermeasure, especially in the context of endoscopy complications in the higher-risk patient and procedure. Endoscopy in children remains a very safe group of procedures, although a more detailed understanding of risk factors and ideal training and practice organization is lacking.

Risk Factors for ERCP-Related Complications: A Prospective Multicenter Study in Guayaquil, Ecuador

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. A reported complication rate a! er ERCP varies between 5 % and 10 %. The aim of the present study was to investigate the potential risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complications and to identify whether the risk factors are different for pancreatitis and asymptomatic hyperamylasemia. Methods: Consecutive ERCP procedures were studied at three centers in Guayaquil, Ecuador from October 2013 to May 2017. The complications after the patients' first-only procedures were evaluated. Multivariate analysis based on the first-only procedures was used to identify the risk factors Results: A total of 652 procedures were performed. The mean number of ERCP procedures performed at each center ranged from 2.1 to 6.0 per endoscopist per week. Overall, complications developed in 52 (7.92%) patients, pancreatitis in 28 (4.31%), and asymptomatic hyperamylasemia in 96 (14.72%). In the multivariate analysis, female gender (adjusted odds ratios (ORs): 1.52, 95% confidence interval (CI): 1.14-2.02, P=0.004), periampullary diverticulum (OR: 2.02, 95% CI: 1.49-2.73, P10 min (OR: 1.51, 95% CI: 1.08-2.10, P=0.016), > or =1 pancreatic deep wire pass (OR: 1.80, 95% CI: 1.33-2.42, P10 min (OR: 1.76, 95% CI: 1.13-2.74, P=0.012), > or =1 pancreatic deep wire pass (OR: 2.77, 95% CI: 1.79-4.30, P10 min (OR: 1.96, 95% CI: 1.52-2.54, P or =1 pancreatic deep wire pass (OR: 2.24, 95% CI: 1.74-2.89, P Conclusion: In conclusion, patient-related risk factors are as important as procedure-related ones in determining the risk for overall post-ERCP complications and pancreatitis. I ese & ndings emphasize the importance in the avoidance of high-risk procedures such as unintentional pancreatic deep wire pass, prolonged cannulation time, and needle-knife precut, especially in high-risk patients such as younger women and patients with periampullary diverticulum. However, the risk factors for asymptomatic hyperamylasemia may be mostly procedure related. I e diJ erence in patient-related factors between pancreatitis and asymptomatic hyperamylasemia suggests that the host susceptibility represents an important factor in the mechanism by which post-ERCP pancreatitis develops.

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

Post-Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Complications: Our Experience and Comparison with the Literature

Post-Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Complications: Our Experience and Comparison with the Literature

Endoscopic inside stent placement is suitable as a bridging treatment for preoperative biliary tract cancer.

BackgroundEndoscopic biliary stenting (EBS) is one of the most important palliative treatments for biliary tract cancer. However, reflux cholangitis arising from bacterial adherence to the inner wall of the stent must be avoided. We evaluated the use of EBS above the sphincter of Oddi to determine whether reflux cholangitis could be prevented in preoperative cases.MethodsFifty-seven patients with primary biliary tract cancer were retrospectively recruited for the evaluation of stent placement either above (n = 25; inside stent group) or across (n = 32; conventional stent group) the sphincter of Oddi. We compared the stent patency periods prior to the time of surgical resection.ResultsThe preoperative periods were 96.3 days in the conventional stent group and 96.8 days in the inside stent group (P = 0.979). Obstructive jaundice and/or acute cholangitis occurred in 7 patients (28.0%) in the inside stent group and in 15 patients (46.9%) in the conventional stent group during the preoperative period (P = 0.150). The average patency periods of the stents were 85.2 days (range, 13–387 days) for the inside stent group and 49.1 days (range, 9–136 days) for the conventional stent group (log-rank test: P = 0.009). The mean numbers of re-interventions because of stent occlusion were 0.32 for the inside stent group and 1.03 for the conventional stent group (P = 0.026). Post-endoscopic retrograde cholangiopancreatography complications occurred in 2 patients in the inside stent group and 4 patients in the conventional stent group (P = 0.516). Postoperative liver abscess occurred in 1 patient in the inside stent group and 5 patients in the conventional stent group (P = 0.968). Inside stent placement was the only significant preventative factor associated with stent obstruction based on univariate (hazard ratio [HR], 0.286; 95% confidence interval [CI], 0.114-0.719; P = 0.008) and multivariate (HR, 0.292; 95% CI, 0.114-0.750; P = 0.011) analyses.ConclusionTemporary plastic stent placement above the sphincter of Oddi is a better bridging treatment than conventional stent placement in preoperative primary biliary tract cancer.

Twenty-Second versus Sixty-Second Dilation Duration in Endoscopic Papillary Balloon Dilation for the Treatment of Small Common Bile Duct Stones: A Prospective Randomized Controlled Multicenter Trial.

Background/AimsEndoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for the treatment of common bile duct (CBD) stones. However, there is no established consensus on the optimal balloon dilation duration (BDD). We prospectively evaluated the efficacy and post-endoscopic retrograde cholangiopancreatography (ERCP) complications between the 20- and 60-second EPBD groups.MethodsA total of 228 patients with small CBD stones (≤12 mm) were randomly assigned to undergo EPBD with a 20- or 60-second duration at six institutions. We evaluated baseline patient characteristics, endoscopic data, clinical outcomes, and procedure-related complications. In addition, we analyzed risk factors for postprocedural pancreatitis.ResultsCBD stones were removed successfully in 107 of 109 patients (98.1%) in the 20-second group and in 112 of 119 patients (94.1%) in the 60-second group (p=0.146). Post-ERCP pancreatitis developed in seven patients (6.4%) in the 20-second group and nine patients (7.5%) in the 60-second group (p=0.408). In multivariate analysis, contrast dye injection into the pancreatic duct is a significant risk factor for post-EPBD pancreatitis.ConclusionsBased on the data showing that there were no significant differences in safety and efficacy between the two BDD groups, 20 seconds of BDD may be adequate for treatment of small CBD stones with EPBD.

Surgical and Non-Surgical Management of Endoscopic Retrograde Cholangiopancreatography Complications

Surgical and Non-Surgical Management of Endoscopic Retrograde Cholangiopancreatography Complications

Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: A prospective, randomized trial

ObjectivesPancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications. MethodsA total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6–8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain. ResultsThe overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001). ConclusionsThere was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.

High Rate of Post-ERCP Pancreatitis in Patients Undergoing Endoscopic Treatment of Benign Biliary Stricture

Endoscopic treatment is the best option for patients with postsurgical stricture of main biliary duct. There is scarce information about the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in this condition. The aim was to evaluate the incidence of complications and the associated risk factors in patients undergoing ERCP for postcholecystectomy biliary stricture. Prospective analysis of patients with postsurgical stenosis of main biliary duct was carried out. Rate of post-ERCP complications was determined and the associated risk factors were analyzed. A total of 25 patients were included. The success rate of endoscopic treatment was 92% (n=23). Two patients had recurrence of stricture with median follow-up of 23 months (range, 0.3 to 65.4 mo). Five patients (20%) developed acute pancreatitis after ERCP. No risk factors were detected in multivariate analysis. Incidence of post-ERCP pancreatitis is high in patients with biliary stricture associated with surgical procedures.

Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis.

To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach. Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials (RCT) studies which met our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCP-related bleeding, perforation and cannulation success rates. Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group (OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis (PEP) was not different between the two groups (3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation (6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41). This meta-analysis suggests that pre-cut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: a meta-analysis.

To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (≥ 10 mm). PubMed, Web of Knowledge, EBSCO, the Cochrane Library, and EMBASE were searched for eligible studies. Randomized controlled trials (RCTs) that compared EPLBD with EST were identified. Data extraction and quality assessment were performed by two independent reviewers using the same criteria. Any disagreement was discussed with a third reviewer until a final consensus was reached. Pooled outcomes of complete bile duct stone clearance, stone clearance in one session, requirement for mechanical lithotripsy, and overall complication rate were determined using relative risk and 95%CI. The separate post-endoscopic retrograde cholangiopancreatography complications were pooled and determined with the Peto odds ratio and 95%CI because of the small number of events. Heterogeneity was evaluated with the chi-squared test with P ≤ 0.1 and I(2) with a cutoff of ≥ 50%. A fixed effects model was used primarily. A random effects model was applied when significant heterogeneity was detected. Sensitivity analysis was applied to explore the potential bias. Five randomized controlled trials with 621 participants were included. EPLBD compared with EST had similar outcomes with regard to complete stone removal rate (93.7% vs 92.5%, P = 0.54) and complete duct clearance in one session (82.2% vs 77.7%, P = 0.17). Mechanical lithotripsy was performed less in EPLBD in the retrieval of whole stones (15.5% vs 25.2%, P = 0.003), as well as in the stratified subgroup of stones larger than 15 mm (24.2% vs 40%, P = 0.001). There was no statistically significant difference in the incidence of overall adverse events (7.9% vs 10.7%, P = 0.25), post-ERCP pancreatitis (4.0% vs 5.0%, P = 0.54), hemorrhage (1.7% vs 2.8%, P = 0.32), perforation (0.3% vs 0.9%, P = 0.35) or acute cholangitis (1.3% vs 1.3%, P = 0.92). EPLBD could be advocated as an alternative to EST in the retrieval of large common bile duct stones.

Simultaneous bilateral biliary metal stents versus plastic stents under endoscope for treatment of malignant hilar biliary obstruction

Objective To compare the safety and efficacy of simultaneous bilateral biliary metal stents with plastic stents under endoscope for treatment of malignant hilar biliary obstruction(MHBO).MethodsFrom May 2007 to December 2011,142 MHBO patients were selected for this study,with 32 receiving bilateral metal stent drainage and 110 receiving bilateral plastic stent drainage.The success rate of endoscopic operations,postoperative jaundice-reducing effect,post-endoscopic retrograde cholangiopancreatography(ERCP) complications,and stent patency period were observed.ResultsThe procedures were successful in all patients in the two groups.The postoperative jaundice-reducing effect rates were 96.9%(31/32) in the metal stent group and 88.2%(97/110) in the plastic stent group(P0.05).Two patients in the metal stent group and six in the plastic stent group had post-ERCP cholangitis,which was relieved by anti-inflammatory intervention,replacement of stents or endoscopic nasobiliary drainage.Two patients in the plastic stent group had stent slip.There were no pancreatitis,gastrointestinal bleeding,perforation or ERCP-related deaths in the two groups.Two patients in the metal stent group and 4 in the plastic stent group died,and the biliary stents were patent until they died.Eight patients in metal stent group and 29 patients in the plastic stent group developed recurrent obstructive jaundice,which were treated by reimplantation or replacement of the plastic stents.The post-ERCP complication rates were similar in the two groups(P0.05).The median patency period of the metal stent was(248.53±138.61) d and that of the plastic stent was(101.76±38.53) d,showing significant difference by Log-rank test(P0.001).ConclusionFor Bismuth Ⅱ-type,bilateral bile duct invaded,or non-resectable MHBO patients,if biliary drainage range permits and the expected survival period 3 months,double metal stent biliary drainage has more advantages.

The utility of upfront double wire guided biliary cannulation following early unintentional pancreatic cannulation in patients undergoing ERCP

This study aims to assess the impact of upfront double-guidewire technique (DGT) following inadvertent early pancreatic duct (PD) cannulation or biliary cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A pilot non-randomized cohort study was performed in patients undergoing ERCP. DGT was utilized in the first 25 patients followed by standard cannulation technique (SCT) in the subsequent 25. A significantly lower PD cannulation rate [median (range)] was noted in the DGT group [1 (0-5) vs. 3 (0-6); p=0.013]; however, the pancreatitis rate was similar [2 (9 %) DGT, 1 (4 %) SCT; p=0.601]. In the SCT group, 15/25 (60 %) required DGT to achieve biliary cannulation. The majority of our cohort proceeding to an SCT following early PD cannulation required a DGT to achieve biliary cannulation. Early DGT resulted in a significant reduction in unintentional pancreatic cannulation but did not translate into a reduction in pancreatitis in our cohort.

Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis

Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP. We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP. Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95% confidence interval (CI) 0.29-0.53; P<0.001]. Subgroup analysis stratified according to the severity of PEP showed that a PS was beneficial in patients with mild to moderate PEP (RR 0.45; 95% CI 0.32-0.62; P<0.001) and in patients with severe PEP (RR 0.26; 95%CI 0.09-0.76; P=0.01). In addition, subgroup analysis performed according to patient selection demonstrated that PS placement was effective for both high-risk and mixed case groups. This meta-analysis showed that PS placement prevented PEP after ERCP as compared with no PS placement. We therefore recommend PS placement after ERCP for the prevention of PEP.

Endoscopic retrograde cholangiopancreatography complications in the era of cholangioscopy: Is there an increased risk?

BackgroundSingle-operator cholangioscopy allows direct visualization of the biliary tree and is being used in the diagnosis and treatment of various biliary conditions. To date, there are few data examining complications of single-operator cholangioscopy. MethodsWe evaluated all endoscopic retrograde cholangiopancreatography procedures over a two-year period and compared its complication rate to single-operator cholangioscopy in a tertiary care centre with extensive experience in single-operator cholangioscopy.A total of 2087 patients (55% men, mean age 57.4±16.4) had a therapeutic endoscopic retrograde cholangiopancreatography, out of which 169 also had single-operator cholangioscopy performed on them. Results169 single-operator cholangioscopy procedures were performed (53% men) with a mean patient age of 60.7±15.2 years. Out of the 2087 patients, 160 complications occurred (7.7%), and included pancreatitis (n=47, 2.2%), infection (n=24, 1.1%), bleeding (n=44, 2.1%), perforation (n=16, 0.8%) and other (n=29, 1.4%). Univariate analysis on overall complications identified seven variables with a p value<0.2, which were included in the multivariate analysis. Biliary sphincterotomy, pancreatic duct stent placement, and ampullectomy were associated with increased complications. Single-operator cholangioscopy was not associated with increased complications on multivariate analysis. ConclusionSingle-operator cholangioscopy is not associated with an increased rate of complications when compared to endoscopic retrograde cholangiopancreatography. The types and frequencies of overall endoscopic retrograde cholangiopancreatography complications are similar to previously reported series.

Prevention and Management of Post-Endoscopic Retrograde Cholangiopancreatography Complications

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a spectrum of complications such as pancreatitis, hemorrhage, perforation, and cardiopulmonary events. These complications can range from mild to severe resulting in extended hospitalization, requiring surgical intervention, and leading to permanent disability or even death. Complications of ERCP have been better understood in the past decade, with adoption of standardized consensus-based definitions of complications and introduction of new recommendations to minimize risks of ERCP. Adequate selection of patients undergoing ERCP, skilled operators using novel techniques and prompt identification and treatment are key to successful prevention and management.

Post-endoscopic retrograde cholangiopancreatography complications: How can they be avoided?

Endoscopic retrograde cholangiopancreatography (ERCP) has a significant complication rate which can be lowered by adopting technical variations of proven beneficial effect and prophylactic maneuvers such as pancreatic stenting during ERCP or periprocedural non-steroidal anti-inflammatory drug administration. However, adoption of these prophylactic maneuvers by endoscopists is not uniform. In this editorial we discuss the beneficial effects of the aforementioned maneuvers.