Selective Cannulation Research Articles

Usefulness of sheathless guiding catheters in patients with upper extremity vascular anomalies: Sheathless catheters in upper vascular anomalies.

The transradial approach (TRA) reduces hospitalisation and access-site complications as compared to the transfemoral approach. Nevertheless, the TRA technical failure rate is significantly higher compared to the transfemoral approach. The high failure rate of TRA is due to a series of factors. In particular, a wide range of anatomic vascular variants hindering procedural success may be present in patients undergoing TRA procedures. In our retrospective observational study, 1,596 consecutive patients with upper limb vascular anomalies underwent TRA between January 2006 and July 2017. We evaluate the usefulness of the sheathless guiding catheter system (SG) as compared to the conventional guiding catheter (CG). The primary study endpoint was the "procedural success" defined as successful transradial procedure (both selective cannulation of the coronary ostium in the diagnostic procedure and successful stent delivery in the interventional procedure) without access change. All SG procedures were successful, whereas only 1,274 (86%) CG procedures were successfully performed (p=0.0001). At multivariable analysis, age (p=0.001) and sheathless catheter use (p=0.001) were independent predictors of procedural success. The sheathless GC is a safe and useful system not only for small radial access but also in the presence of upper vascular anomalies and it can be used in PCI and diagnostic procedures.

A novel teaching tool for visualizing the invisible bile duct axis in 3 dimensions during biliary cannulation (Compact Disc method).

Selective biliary cannulation is difficult to master, even in cases with normal papillae.1 In the case of a papilla with a long oral protrusion (LOP), the difficulty is greatly increased.2 In such cases, visualization of the invisible bile duct axis in 3 dimensions is required, but this is difficult to master, even for experienced endoscopists. Individual trainers must commit to developing their teaching skills3; however, there is no dedicated teaching tool for this difficult task. Therefore, we developed a novel and simple teaching tool for visualizing the invisible bile duct axis in 3 dimensions, called the compact disc (CD) method.

Su1264 EUS-GUIDED HEPATICOGASTROSTOMY AS SALVAGE TREATMENT FOR ACUTE CHOLANGITIS SECONDARY TO HILAR MALIGNANT OBSTRUCTION

Unresectable malignant hilar biliary obstruction (MHBO) often cause complicated biliary obstruction requiring a challenging endoscopic biliary drainage. Endoscopic transpapillary stenting using multiple metal stent has been recently reported with high technical and clinical success. However, reintervention with transpapillary endoscopic stenting often encounters technical difficulty in selective intrahepatic biliary cannulation when acute cholangitis occurs in the segmental bile duct beyond the indwelling trasnpaillary metal stents or the severe biliary stricture. EUS-guided hepaticogastrostomy (EUS-HGS) potentially provides effective isolated biliary drainage for MHBO as a therapeutic option. In this study, we evaluated the safety and feasibility of EUS-HGS for acute cholangitis in the segmental bile duct in MHBO patients. We retrospectively investigated the clinical outcome of EUS-HGS in acute cholangitis for MHBO after transpappilary endoscopic approach were failed or supposed to be challenging between April 2015 and Octorber 2019. Technical success rate, the details of the procedure, clinical success rate (resolution of acute cholangitis and reintroduction of chemotherapy), and procedural complications were evaluated. A total of 32 patients were underwent EUS-HGS for MHBO during our study period. Technical success rate was 90.6% (n=29). In technical success 29 patients, 21 were men; the median age was 70 (range from 25 to 94 years old). The puncture sites of the intrahepatic bile duct were B2 (52%), B3 (41%) and B6 (7%). The cancer primary was hilar cholangiocarcinoma (34%), gallbladder cancer (24%), intrahepatic cholangiocarcinoma (17%), pancreatic cancer (17%), and other cancers (17%). ECOG performance status (PS) before EUS-HGS was PS 0, 17%; PS 1, 58%; PS 2, 17%; PS 3, 7%; and PS 4, 0%. Cholangitis severity before EUS-HGS was Grade 1 (mild), 38%; Grade 2 (moderate), 62%; Grade 3 (severe), 0%, based on the criterion of Tokyo Guidelines 2018 (TG18). The stents for EUS-HGS were plastic (83%) and metal (17%). Resolution rate of cholangitis was 89%, and reintroduction rate of chemotherapy was 68%. In better performance status (PS 0-1) or milder acute cholangitis by TG18 evaluation criteria, chemotherapy-resume rate were favorable, compared to poor PS (PS 2-4) (88% vs. 58%, p = 0.06) or more severe acute cholangitis (53% vs. 16%, p = 0.04), in any stent types nor drainage route. Complication rate was observed in 4 cases (13%); 2 abdominal emphysema and 2 liver abscess as late complications. All the adverse events were conservatively managed. In our study, EUS-HGS showed a safe and feasible drainage approach for acute segmental isolated cholangitis in MHBO, when endoscopic trasnpapillary approach failed or became difficult.

Endoscopic Extraction of CBD Stone: single centre experience in tertiary care centre

Background and Aims: Introduction: Endoscopic Retrograde Cholangiopancreatography(ERCP) has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to presence of a large stone, multiple stones, periampullary diverticula or CBD stricture. The aim of this study was to evaluate the success of CBD cannulation, Endoscopic Sphincterotomy(EST) and CBD clearance in initial attempt, identify the failures of stone extraction and assess the post-ERCP complications.
 Methods: A prospective study was carried out over the period of January 2019 to January 2020 on 100 consecutive patients with CBD stones. ERCP was done and the stone size and number recorded. EST was performed using a diathermy unit with a cutting current and stones were extracted using a Balloon catheter or a Dormia basket.
 Results: Of the 100 patients, 44 were male and 56 were female with mean age of 52}17years. Selective CBD cannulation and cholangiogram was achieved in 90%, EST was successful in 90% and complete stone clearance was achieved in first attempt in 46 patients (59%). 52 patients had difficult CBD stone. There were nine complications, most of which rapidly resolved on conservative treatment (four post-ERCP pancreatitis, three bleeding and one retroperitoneal perforation) and one mortality in an old lady due to PSVT that couldn’t be directly attributed to ERCP. Among patients with Stone less than 15 mm in diameter(n=58), stone was removed successfully in 45 patients(78%) whereas in patients with stones over 15 mm (n=20) only one was removed successfully (5%) at initial attempt. Of these 32 patients with residual stones, 13 were referred for surgery and 19 had insertion of biliary stent to be followed by repeat ERCP.
 Conclusion: Endoscopic therapy is a simple, effective and safe method of treatment in patients with CBD stone.

Bouncing off the balloon: A new trick for selective cystic duct cannulation.

Selective cannulation of the cystic duct for endoscopic transpapillary gallbladder drainage can be challenging in cases with a caudally branching cystic duct. Gulati and Rustagi describe a novel and simple technique in which a guidewire is bounced off a stone extraction balloon and redirected into the cystic duct.

The intracranial vasculature of canines represents a model for neurovascular ischemia and training residents and fellows in endovascular neurosurgery.

We describe use of a canine model to evaluate physiological effects and neuroprotective strategies in the setting of cerebral ischemia and endovascular neurosurgery training. We performed transfemoral digital subtraction cerebral and cervical angiography on eight anesthetized dogs. Angiographic images of cerebral arteries were obtained following cannulation of the femoral artery. Cerebral ischemia models were made after angiography. The canine cerebral vasculature exhibited extensive tortuosity of the carotid and vertebral arteries. Conversely, the bilateral anterior spinal arteries were easily catheterized using microcatheters and microguidewires. The basilar artery and its branches were facilely cannulable. Circle of Willis continuity sans hypoplasia or aplasia of its constitutive segments was appreciated in all animals. The middle cerebral arteries could be easily accessed via the posterior communicating arteries. We generated an empirically evaluable therapeutically interventional experimental animal model of cerebral ischemia by occluding the middle cerebral artery using small coils for a duration between 15 and 60 min. Unique amenability of the canine intracranial vasculature to selective and microcatheter cannulation renders experimentally induced cerebral, cerebellar, and brainstem via occlusion of the supratentorial and infratentorial arteries a simple matter. The neural vasculature irrigating the canine cerebrum, brainstem, and cerebellum may consequently prove useful in helping young and nascent endovascular neurosurgeons in developing and refining their skills of microcatheter navigation and manipulation and deployment of therapeutic devices to achieve effective occlusion of aneurysms, arteriovenous malformations, arteriovenous fistulas, and neoplasms of the intracranial cavity.

The Expansion of Cholangioscopy: Established and Investigational Uses of SpyGlass in Biliary and Pancreatic Disorders

Direct visualization of bile and pancreatic duct pathology is proving to be beneficial in patients where previous techniques have failed. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. It is already known that SpyGlass is beneficial in patients with difficult bile duct stones and indeterminate biliary lesions through the use of targeted lithotripsy and visually guided biopsy. Cholangioscopy allows the visualization of hidden stone and guide wire placement across difficult strictures and selective cannulation of the intrahepatic and cystic ducts. It is also demonstrating its utility in investigational applications such as post-liver transplant and primary sclerosing cholangitis stricture treatment, evaluation of hemobilia, and guided radiofrequency ablation of ductal tumors. In addition to having clinical utility, cholangioscopy may also be cost-effective by limiting the number of repeat procedures. Cholangioscopy overall has similar complication rates compared to other standard endoscopic retrograde cholangioscopy (ERCP) techniques, but there may be higher rates of cholangitis. This could be mitigated with prophylactic antibiotic use, and overall, cholangioscopy has similar complication rates compared to other techniques.

Percutaneous Coronary Intervention in an Octogenarian With Anomalous Origin Arising From Right Sinus: A Rare Case Report

Anomalous coronary artery origins are not common in routine clinical practice. The incidence of coronary anomalies in patients undergoing coronary angiography is less than 1%. The greatest challenges faced in the management are delays in identification and difficulty engaging the anomalous coronary artery. Operator experience in promptly identifying the anomaly and selection of the appropriate catheter is critical for successful intervention. We are presenting a case of acute inferior and posterior wall myocardial infarction (MI) with an anomalous origin of the left circumflex artery from the right coronary sinus. Learning objective is that percutaneous coronary intervention (PCI) in an anomalous left circumflex can be technically difficult because selective cannulation of the vessel may not be easy. An anomalous left circumflex artery has a rare presentation of ST-elevation myocardial infarction (STEMI). Complicated STEMI with cardiogenic shock is not commonly seen in anomalous coronary artery origin from the right sinus. Percutaneous intervention in patients with STEMI with an anomalous left circumflex artery has a high risk and is technically challenging. J Med Cases. 2020;11(2):41-43 doi: https://doi.org/10.14740/jmc3429

A272 THE CANADIAN DIRECT OBSERVATION OF PROCEDURAL SKILLS (CANDOPS) TOOL FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A MULTI-CENTRE PROSPECTIVE STUDY

Abstract Background Previous studies have demonstrated that many graduating trainees may not have all of the skills needed to independently practice endoscopic retrograde cholangiopancreatography (ERCP) safely and effectively. As a part of competency-based learning curriculum development, it is essential to provide formative feedback to trainees and ensure they acquire the knowledge and skills for independent practice. Aims To assess the performance of advanced endoscopy trainees across Canada using the Canadian Direct Observation of Procedural Skills (CanDOPS) ERCP assessment tool. Procedural items evaluated include both technical (cannulation, sphincterotomy, stone extraction, tissue sampling, and stent placement) and non-technical (leadership, communication and teamwork, judgment and decision making) skills. Methods We conducted a prospective national multi-centre prospective study. Advanced endoscopy trainees with at least two years of gastroenterology training or five years of general surgery in North America and minimal experience performing ERCPs (less than 100 ERCP procedures) were invited to participate. The CanDOPS tool was used to measure every fifth ERCP performed by trainees over a 12-month fellowship training period. ERCPs were evaluated by experienced staff endoscopists at each study site under standard clinical protocol. Cumulative sum (CUSUM) analyses were used to generate learning curves. Results The data from five Canadian sites and 11 trainees participated in the study. A total of 261ERCP evaluations were completed. Median number of evaluations by site and trainee was 49 (IQR 31–76) and 15 (IQR 11–45). Median number of cases trainees performed prior to their ERCP training was 50 (IQR 25–400). There was a significant improvement in almost all scores over time, including selective cannulation, sphincterotomy, biliary stenting and all non-technical skills (P<0.01). CUSUM analyses using acceptable and unacceptable failure rates of 20% and 50% demonstrated trainees achieved competency for most measures in their final month of their training. Competency in tissue sampling was not achieved within a one-year training period. Conclusions This is the first ERCP performance evaluation tool that examines multiple technical and non-technical aspects of the procedure. Although trainee ERCP skills do improve during their training period, there exists a notable variability in time to competency for the different skills measured using the CanDOPS tool. Large prospective research is required to determine if competency is achieved using more stringent definitions of ERCP competency and to determine factors associated with reaching competency. Funding Agencies None

COMPLICATIONS OF TRANSPAPILLARY ENDOSCOPIC INTERVENTIONS (TEI)

Summary. Objective — a retrospective analysis of the causes of TEI complications and the results of their treatment.
 Materials and methods. The long-term results of performed TEI in 2909 patients were analyzed. The most common indication for TEI was choledocholithiasis, which was found in 1873 (65.4 %) patients and stenosis of papilla was detected in 454 (15.6 %) patients. Complications arose in 112 (3.85 %) patients. 4 (0.14 %) patients died.
 Results. Bleeding occurred in 28 (0.96 %) patients. In 12 of 26 patients, endoscopic hemostatic manipulations were additionally performed. Two patients with profuse bleeding from a papillotomy wound were urgently operated on, one patient died. Acute pancreatitis occurred in 68 (2.33 %) patients, of which 56 (1.92 %) had an edematous form, and 12 (0.41 %) patients had a destructive form. 11 patients were operated on from 2 to 15 days from the onset of the disease. Two patients with pancreatic necrosis died of intoxication, the source of which was progressive retroperitoneal necrosis. In 5 (0.17 %) patients, intervention on the papilla was complicated by perforation of the wall of the duodenum. 4 out of 5 patients were urgently operated on (B-2 antrumectomy, external drainage of the common bile duct and retro duodenal space). All 4 patients recovered. In 1 patient, complication was diagnosed on the 5th day after the intervention, which led to delayed surgery and the death of the patient. In 11 patients (0.38 %), a Dormia basket with a stone in the distal part of the common bile duct wedged when trying to extract it. Only one of 11 patients was operated on as planned; in the remaining 10, the problem was resolved with repeated TEI.
 Conclusions. Punctual technical implementation of all stages of manipulation, selective cannulation of the bile ducts, careful x-ray control of the position and advancement of the instrument in the ducts helps to reduce the number of complications after TEI.

Validation of a Novel Endoscopic Retrograde Cholangiopancreatography Cannulation Simulator.

Background/AimsEndoscopic retrograde cholangiopancreatography (ERCP) requires a unique skill set. Currently, there is no objective methodology to assess and train a professional to perform ERCP. This study aimed to develop and validate a novel ERCP simulator. MethodsThe simulator consists of papillae presenting different anatomy and positioned in varied locations. Deep cannulation of the pancreatic duct, followed by the bile duct, was performed. The time allotted was 5 minutes. The content validity indexes (CVIs) for realism, relevance, and representativeness were calculated. Correlation between ERCP experience and simulator score was determined. ResultsTwenty-three participants completed the simulation. The CVIs for realism were orientation of duodenoscope to papilla (1.00), angulation of papillotome to achieve cannulation (0.71), and haptic feedback during cannulation (0.80). The CVIs for relevance were use of elevator (1.00), wheels to achieve en face orientation (1.00), and papillotome for selective cannulation (1.00). Regarding CVI for representativeness, the results were as follows: basic cannulation (0.83), papilla locations (0.83), and papilla anatomies (0.80). The novice, intermediate, and experienced groups scored 6.7±8.7, 30.0±16.3, and 74.4±43.9, respectively (p<0.0001). There was a strong correlation between the ERCP experience level and the individual’s simulator score (Pearson value of 0.77, R2 of 0.60). ConclusionsThis simulator appears to be realistic, relevant, and representative of ERCP cannulation techniques. Additionally, it is effective at objectively assessing basic ERCP skills by differentiating scores based on clinical experience.

Difficult Biliary Cannulation from the Perspective of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Identifying the Optimal Timing for the Rescue Cannulation Technique.

Background/AimsRecently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP).MethodsAn ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis.ResultsWe analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2=49.857, p<0.001) and inadvertent PD manipulation (χ2=8.556, p=0.010) were decisive factors. PEP occurred in 3.9%, 11.8%, and 16.2% of patients with biliary cannulation duration lasting 3 to 5 minutes, >5 minutes, and >5 minutes with inadvertent PD manipulation, respectively.ConclusionsBiliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique. (Gut Liver 2021;15-465)

Fallopian tubal obstruction is associated with increased pain experienced during office hysteroscopy: a retrospective study.

This study aimed at evaluating the pain experienced during office hysteroscopy, with selective tubal cannulation and chromopertubation, by women with and without tubal obstruction in order to determine if such condition would be associated with increased pain during the examination. Women with a history of infertility underwent in-office hysteroscopy with selective chromopertubation using a continuous flow office hysteroscope with a 5Fr operating channel fitted with a 4Fr catheter for the injection of methylene blue dye. Experienced pain was recorded on a Visual Analog Scale (VAS) during diagnostic hysteroscopy after access to the uterine cavity. Of 90 women, 58 (66.4%) were found with at least one patent fallopian tube and inserted in the group "any", meanwhile 32 (33.6%) were categorized into group "none" as both tubes were judged obstructed. There was no significant difference between groups in BMI and primary infertility rate, but the difference was significant concerning mean age (32.6 vs. 35.8; p < 0.001). The mean VAS score was 3.34 (± 1.07) in the group "any" and 4.25 (± 1.11) in "none". Comparing the VAS score of the two groups, the difference was significant (p < 0.001). Tubal occlusion may have a potential role in the pain experienced by women undergoing in-office hysteroscopy. Women with bilateral tubal occlusion experienced a higher level of pain compared with patients with at least one patent fallopian tube. Operators may use milder intrauterine pressure of fluid distension medium when these patients are undergoing in-office hysteroscopy to reduce discomfort.

Double balloon enteroscopy improves ERCP success in patients with modified small bowel anatomy.

OBJECTIVE:The aim of this study was to evaluate the effect of double-balloon enteroscopy (DBE) on the success of endoscopic retrograde cholangiopancreatography (ERCP) procedures in patients with surgically modified gastrointestinal (GI) tract anatomy.METHODS:The medical records of patients who underwent ERCP in the Gastroenterology Department of Kocaeli University School of Medicine hospital between December 2008 and September 2014 were examined. From the patient group that was scheduled to undergo DBE-ERCP, the details of cases in which ERCP via standard duodenoscope or DBE-ERCP was performed during the same session because standard ERCP failed were included. Procedure parameters, outcomes, and complications related to the procedure in both groups were analyzed. Patients who underwent the DBE-ERCP procedure directly, those who underwent push enteroscopy, or gastroscopy to evaluate the GI tract anatomy before the day of ERCP, and who underwent DBE-ERCP on a day other than the initial ERCP session were excluded. Afferent loop intubation, access to the major papilla, selective cannulation, therapeutic success rates, and the effect of DBE on overall procedure success were evaluated.RESULTS:Fifty-one patients with a history of BII gastrojejunostomy and 11 patients with hepaticojejunostomy (with or without Roux-en-Y) were included in the study. In all patients, the ERCP procedure was initiated with a standard duodenoscope. If intubation of the afferent loop was unsuccessful in reaching the major papilla or enterobiliary anastomosis, DBE was used. In 30 (48.4%) of the 62 patients whose GI tract was anatomically altered, the duodenoscope was successfully advanced to the ampulla and 27 (43.5%) were cannulated successfully. Thirty-one patients underwent DBE-ERCP. DBE reached the ampulla or enterobiliary anastomosis in 30 patients (96.8%) and selective choledocus cannulation was achieved in all patients but 3 (90%), including 1 patient with a hepaticojejunostomy. The overall ERCP success rate increased from 43.5% (27/62) to 87.1% (54/62). Two perforations (1 during standard duodenoscopy and 1 with DBE-ERCP) were observed.CONCLUSION:The overall success rate of ERCP increased with use of the DBE technique in patients with small bowel anatomic variations that were the result of previous surgery.

442 Anomalous Coronary Circulation Arising From a Solitary Coronary Ostium: First Australian Report

Anatomical variations whereby all three coronary arteries arise from a solitary coronary ostium are very rare. A 61-year-old female underwent coronary angiography for assessment of severe biventricular systolic dysfunction. This demonstrated the entire coronary circulation, comprising of all 3 major epicardial arteries, arising from a solitary coronary ostium located in the right coronary cusp. Selective cannulation of all 3 arteries was achieved with the 5F internal mammary catheter. The LAD had an initial posterior course, likely between the aorta and pulmonary artery, and was dual supplied by the RCA, which was large and dominant. An aortogram confirmed no other coronary arteries arising from the remaining aortic cusps. A CT coronary angiogram was scheduled, however the patient unfortunately died from a sudden asystolic arrest. To our knowledge, this is the first reported case of anomalous coronary circulation arising from a solitary coronary ostium in Australia.Figure 1RCA, 2 – LAD, 3 – LCxView Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 1RCA, 2 – LAD, 3 – LCxView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of cone beam - CT on adrenal vein sampling in primary aldosteronism

PurposeThe aim of this study in a group of patients with primary aldosteronism was to evaluate the contribution of CB-CT (cone beam CT) to the overall success rate of adrenal vein sampling (AVS), and in particular to the selective cannulation of the right adrenal vein (RAV). MethodThis was a retrospective single-center study including 91 AVS procedures performed by our consultant radiologist between March 2011 and January 2017. Fifty cases were performed with CB-CT and 50 were performed without. Angiography with CB-CT was carried out after RAV cannulation to check the accurate catheter position. For each patient, we collected technical and biochemical success rates, as well as irradiation data. ResultsThe overall success rate of AVS with CB-CT was 80 %, vs. 44 % without (p = 0.00046), with right-sided selectivity of 88 % vs. 49 % (p < 0.0001). There was no significant increase in radiation exposure with CB-CT (p = 0.8206). Fluoroscopy time and quantity of iodine injected were significantly lower with CB-CT than without (p = 0.0039 and p < 0.0001). ConclusionCB-CT allows a better evaluation of the selectivity of right-sided adrenal catheterization and greatly increases the overall success rate of AVS.

Selective Biliary Cannulation for a Papilla in the 9 o’clock Position Using Pull and Rotatable Sphincterotome

Selective Biliary Cannulation for a Papilla in the 9 o’clock Position Using Pull and Rotatable Sphincterotome

Multicenter database registry for endoscopic retrograde cholangiopancreatography: Japan Endoscopic Database Project

Few studies have reported on a national, population-based endoscopic retrograde cholangiopancreatography (ERCP) database. Hence, in 2015, we established a multicenter ERCP database registry, the Japan Endoscopic Database (JED) Project in preparation for a nationwide endoscopic database. The objective the present study was to evaluate this registry before the establishment of a nationwide endoscopic database. From 1 January 2015 to 31 March 2017, we collected and analyzed the ERCP data of all patients who underwent ERCP in four participating centers in the JED Project based on the JED protocol. Four centers carried out 4104 ERCP on 2173 patients. Data entry of ERCP information (age, 100%; gender, 100%; American Society of Anesthesiologists Physical Status Classification System, 74.5%; scope, 92.7%; time to ERCP, 100%; antithrombotic drug information, 55.0%; primary selective common bile duct [CBD] cannulation methods, 73.0%; number of attempts at primary selective CBD cannulation, 67.6%; overall selective CBD cannulation methods, 68.9%; ERCP procedure time, 66.3%; fluoroscopy time, 65.1%; adverse events, 74.9%; serum amylase levels 1day post-ERCP, 36.5%) was accurately extracted from the four centers. Success rate of CBD cannulation by level of ERCP difficulty was 98.5%, 99.0%, and 96.4% in grades 1, 2, and 3, respectively. Complication rate by overall selective CBD cannulation method was 5.6%, 7.6%, and 10.5% in the contrast-assisted technique, guidewire-assisted technique, and cross-over method, respectively. Data from this evaluation of the JED Project, a multicenter ERCP database registry, suggest the feasibility of establishing a nationwide ERCP database and its challenges.

1294 Large Common Bile Duct Stones Creating a Rare Distal Choledochoduodenal Fistula Requiring Unusual Extraction Method

INTRODUCTION: Choledochoduodenal fistulas (CDF) are abnormal connections of the common bile duct to the duodenum separated into proximal and distal. Of the various enterobiliary fistula, the most common is cholecystoduodenal. The rare occurring distal CDF etiologies include cholecystolithiasis, malignancy, peptic ulcers and iatrogenic. In the case presented, common bile duct (CBD) stones were large enough to create a fistula from the common bile duct superior to the sphincter of Oddi requiring unique extraction. CASE DESCRIPTION/METHODS: A 75-year-old Caucasian female with past medical history significant for biliary colic status post cholecystectomy was found to have multiple large CBD stones on abdominal ultrasound outpatient. Physical exam and laboratory analysis was unremarkable. When the ERCP was performed, the papilla was identified and noted be abnormal. The papilla was downward facing. Shockingly, superior to the papilla was a CDF created by an impacted black CBD stone. Subsequently to this unexpected finding, selective deep cannulation of CDF, adjacent to the CBD stone, was done using a sphincterotome with a 0.035 wire. No attempts were made of cannulating the papilla. The cholangiogram showed multiple CBD stones throughout the distal CBD. A 13 mm sphincterotomy superiorly at the CDF, followed by balloon sweeps removing several large yellow cholesterol appearing stones. DISCUSSION: Distal CDF is diagnosed via endoscopy and categorized based on location using the Ikeda classification. Type 1 (distal) fistulas occur along longitudinal fold adjacent to the papilla, often due to an impacted stone. Type 2 (proximal) occurs on the posterior wall of the duodenal bulb. The classification system further separates CDF into type A, opening greater than 2 cm from the papilla, type B, opening within 2 cm from the papilla, and type C, opening on the papillary fold. In this rare case of distal CDF, the diagnosis was likely type 1A (distal and greater than 2 cm from the papilla). Treatment is often based upon the etiology of CDF formation. Given the rare occurrence, it is important for gastroenterologist to be aware of the classifications as it may assist in treatment and safe stone removal.

Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis.

Background and study aims Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.