Success Rate Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting.

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

BackgroundTo improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP.MethodsWe performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children.ResultsBased on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03).ConclusionsERCP appears to be performed safely in children with a similar success rate as in the adult population.

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

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

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum.

Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV. Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected. Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology-assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%. The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology-assisted rendezvous ERCP can be considered.

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

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

Safety and Efficacy of Endoscopic Retrograde Cholangio-Pancreatography in Patients of Liver Cirrhosis: A Case-Control Study.

Background With the improvement in noninvasive diagnostic imaging modalities, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has evolved into a primarily therapeutic procedure. Besides being efficacious and one of the most commonly done procedures, ERCP is also associated with a high risk of complications. However, there is a lack of studies analyzing the safety and success of ERCP in patients with liver cirrhosis. We retrospectively evaluated the outcome of ERCP in patients with cirrhosis of the liver compared to non-cirrhotic patients using the database from our institute. Methods Patients with liver cirrhosis who underwent ERCP from January 2010 to March 2020 were analyzed. This was a matched case-control study in which one cirrhotic patient undergoing ERCP was age and gender-matched randomly to one non-cirrhotic patient. We compared adverse events and the success rate of ERCP between cirrhotic patients and non-cirrhotic patients. The primary outcome of the study was analyzing the prevalence of procedure-related adverse events and their independent risk factors in patients of cirrhosis compared to the non-cirrhotic population. Results Two hundred patients were analyzed in both groups. Choledocholithiasis was the most common reason for ERCP in both groups. Mean Child-Turcotte-Pugh (CTP) score and Model for End-stage Liver Disease (MELD) score in the cirrhosis group were 9.16 ±1.78 and 19.09 ±7.06 respectively. Patients in the cirrhosis group had a significantly higher frequency of complications compared to the controls: 41 (20.5 %) versus 15 (7.5%), p < 0.01. Bleeding was the most common adverse event in both groups: 19 (9.5%) vs 6(3%). High International Normalised Ratio (INR), low platelets, and cholangitis at presentation were independently predictive of post-ERCP complications. Despite a similar technical success rate, the clinical success rate was lower in the cirrhotic than in the noncirrhotic group (83.9% versus 97.9%, p=0.006). Conclusion The prevalence of complications following ERCP was nearly three-fold higher in patients with cirrhosis than in non-cirrhotic patients. These events were related primarily to cholangitis, coagulopathy, and the advanced status of chronic liver disease.

Outcomes of delayed versus early endoscopic intervention for acute biliary pancreatitis with non-severe acute cholangitis

BackgroundDespite previous studies on endoscopic interventions in patients with acute biliary pancreatitis (ABP), the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) for ABP with non-severe acute cholangitis (AC) remains controversial.MethodsWe performed a retrospective cohort analysis of patients with concurrent ABP and non-severe AC. The patients were divided into two groups: those who underwent ERCP ≤ 72 h after admission (early ERCP group) and those who underwent ERCP > 72 h after admission (delayed ERCP group). The primary outcomes were the technical success rate and ERCP-related complications.ResultsThe study involved 164 patients (early ERCP, n = 70; delayed ERCP, n = 94) who were treated from 1 December 2 to 2016 to 12 December 2021. The patients’ baseline characteristics were not significantly different between the two groups. The technical success rate of ERCP was similar between the two groups (94.29% vs. 97.87%, p = 0.43). Morbidity was also similar between the two groups (p = 0.83). There was no significant difference in the total hospital stay (p = 0.13). However, the early ERCP group had a longer post-ERCP hospital stay (p < 0.001).ConclusionThis retrospective analysis showed that delayed ERCP performed > 72 h after admission has economic and safety outcomes similar to those of early ERCP for patients with concurrent ABP and non-severe AC.

Impact of periampullary diverticulum on biliary cannulation: A retrospective cohort study

AbstractThe prevalence of periampullary diverticulum (PAD) is relatively high in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). It is currently unclear if the presence of PAD impacts the success, difficulty, and complication rates of ERCP. The aim of the study is to investigate and compare the success rate, procedure difficulty, and complication rate between patients with or without PAD. Patients with PAD were further analyzed according to location and size. A total of 548 ERCP procedures were performed at our endoscopy center from 2015 to 2016. Those patients with previous ERCP, inability to locate the ampulla or abandoned procedure were excluded. 357 procedures were analyzed. A t test (normally distributed) or Mann‐Whitney U test (skewed) for continuous data and chi‐square or fisher's exact test for categorical data. A total of 116 were found to have PAD. The ampulla was located within the diverticulum in 8.9%, on the edge in 38.9%, and near in 52.2%. 64.3% of the PAD was large and 35.7% small. Patients with PAD were significantly older (P &lt; .001) and more likely to undergo ERCP for common bile duct stone (P = .007). There was no difference in ERCP grade, cannulation difficulty, cannulation success, procedure time, and complication rate between the two groups. Location and size of PAD also did not impact ERCP. The presence of PAD did not affect ERCP cannulation rates, increase the difficulty of cannulation or caused more complications.

Can endoscopic retrograde cholangiopancreatography-related procedures for resolving acute cholangitis be effectively and safely performed in patients with surgically altered anatomy? Comparison study to evaluate the timing of short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography.

Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)-assisted ERCP in patients with SAA and AC. Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS). Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4-9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS. Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.

S106 Management of Post-Cholecystectomy Bile Leaks: Predictors for Persistent Leak After Initial ERCP

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a 1st-line treatment for post-cholecystectomy bile leaks (PCBL). Despite appropriate initial ERCP interventions that optimize transpapillary bile flow, PCBL can persist. We aim to evaluate baseline clinical factors associated with persistent PCBL after initial ERCP. Methods: We created a retrospective database of patients with PCBL referred for ERCP at Indiana University Health (IUH) University Hospital. Data collected included endoscopic reports, fluoroscopic imaging, patient demographics, type of PCBL, ERCP timing and interventions, technical success, and treatment outcomes. A high-grade bile leak (HG-BL) was defined as visualization of contrast extravasation from the bile duct before filling of intrahepatic biliary branches with contrast. The PCBL was deemed to be persistent if > 1 interventional ERCP was required for the leak to resolve on cholangiogram. (Figure) Results: From 2011 to 2021, 369 cases of PCBL were referred for ERCP. After excluding cases with transected bile ducts (n=21) and patients lost to follow up (n=15), 333 cases were included in data analysis (Image 1). 21 patients received their initial ERCP at an outside hospital. All patients received biliary sphincterotomy with stenting unless there was coagulopathy or Roux-en-Y gastric bypass (n=12). Univariate logistic regression analysis identified male gender, steroids use at time of ERCP, presence of duodenal stricture, a HG-BL, Strasberg class D PCBL, presence of biloma, presence of abdominal drain, presence of biliary stricture, and initial ERCP performed at outside hospital to be significant variables for persistent PCBL (Table). On multivariate analysis, presence of a HG-BL (OR 7.08, CI 1.96 – 25.58, p = 0.003) and initial ERCP performed at an outside facility (OR 29.14, CI 3.35 – 253.63, p=0.002) remained significantly associated with persistent PCBL. Being a female gender (OR 0.30, CI 0.11 – 0.85, P = 0.022) remained significant for higher odds of PCBL resolution after initial ERCP. Conclusion: Our study suggests that a HG-BL in a male patient may justify more aggressive ERCP interventions or more prolonged stent indwell time. As a tertiary referral hospital, we had a significant referral bias in our cohort, which could have acted as a confounder causing statistical significance for lower initial ERCP success rates at outside medical facilities. The relatively high volume of ERCP cases at our center may also have contributed to better ERCP outcomes.Figure 1.: Flowchart of the Study Table 1. - Univariate analysis of clinical variables for persistent PCBL after initial ERCP treatment Variables Initial ERCP failure OR (95% CI) P value Patient Characteristics Female 25/204 (12.25%) 0.49 (0.27 – 0.86) 0.013 Age 55 years old or more 34/175 (19.43%) 1.60 (0.90-2.86) 0.112 Median BMI (IQR) 32.0 (26.0, 36.0) 1.00 (0.98 – 1.03) 0.874 On diabetic treatment 13/58 (22.41%) 1.81 (0.93 – 3.53) 0.083 On steroids 4/6 (66.67%) 10.18 (1.82 – 57.00) 0.008 Major papilla within duodenal diverticulum 11/57 (19.30%) 1.46 (0.73 – 2.93) 0.282 Duodenal stricture/stenosis 5/10 (50.00%) 5.17 (1.45 – 18.48) 0.011 Location and timing of ERCP Procedure ERCP performed > 3 days 48/273 (17.58%) 1.00 (0.47 – 2.12) 0.994 Initial ERCP performed at outside facility 17/21 (80.95%) 30.94 (9.96 -96.06) < 0.001 Bile leak characteristics Strasberg Class A bile leaks 44/302 (14.57%) 0.26 (0.12 – 0.54) < 0.001 Strasberg Class D bile leaks 10/31 (32.26%) 2.70 (1.19 – 6.12) 0.018 Bile leak from cystic duct* 34/192 (17.71%) 1.25 (0.70 – 2.24) 0.446 Bile leak from duct of Luschka 4/104 (3.85%) 0.21 (0.09 – 0.50) < 0.001 Bile leak from common bile duct/common hepatic duct 7/25 (28.00%) 2.66 (1.13 – 6.27) 0.025 High-grade bile leak 25/63 (39.68%) 4.80 (2.58 – 8.95) < 0.001 Concomitant biloma present 27/115 (23.48%) 2.06 (1.13 – 3.76) 0.018 Percutaneous abdominal drain present 42/204 (20.59%) 2.02 (1.07 – 3.82) 0.030 Presence of biliary stones 5/67 (7.46%) 0.34 (0.13 – 0.88) 0.026 Presence of biliary stricture 7/21 (33.33%) 2.63 (1.01 – 6.84) 0.048 ERCP interventions Biliary sphincterotomy performed 56/325 (17.23%) 1.04 (0.22 – 4.88) 0.960 Biliary sphincterotomy alone 2/6 (33.33%) 2.46 (0.44 – 13.73) 0.306 Biliary stenting alone 2/12 (16.67%) 0.96 (0.21 – 4.51) 0.960 Bridging biliary stents 20/134 (14.93%) 0.78 (0.43 – 1.43) 0.426 Multiple biliary plastic stents 6/55 (10.91%) 0.55 (0.22 – 1.36) 0.198 Self-expandable metal stent 2/11 (18.18%) 1.09 (0.23 – 5.21) 0.910 *Reference group. IQR, interquartile range; IUH, Indiana University Health.

S111 Outcomes of Endoscopic Retrograde Cholangiopancreatography in Patients With Situs Inversus Viscerum

Introduction: Situs inversus (SIV) is a rare congenital condition defined by the left to right transposition of all viscera as a mirror image. This uncommon anatomic variant has been reported to cause technical challenges while performing endoscopic retrograde cholangiopancreatography (ERCP). Data of patients with situs inversus undergoing ERCP is limited to case reports and the clinical and technical success rate of ERCP in these patients is unknown. The goal of our study is to evaluate the clinical and technical success rates and procedural characteristics of patients with situs inversus undergoing ERCP. Methods: A retrospective review of data from consecutive patients with SIV undergoing ERCP. Data was collected by querying the nationwide Veterans Affairs Health System database for patients with a diagnosis of situs inversus (ICD Q89.3) who underwent ERCP between January 1, 2010, to March 31, 2022. Patient demographic and procedure characteristics were collected (Table). Results: A total of 654 patients with situs inversus were identified. Eight of these patients had undergone ERCP. The median age was age of 68. The most common indication for ERCP was choledocholithiasis (5 patients, 62.5%). The technical success rate (defined as ability to achieve successful biliary cannulation) was 63%. Subsequent ERCP with interventional radiology assisted rendezvous increased the technical success rate to 88%. Clinical success (defined as successful management of choledocholithiasis, cholangitis, stricture, or obtaining specimens for the diagnosis of malignancy) was achieved in 63% of cases. When considering subsequent rendezvous ERCP if conventional ERCP failed, clinical success was achieved in 88% of cases. Conclusion: In our limited series, the clinical and technical success rate of ERCP for patients with SIV is higher than previously reported. In patients with SIV where conventional ERCP biliary cannulation fails, IR assisted rendezvous ERCP can be considered. Table 1. - Patient demographic and procedure characteristics Gender Race Age Indication Technical Success Clinical Success Reason for failure Rendezvous ERCP attempted Rendezvous ERCP technically successful Rendezvous ERCP clinically successful Male White 72 Choledocholithiasis Yes Yes Male African American 74 Pancreatic adenocarcinoma Yes Yes Male White 88 Choledocholithiasis with cholangitis No No Unable to cannulate the ampulla Yes Yes Yes Male White 62 Periampullary Adenocarcinoma Yes Yes Male White 59 Choledocholithiasis No No Unable to cannulate the ampulla No Male White 88 Choledocholithiasis Yes Yes Female Native American 63 Benign biliary stricture Yes Yes Male Hispanic 63 Choledocholithiasis with cholangitis No No Unable to visualize the ampulla Yes Yes Yes

The reasonable therapeutic modality for biliary duct-to-duct anastomotic stricture after liver transplantation: ERCP or PTC?

ObjectiveTo compare the initial success rate, feasibility, and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTC) for anastomotic biliary stricture after liver transplantation (LT).MethodsWe retrospectively analyzed the data collected during January 2015 to December 2021 from liver transplantation recipients who developed anastomotic biliary stricture after liver transplantation and treated by ERCP and/or PTC. The success rate, complications and patients’ survival rate of ERCP and PTC procedures was evaluated.ResultsForty-eight patients who underwent LT and were confirmed to have the anastomotic biliary stricture were enrolled. Overall, 48/48 patients underwent single or multiple ERCP procedures as the first line therapy; 121 therapeutic ERCPs (3.36 ± 2.53 ERCPs per patient) were performed in 36/48 patients successfully. All the 12 patients who failed ERCP tend to have special bile duct conditions such as overlong, angle shaped, and/or extremely narrowed bile duct and underwent PTC as an alternative treatment. The initial success rate of ERCP was 75% (36/48) while the success rate of ERCP for the 12 patients with special bile duct was 0% (0/12). PTC was an effective second-line treatment for those 12 patients who failed ERCP, and 58.33% (7 of 12 cases) were treated successfully. The average procedure time in PTC group was significantly lower than ERCP group (t=2.292, P=0.027). The feasibility of ERCP was associated with the anatomical shape of bile duct and the severity of the stricture site. Finally, the cumulative survival rate was 100% (12/12) in PTC group compared to 86.11% (31/36) in ERCP group (χ2 = 0.670, P=0.413).ConclusionERCP is the gold standard method for the diagnosis and effective intervention for the management of biliary complications after LT. However, its use in certain types of biliary complications (e.g., patients with severe anastomotic biliary stricture and those with overlong and angle shaped bile ducts) is not promising and associated with significant risk of complications. PTC and other interventions should be studied along with ERCP for patients for whom ERCP may not work. The feasibility and efficacy of primary management can be predicted by the noninvasive imaging examinations like Magnetic Resonance Cholangiopancreatography (MRCP) before the procedure, which may help with the choice of the most reasonable therapeutic modality and avoiding unnecessary financial burden and complications.

“Salvage techniques” are the key to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography

Although the efficacy and safety of salvage techniques for biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) have been reported, few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with native papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, cannulation success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate using standard technique alone was 62.8%, which increased to 94.3% including salvage techniques. Salvage techniques were frequently required in patients with long oral protrusions (OR 2.38; 95% CI 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Salvage techniques may help to overcome many difficult biliary cannulation cases.

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review.

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.

Increased severity of complications after therapeutic ERCP in geriatric patients with chronic pancreatitis: An observational study.

Studies of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in geriatric patients have mainly examined patients with biliary diseases, rather than chronic pancreatitis (CP). This study aimed to evaluate the safety and success rate of therapeutic ERCP in geriatric patients with CP.The medical records of patients with CP aged over 65 years (group A) were retrospectively collected in a tertiary hospital from January 2013 to December 2018. Sex-matched CP patients under 65 years (group B) were randomly selected into the control group (matching ratio = 1:2). The success rate and the complication rate of therapeutic ERCP in 2 groups were compared. The risk factors for post-ERCP pancreatitis were investigated by univariate and multivariate analyses.A total of 268 ERCPs were performed in 179 patients of group A and 612 ERCPs in 358 patients of group B. The success rate of ERCP in group A was similar to that of group B (92.16% vs 92.32%; P = .936). The overall incidence of post-ERCP complications was 7.09% (19/268) and 5.72% (35/612) in group A and B, respectively (P = .436). However, geriatric patients had a significantly increased occurrence of moderate to severe complications (2.61% vs 0.16%; P = .002). Female gender (odds ratio [OR] = 3.40; P = .046), pancreas divisum (OR = 7.15; P = .049), dorsal pancreatogram (OR = 7.40; P = .010), and lithotripsy (OR = 0.15; P = .016) were significantly associated with risk of post-ERCP pancreatitis in geriatric patients.Therapeutic ERCP is safe and feasible in elderly patients with CP. However, occurrence of moderate to severe complications after ERCP increased in geriatric patients.

Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery.

Endoscopic Retrograde Cholangiopancreatography (ERCP) with conventional side-viewing duodenoscope can be challenging and unsuccessful at altered anatomy in the gastrointestinal tract. This study aimed to evaluate our experience with ERCP in patients with previous gastric surgery. Patients on whom ERCP was performed from January 2017 to August 2021 and who had previous gastric surgery were included into the study. Age, sex, comorbidity, Charlson's Comorbidity Index (CCI), ERCP indication, previous gastric surgery (indication, type of resection and reconstruction), history of cholecystectomy, and MRCP results were evaluated retrospectively. The results were compared as successful ERCP (SERCP) or unsuccessful ERCP (USERCP). Also, odds ratio ERCP failure was also evaluated. Forty-three patients were included into study. Mean age was 68.8 ± 13.6 years. The most common sex was female (51.2%). The most common ERCP indication was choledocholithiasis with 44.2%, gastric surgery indication was peptic ulcer with 72.1%, gastric resection was subtotal with 67.4%, and reconstruction was gastrojejunostomy with 58.1%. The success rate of ERCP was 44.2%. Mean CCI was 4.16 ± 2.28. Only malignancy history was significantly higher in the USERCP group (p= 0.026). Male sex, non-choledocholithiasis indication, history of malignancy, CCI> 4, total gastrectomy, Roux-NY (RNY) reconstruction, history of cholecystectomy, and intercalarily to the bile duct dilatation in MRCP were likelihood for USERCP. While history of malignancy and cholecystectomy were the only significant factor for unsuccessful ERCP, male sex, total gastrectomy, RNY anastomosis result in a higher likelihood of ERCP failure in patients with previous gastric surgery. Alternative devices to side-viewing duodenoscope will increase success in selected patients.

Long-Term Outcomes of Endoscopic Intervention in the Treatment of Symptomatic Pancreas Divisum.

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of patients with symptomatic pancreas divisum (PD) and to discuss the possible risk factors of endoscopic reintervention for symptomatic PD. A total of 50 patients with symptomatic PD who underwent ERCP from January 2010 to December 2019 were finally brought into study. All patients were divided into the nonage and the adult group according to their ages. Meanwhile, all patients were also divided into the intervention and the reintervention group according to times of ERCP. The long-term outcome of each patient was collected during the follow-up by phone call. The total success rate of ERCP was 94.7% (89/93), and the effective rate of first ERCP was 58% (29/50). There were no statistical differences on the outcomes of ERCP treatment between the adult and nonage group. There were 17 patients with complete pancreas divisum and 19 patients with chronic pancreatitis in the reintervention group, which were more than 6 patients and 8 patients in the intervention group (P < 0.05). In bivariate regression analysis, chronic pancreatitis and complete pancreas divisum might be significant risk factors for endoscopic reintervention for patients with symptomatic PD (OR, 8.010, 95% CI, 1.483–43.276, P=0.016; OR, 8.869, 95% CI, 1.450–54.254, P=0.018, respectively). ERCP in treating adult and nonage patients with symptomatic PD are effective and safe. But, many patients may need endoscopic reintervention. Complete pancreas divisum and chronic pancreatitis may be risk factors of ERCP reintervention for patients with symptomatic PD.

Nonradiation-to-endoscopist ERCP is non-inferior to standard ERCP

BackgroundRadiation exposure is inherently involved in endoscopic retrograde cholangiopancreatography (ERCP), which could cause radiation-induced injury to endoscopists with long-term exposure. Nonradiation ERCP has been applied to pregnant patients. Conceivably, the same techniques could be used to benefit endoscopists. This study was designed to evaluate the effectiveness and safety of nonradiation-to-endoscopist (NRE) ERCP, compared with standard ERCP.MethodsA retrospective, single-center study was conducted from August 2010 to December 2015. Patients aged 18–90 years and with choledocholithiasis (< 15 mm) or distal biliary stricture were eligible. Pre-ERCP evaluation with magnetic resonance cholangiopancreatography was mandatory. To overcome selection bias, we performed 1:2 match using propensity score matching (PSM) between NRE and standard groups. The primary endpoint was overall ERCP success rate. Secondary endpoints were cannulation success rate, stone clearance rate, complication rate, and duration of hospitalization.ResultsA total of 329 patients met inclusion criteria. After PSM, 73 patients were included in the NRE group and 146 in the standard group. The ERCP overall success rate for NRE and standard groups was equivalent (94.5% vs. 93.2%, P = 0.70). There was no difference in cannulation success rates between the two groups (95.6% vs. 97.8%, P = 0.39). A total of 88.3% of patients in the NRE group and 93.9% of patients in the standard group had stones cleared at initial ERCP (P = 0.57). No difference in overall stone clearance rate between the two groups (95.0% vs. 93.9%, P = 0.77) was found after second ERCP. The complication rate (1.4% vs. 1.4%, P = 1.00) and hospital duration (8.3 ± 5.1 vs. 10.2 ± 8.8 days, P = 0.07) were not different between the two groups.ConclusionAlthough technically demanding, NRE-ERCP is both safe and feasible in selected patients compared with standard ERCP.

Success Rate of Wire Control-Assisted ERCP Sphincterotomy Versus Non-assisted ERCP Cannulation of Common Bile Duct in a Secondary Care Unit During the First COVID-19 Peak: A Retrospective Observational Study of 281 Patients

BackgroundThe British Society of Gastroenterology (BSG) recommended that during the COVID-19 pandemic, endoscopy units perform endoscopic retrograde cholangiopancreatography (ERCP) for obstructive biliary pathologies in an emergency. We assessed the local performance of ERCP during the first wave of COVID-19 at our local endoscopy center, in particular the technique to common bile duct (CBD) cannulation.MethodologyAll ERCP procedures performed from January to June 2020 were retrospectively assessed and compared with procedures performed between January and June 2019 at the Royal Lancaster Infirmary. The indications for ERCP, success rate, and complications were studied separately. Correlation analysis was conducted using Spearman's rank correlation coefficient. The binary logistic regression model was used to compute the factors associated with successful ERCP. Significance was established when the two-sided P-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 25 for Windows (SPSS Inc., Chicago, IL, USA, 2017).ResultsA total of 281 ERCP were included in this study, with 169 and 112 performed during the first six months of 2019 and 2020, respectively. A statistically significant (0.0087) higher proportion of cases with liver dysfunction presented for ERCP before the COVID-19 outbreak (152, 89.94%). All patients before COVID-19 underwent wire control-assisted ERCP, while 82 (73.21%) received assisted ERCP during the first wave (P < 0.001). There was no statistically significant difference (P = 0.10) in the number of patients who underwent sphincterotomy before and during the first wave of COVID-19, with 97 (57.39%) and 76 (67.85%), respectively. The success rate of ERCP before COVID-19 was relatively high, accounting for 146 (86.39%) patients in contrast to 87 (77.67%) patients during the first wave (P = 0.074). Sphincterotomy (β = 2.800, P = 0.028) and stent insertion (β = 0.852, P = 0.046) were statistically significant predictors of ERCP outcomes. There was no statistically significant impact of cholangitis on the success of ERCP (β = 1.672, P = 0.109).ConclusionThe first wave of COVID-19 had a statistically proven negative impact on the expected standards of ERCP performance. Although the complication rate was significantly higher during the first wave case difficulty, the American Society of Anesthesia (ASA) status was not assessed on an individual basis. Both ASA status and case difficulty are now included in our endoscopy selection process. We recommend adding the complexity of cases and ASA to the local and national recording databases. This is a rare study on UK-based hospitals.

Endoscopic retrograde cholangiopancreatography using short‐type double‐balloon enteroscope: Experience in Hong Kong

To illustrate the efficacy and safety profile of double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using a short enteroscope in patients with surgically altered anatomy. A retrospective study was performed to review the endoscopic outcomes of patients undergoing DBE-assisted ERCP for biliary diseases in Tuen Mun and Pok Oi hospitals in Hong Kong SAR, China from December 2015 to December 2020. Altogether 46 DBE-assisted ERCP procedures were performed in 37 patients. The enteroscopic success rate, defined as reaching the papilla or bilioenteric anastomosis, was 95.7% (95% confidence interval [CI] 85.2%-99.5%), which was significantly lower in patients with intact stomach than in those who had a previous gastrectomy (67% vs 100%, P=0.014). The diagnostic ERCP success rate, defined as performance in an informative cholangiogram, was 84.1% (95% CI 69.9%-93.4%) in cases where it was attempted. Intended biliary therapeutic interventions were successfully performed in 76.1% (95% CI 61.2%-87.4%) of all procedures. Adverse events were reported in six (13.0%) procedures (95% CI 4.9%-26.3%), including the micro-perforation of the intestine in two (4.3%) patients with prior Roux-en-Y gastrectomy, three (6.5%) of acute cholangitis and one (2.2%) of acute pancreatitis. All adverse events were managed successfully using conservative methods except in one case of micro-perforation, which required a laparotomy. DBE-assisted ERCP using a short enteroscope is a promising technique for managing biliary diseases in patients with surgically altered anatomy. It must be performed to avoid perforation, particularly in patients with a Roux-en-Y reconstruction.