Therapeutic Endoscopic Retrograde Cholangiopancreatography Procedures Research Articles

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration.

BACKGROUNDBilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown.AIMTo explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China.METHODSThis is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated.RESULTSForty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred.CONCLUSIONBased on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

Radiation protection effect of mobile shield barrier for the medical personnel during endoscopic retrograde cholangiopancreatography: a quasi-experimental prospective study

ObjectiveTo investigate the effectiveness of radiation protection offered by a newly designed mobile shield barrier for medical personnel during endoscopic retrograde cholangiopancreatography (ERCP).DesignQuasi-experimental prospective study.SettingERCP procedures conducted between October 2016...

Complications of endoscopic retrograde cholangiopancreatography: an imaging review.

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

Plasma-activated water: a new and effective alternative for duodenoscope reprocessing.

IntroductionDuodenoscopes have been widely used for both diagnostic and therapeutic endoscopic retrograde cholangiopancreatography procedures. Numerous outbreaks of duodenoscope-associated infections involving multidrug-resistant bacteria have recently been reported. Plasma activated water (PAW) has been widely considered an effective agent for surface decontamination and is increasingly used for disinfection of medical equipment. The aim of this study was to evaluate whether the duodenoscopes currently on market are suited for the repeated use of PAW and to test the efficacy of PAW for their disinfection.Materials and methodsIn order to evaluate the disinfection efficacy and the required time of contact, the duodenoscope samples were contaminated by immersing them in fasted-state simulated intestinal fluid containing Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, prior to PAW exposure. In order to test the duodenoscope polymer compatibility with PAW, a challenge test was conducted by immersing the samples in PAW for 30 minutes daily for 45 consecutive days.ResultsSignificant reductions in bacterial populations were achieved after 30 minutes of PAW treatment, indicating a high-level disinfection. Atomic force microscopy and scanning electron microscopy were used to demonstrate that repeated PAW treatment of duodenoscope coating polymer samples did not result in significant differences in morphological surface between the treated and untreated samples. Energy-dispersive X-ray spectroscopy analysis also showed no significant differences between the elemental composition of the duodenoscope coating polymer samples before and after repeated PAW treatment.ConclusionConsidering these preliminary results, PAW could be considered as a new alternative for duodenoscope reprocessing.

Preliminary diagnostic reference levels for endoscopic retrograde cholangio-pancreatography in Greece

The main objective of this study was to determine the preliminary Diagnostic Reference Levels (DRLs) in terms of Kerma Area Product (KAP) and fluoroscopy time (Tf) during Endoscopic Retrograde Cholangio-Pancreatography (ERCP) procedures. Additionally, an investigation was conducted to explore the statistical relation between KAP and Tf.Data from a set of 200 randomly selected patients treated in 4 large hospitals in Greece (50 patients per hospital) were analyzed in order to obtain preliminary DRLs for KAP and Tf during therapeutic ERCP procedures. Non-parametric statistic tests were performed in order to determine a statistically significant relation between KAP and Tf.The resulting third quartiles for KAP and Tf for hospitals (A, B, C and D) were found as followed: KAPA=10.7Gycm2, TfA=4.9min; KAPB=7.5Gycm2, TfB=5.0min; KAPC=19.0Gycm2, TfC=7.3min; KAPD=52.4Gycm2, TfD=15.8min. The third quartiles, calculated for the total 200 cases sample, are: KAP=18.8Gycm2 and Tf=8.2min. For 3 out of 4 hospitals and for the total sample, p-values of statistical indices (correlation of KAP and Tf) are less than 0.001, while for the Hospital A p-values are ranging from 0.07 to 0.08. Using curve fitting, we finally determine that the relation of Tf and KAP is deriving from a power equation (KAP=Tf1.282) with R2=0.85.The suggested Preliminary DRLs (deriving from the third quartiles of the total sample) for Greece are: KAP=19Gycm2 and Tf=8min, while the relation between KAP and Tf is efficiently described by a power equation.

PATIENT DOSE DURING THERAPEUTIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURE.

Endoscopic retrograde cholangiopancreatography (ERCP) is a standard technique for the diagnosis and treatment of disorders of the pancreas or bile ducts. The aim of this study was the measurement of the radiation dose to patients during therapeutic ERCP procedures, in order to estimate the patient effective dose (ED). Fifteen patients were studied using a fluoroscopy system equipped with automatic brightness control and pulse fluoroscopy mode. Fluoroscopy time (FT), cumulative dose (Ka,r) and air kerma-area product (PKA) were collected for ERCP procedures. The ED was calculated from PKA values. The FT was ranged from 0.68 to 5.57 min, with the mean value of 2.50 min; the Ka,r was ranged from 2.22 to 19.10 mGy, with the mean value of 7.71 mGy; and the PKA was ranged between 0.59 and 5.10 Gycm2, with the mean value of 2.03 Gycm2. The ED ranged from 0.11 to 0.97 mSv, whilst the mean and median ED values were 0.39 and 0.32 mSv, respectively. FT and radiation dose to the patients were either comparative or significantly lower than those previously reported.

Diverticulum With Papillae: Does Position of Papilla Affect Technical Success?

The presence of peripapillary diverticulum (PPD) can cause some biliary diseases, especially common bile duct stones, and also, literally, can change the technique of endoscopic retrograde cholangiopancreatography (ERCP) and affect the complication ratio of this procedure. In this study, we investigate the effect of localization and position of the papilla according to the diverticulum on the success of therapeutic ERCP procedures. The study was conducted prospectively in the patients with naive papillae, who underwent ERCP for a period of 16 months. In all patients, the position of papillae according to the diverticulum (the periphery of the diverticulum is thought as the clock circumference, and the position of papillae is defined as the dials of clock), the success rate of biliary cannulation, total procedure time, overall treatment success rate of ERCP, and the complications are investigated. During this period, 222 (18.5%) of the 1205 enrolled patients who underwent ERCP had PPD. Of the patients with PPD, 123 (55.4%) were female and 99 (44.6%) were male, and the median age was 68.9±10.1 years. According to the position of the papilla by the diverticulum, 90 (40.5%) patients have it on 7 o'clock position, 64 (28.8%) patients have on 6 o'clock position, 63 (28.3%) patients have on 5 o'clock position, and 5 (2.3%) patients have on 1 o'clock position. In the cases of the papilla on 1 o'clock position according to the diverticulum, cannulation procedures were found to be more difficult than other patients (P<0.05). The presence of the diverticulum did not affect the success of therapeutic procedures and did not increase the ratio of complications. In the presence of PPD, additional cannulation techniques may be required for the procedure. Particularly, the aid of percutaneous techniques may be needed for the papilla on 1 o'clock position.

The Impact of Endoscopic Retrograde Cholangiopancreatography Education on Radiation Exposure to Experienced Endoscopist: “Trainee Effect”

Endoscopic retrograde cholangiopancreatography(ERCP), as with other fluoroscopic procedures, carries the risk of exposure of staff to radiation. However, over the last two decades, only a few studies have investigated this risk. The aim of this work was to evaluate the dose of radiation exposure to staff participating in ERCP procedures in a busy teaching hospital that performs more than 1,850 procedures annually. The entire ERCP staff consisted of the experienced endoscopist, the assistant, and two nurses who were responsible for monitoring patients as well as keeping their heads in position during the procedure. RAD DOSE NEB.226 dosimeters, which were provided by the Turkish Atomic Energy Authority, were used for this study. Data on 110 consecutive therapeutic ERCP procedures was recorded. The mean fluoroscopy time was 5.65 ± 4.71 min. The mean fluoroscopy time of the 61 procedures performed by an experienced endoscopist alone was 5.41 ± 4.65 min, whereas the mean fluoroscopy time for the 49 procedures during which an assistant was involved was 5.94 ± 4.81 min (p = 0.56). In terms of median dose of ionizing radiation exposure to the eyes, the dose measurement per procedure in which the primary endoscopist participated alone was 72 microsievert (μSv), compared to 92 μSv when an assistant took part in theproceedings. Considering that the recommended annual equivalent dose limit to the lens of the eye is 150 mSv, by performing 1,850 procedures annually, the primary endoscopist exceeds this limit. Based on our results, taking into consideration the heavy workload in our hospital, it would seem that more experienced endoscopists are required to help provide training in ERCP, and that the use of lead acrylic goggles is required to decrease radiation exposure to the eyes.

Occupational exposure to staff during endoscopic retrograde cholangiopancreatography in Sudan

Endoscopic retrograde cholangiopancreatography (ERCP) procedure is an invasive technique that requires fluoroscopic and radiographic exposure. The purpose of this study was to determine the occupational dose of ionising radiation at three gastroenterology departments (Fedial, Soba and Ibn seena hospitals) in Khartoum, Sudan. The radiation dose was measured during 55 therapeutic ERCP procedures. Thermoluminescence dosemeters were used. The mean radiation dose for the first operator was 0.27 mGy for the eye lens, 0.21 for the thyroid, 0.32 for the chest, 0.17 for the hand and 0.22 for the leg. The mean radiation dose for the second operator was 0.21 mGy for the hand and 0.20 mGy for the chest, while the mean radiation dose for the nurse was 0.44 mGy for the hand and 0.19 for the chest. The radiation dose received by the staff in these hospitals was found to be higher than most of the values in the literature. The radiation absorbed dose received by the different organs is relatively low. Additional studies need to be conducted for radiation dose optimisation.

Endoscopic retrograde cholangiopancreatography catheter and accessory exchange using a short hydrophilic guide wire: a prospective study

Although hydrophilic guide wires can be used to facilitate stricture cannulation during endoscopic retrograde cholangiopancreatography (ERCP), some endoscopists avoid using them because of concerns about wire loss during exchange. There are no data available on the outcomes of using a short hydrophilic guide wire during ERCP. The aim of this study was to assess the outcomes of therapeutic ERCP procedures in which a short, completely hydrophilic guide wire was used exclusively. A total of 100 patients undergoing ERCP were studied prospectively. A 0.035-inch, 260-cm long, angled-tip hydrophilic wire (Terumo Glidewire) was used initially. Hydraulic catheter exchange was performed as follows: during catheter withdrawal the assistant advanced all the available wire into the catheter; a 12-ml syringe was then attached to the catheter and water was flushed under pressure to "float the wire" and maintain its position during catheter removal. Variables evaluated included exchange times and wire loss rates. A total of 223 catheter exchanges were performed, 132 (59%) using the Olympus V-Scope (which held the wire in 62% of cases): 15% of exchanges were with catheters/accessories designed for short-wire use (Boston Scientific Rapid Exchange Biliary System or Rx System), and 85% were with a variety of standard-length accessories. Overall, the mean exchange time was 26 seconds (range 6 - 90 seconds, standard deviation 12 seconds). The mean exchange time was faster with the V-Scope and with non-Rx-System accessories. Wire loss occurred in 5 % of all exchanges. Desired ductal/stricture access was achieved in all the patients. Exchange of short hydrophilic wires is quick and reliable. The Olympus V-Scope is able to hold the wire in some cases. Monorail-type devices and accessories slow catheter exchange down slightly because hydraulic exchange cannot be performed using these systems.

Pharmacological prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

The incidence of clinically significant pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) ranges from 1-13.5%. It is more common after therapeutic procedures such as sphincterotomy or balloon dilatation of the sphincter, and diagnostic procedures such as biliary or pancreatic manometry. The severity of post-ERCP pancreatitis may vary from very mild to extremely severe disease with multiple organ failure and fatal outcome. Several factors including papillary oedema, injection of hyperosmolar contrast-material, introduction of previously activated enzymes during repeated cannulation, bacterial contamination and thermal injury from endoscopic sphincterotomy have been implicated as triggering factors that initiate the sequential cascade of pancreatic autodigestion and release of proinflammatory cytokines leading to acute pancreatitis. Recovery from post-ERCP pancreatitis is usually rapid when the injury is confined to the pancreas. However, systemic production of inflammatory mediators may lead to the development of more serious manifestations including multiorgan failure.A wide range of pharmacological agents has been tested in experimental and clinical trials, but the results have been largely disappointing. Several drugs are discussed in this review, but only somatostatin and gabexate (gabexate mesilate) have consistently shown a moderate beneficial effect. In clinical trials, both gabexate and somatostatin appear equally effective in reducing the incidence of pancreatitis by two-thirds compared with controls. However, both drugs need to be given by continuous infusion for about 12 hours and this makes them less cost-effective than conventional treatment. One potential strategy is to reserve these drugs for high-risk patients undergoing ERCP. Preliminary studies have shown encouraging results with nitroglycerin, antibacterials and heparin. However, these observations need to be corroborated in a rigorous fashion in large, randomised, double-blind, controlled trials. If these drugs are found to be effective in further trials, it may become cost-effective to use them routinely for the prevention of post-ERCP pancreatitis. Despite the theoretical benefits, interleukin-10 has not shown a consistent benefit in clinical trials. It is probable that other cytokine inhibitors or modulators may become available for future trials to prevent pancreatitis or more probably, to reduce the severity of pancreatitis. Further research also should focus on developing newer molecules or the use of a combination of currently available drugs to prevent pancreatitis in high-risk patients undergoing therapeutic ERCP procedures.

Patient and staff exposure during endoscopic retrograde cholangiopancreatography.

Despite a number of efforts being put into the radiological protection of both patient and staff during interventional radiological (IR) procedures during recent years, information about radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) procedures remains scarce. The purpose of this study was to estimate both patient and staff radiation doses during therapeutic ERCP procedures by direct measurement and to compare these results with data from other IR procedures. For 54 patients, effective dose and skin dose were estimated by measuring the dose-area product. For staff, entrance surface doses to the lens of the eye, thyroid and hands were estimated by thermoluminescent dosemeters. A median effective dose of 7.3 mSv and a median entrance surface dose of 271 mGy per procedure were estimated for patients. The gastroenterologist received a median dose of 0.34 mGy to the lens of the eye, 0.30 mGy to the skin at the level of the thyroid and 0.44 mGy to the skin of the hands, per procedure. When comparing the dosimetric quantities presented in this study with data from other IR procedures, it is clear that patient skin doses and doses to staff are high owing to the use of inappropriate X-ray equipment. ERCP requires the same radiation protection practice as all IR procedures. It should be consistently included in future multicentre IR patient and staff dose survey studies at national or international level.

Therapeutic ERCP in the management of pancreatitis in children

Background: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. Methods: Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). Results: Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency ( p < 0.01) and severity of pain ( p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement ( p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters ( p < 0.05) and improvement in general condition ( p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. Conclusions: Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction. (Gastrointest Endosc 2000;51:396-400.)