Therapeutic Endoscopic Retrograde Cholangiopancreatography Research Articles

Endocut Versus Conventional Blended Electrosurgical Current for Endoscopic Biliary Sphincterotomy: A Meta-Analysis of Complications.

Endoscopic biliary sphincterotomy (EST) is commonly performed during therapeutic endoscopic retrograde cholangiopancreatography (ERCP), but is an independent risk factor for post-ERCP pancreatitis, bleeding and duodenal perforation. These are partly ascribed to the electrosurgical current mode used for EST, and currently the optimal current model for EST remains controversial. In this study, we aimed to compare the rate of complications undergoing EST using the Endocut versus the blended current. A systematic search of databases was performed for relevant published and prospective studies including randomized clinical trials (RCTs) to compare Endocut with blended current modes for EST. Data were collected from inception until 1 July 2018, using post-ERCP pancreatitis, bleeding and perforation as primary outcomes. Three RCTs including a total of 594 patients met the inclusion criteria. Our meta-analysis results showed the rate of post-ERCP pancreatitis, primarily mild to moderate pancreatitis, was no different between Endocut versus blended current modes [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.25-1.52, P = 0.29]. However, the risk of endoscopically bleeding events, primarily mild bleeding, was lower in studies using Endocut versus blended current (RR 0.54, 95% CI 0.31-0.95, P = 0.03). Notably, none of the patients experienced perforation in these three trials. The rate of post-ERCP pancreatitis was not significantly different when using the Endocut versus blended current during EST. Nevertheless, compared with the blended current, Endocut reduced the incidence of endoscopically evident bleeding; however, the available data were insufficient to assess the perforation risk.

Safety and efficacy of enhanced recovery after surgery in elderly patients after therapeutic endoscopic retrograde cholangiopancreatography.

IntroductionThe number of elderly patients with biliary and pancreatic diseases has increased significantly. The characteristics of biliary and pancreatic diseases in the elderly increase the risk of treatment.AimTo study the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients with biliary and pancreatic diseases with the concept of enhanced recovery after surgery (ERAS).Material and methodsPatients receiving ERCP under ERAS were grouped into an elderly group (group A, n = 58, aged 75 years or above) and a young and middle-aged group (group B, n = 202, aged less than 60 years). The clinical parameters before, during and after the operation of the two groups were compared.ResultsBefore the operation, the incidences of cholangiocarcinoma and complications, nutritional screening score ≥ 3, ASA degree III and Child-Pugh grade A in group A were significantly higher than those in group B (p < 0.05), while the incidences of nausea and vomiting, abdominal pain, nutritional screening < 3 and ASA grade I in group A were significantly lower than those in group B (p < 0.05). Intraoperatively, the incidence of juxta-ampullary duodenal diverticulum (JAD) in internal or bottom papilla in the elder patients with difficult selective biliary cannulation (DSBC) was significantly higher than that in the young and middle-aged group (p < 0.05). In addition, the continuous ECG monitoring duration and the first exhaust time in group A were significantly longer than those in group B (p < 0.05).ConclusionsEndoscopic retrograde cholangiopancreatography under ERAS in elderly patients is as safe and effective as in young patients.

Endoscopic Retrograde Cholangiopancreatography (ERCP) Experience in a Tertiary Level Hospital in Bangladesh

Background: Although endoscopic retrograde cholangiopancreatography (ERCP) was first described as a diagnostic technique, now-a-days we mainly do ERCP with a therapeutic intent for management of various biliary and pancreatic diseases.&#x0D; Objectives: This study intends to find out the diagnosis obtained by ERCP procedure and the therapeutic interventions done for appropriate cases in a tertiary level hospital in Bangladesh.&#x0D; Materials and Methods: This prospective observational study was performed in the Department of Gastroenterology in Enam Medical College &amp; Hospital over a period from June 2014 to October 2016. Eighty patients, aged 15–70 years, were selected only for therapeutic ERCP. They were diagnosed and selected after taking history, physical examination and appropriate investigations. ERCP was done under short-term general anesthesia or deep sedation by using propofol or fentanyl. Results are shown in tables.&#x0D; Results: Majority of the cases were choledocholithiasis (53.75%) followed by cholangiocarcinoma (11.25%), ampullary carcinoma (8.75%), carcinoma of the gall bladder (6.25%), biliary ascariasis (6.25%), biliary stricture (5%), papillary stenosis (5%), chronic pancreatitis (2.5%) and sludge in the CBD (1.25%). Types of therapeutic intervention depended on diagnosis. Papillotomy with stone removal was done in patients with choledocholithiasis. Papillotomy with stenting was done in the patients with cholangiocarcinoma, ampullary carcinoma, gall bladder carcinoma, biliary stricture and paillary stenosis. Papillotomy with worm extraction was done in cases of biliary ascariasis. Papillotomy with clearing of sludge was done for sludge in the CBD and only papillotomy was done in two patients of chronic pancreatitis.&#x0D; Conclusion: In this study we found that choledocholithiasis and biliary tract malignancy were the two major ERCP findings. Therapeutic interventions were done according to diagnosis. The most common therapeutic intervention was papillotomy with stone removal. Next common intervention was papillotomy with stenting.&#x0D; J Enam Med Col 2019; 9(1): 9-15

ERCP in infants, children, and adolescents-Different roles of the methods in different age groups.

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is seldom used in children, and published series have limited numbers of pediatric patients. The aim of this retrospective observational study was to assess the efficacy and safety of pediatric ERCP in a large group of children.MethodsData were evaluated from 626 children with biliopancreatic disorders admitted to University Hospital Motol, Prague, between January 1999 and January 2018. Clinical data were obtained by retrospective evaluation of our database of pediatric ERCP procedures and from clinical records.ResultsWe performed 856 ERCPs on 626 pediatric patients; of these procedures, 59% were therapeutic and 41% were diagnostic. We achieved 96% technical success. Indications for ERCP and pathological findings differed in different age groups. The main role of ERCP was in excluding biliary atresia in those aged less than one year. In children aged 1 to 6 years, the most frequent diagnoses were choledochal cyst followed by choledocholithiasis. In children aged 7 to 12 years and 13 to 19 years, the most frequent diagnoses were choledocholithiasis followed by pancreatic pathology. The overall complication rate found in this study was similar to rates observed in adult populations.ConclusionsOur study shows the efficacy and safety of diagnostic and therapeutic ERCP in a large series of infants and children with technical success and complication rates comparable to those in adults. Our data show that ERCP had different roles in different age groups of children.

Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis.

AIMTo assess the effect of early vs late endoscopic retrograde cholangiopancreatography (ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODSWe used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day (days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure, acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with in-hospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex, severe disease and comorbidities.RESULTSFour thousand five hundred and seventy patients satisfied the inclusion criteria; with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs 2.4%, adjusted odds ratio (aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality (1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions (9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group (6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group ($21459 vs $16939, P < 0.0001).CONCLUSIONEarly ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.

Risk factor of bleeding after endoscopic sphincterotomy in average risk patients.

For therapeutic endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (ES) is necessary but it can lead to complications such as bleeding. Thus, we investigated the risk factors of post-ES bleeding in average risk patients. We retrospectively reviewed the medical records of patients who had been treated for ERCP between April 2006 and March 2013. The length of the ES incision was defined as minimal (up to proximal hooding fold), medium (between minimal and full length), and full (up to superior margin of sphincter opening). Exclusion criteria were as follows: if performed precut sphincterotomy or balloon dilatation, patients having altered anatomy or anticoagulant medications. A total of 3620 patients underwent ERCP and 1121 patients who underwent biliary ES were enrolled. Post-ES bleeding occurred in 108 of 1121 patients (9.6%) and mostly minor bleeding (94 patients, 87%). Length of ES was the only risk factor for post-ES bleeding in multivariate analysis. Complete hemostasis was achieved by endoscopic modalities and no serious complication developed after hemostasis. In average risk patients, length of ES was independent risk factor for post-ES bleeding and endoscopic hemostasis was safe and effective.

Patient-Derived Organoids from Human Bile: An In Vitro Method to Study Cholangiopathies.

Cholangiopathies, including primary sclerosing cholangitis, are a group of heterogeneous diseases characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile duct epithelium. Studies, especially of primary sclerosing cholangitis, have been hampered by the difficulty in accessing the cholangiocyte, instability of in vitro culture systems, and reliance on (limited) samples from end-stage disease. Here we describe a novel method of culturing biliary cells from bile of primary sclerosing cholangitis patients undergoing endoscopic retrograde cholangiopancreatography for clinical indications. These 3D organoid cultures demonstrate a biliary phenotype, can be maintained in vitro, and biobanked for future analyses. Given the need for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography throughout the disease in many primary sclerosing cholangitis patients, this method can provide longitudinal studies in individual patients, allowing for a correlation of gene expression with disease status. These organoids can react to inflammatory stimuli, resulting in the secretion of chemo/cytokines indicative of the reactive immune phenotype characteristic of primary sclerosing cholangitis. Therefore, bile-derived organoids provide a model to study the pathogenesis and pharmacotherapeutic treatment of cholangiopathies.

A Case of Intra-abdominal Hemorrhage from Liver Caused by Therapeutic Endoscopic Retrograde Cholangiopancreatography

A Case of Intra-abdominal Hemorrhage from Liver Caused by Therapeutic Endoscopic Retrograde Cholangiopancreatography

Efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: A single-center retrospective study.

Objective: This study aimed to assess the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of 3 or 4.Patients and Methods: We reviewed the data of 287 patients with native papillae who underwent therapeutic ERCP for biliary disease at our hospital between October 2016 and October 2018. The patients were divided into two groups; those with an ECOG-PS score of 3 or 4 (group A; n=78) and those with an ECOG-PS score of 0–2 (group B; n=209).Results: The rate of technical success was not significantly different between the two groups (95% versus 89%, P=0.13). Although the occurrence rate of overall adverse events (10% versus 11%, P=0.95) was not significantly different between the groups, the occurrence rates of aspiration pneumonia (3.8% versus 0%, P=0.0044) and heart failure (2.6% versus 0%, P=0.020) were significantly higher in group A.Conclusion: The rates of technical success and overall adverse events did not significantly differ between patients with an ECOG-PS score of 3 or 4 and those with a score of 0–2; however, aspiration pneumonia and heart failure were more likely to occur among patients with an ECOG-PS score of 3 or 4.

The impact of selective serotonin receptor inhibitors on post-endoscopic sphincterotomy bleeding, alone or with concurrent aspirin or nonsteroidal anti-inflammatory drugs.

Background:Observational studies have shown an increased risk of upper gastrointestinal bleeding in users of selective serotonin receptor inhibitors (SSRIs). We retrospectively investigated the impact of SSRIs, alone or combined with aspirin (ASA) or nonsteroidal anti-inflammatory drugs (NSAIDs), on the incidence of post-endoscopic sphincterotomy (post-ES) bleeding.Methods:A total of 3058 patients were included. Of these, 457 patients received SSRIs, alone or plus ASA or NSAIDs, until the day of ES (SSRIs group), while 2659 patients (non SSRIs group) had never been on SSRIs (n=1925), though some had been on ASA (n=613) or NSAIDS (n=121). Patient assessment included indication for endoscopic retrograde cholangiopancreatography (ERCP), comorbid diseases, detailed drug history before and after ES, procedural details, and risk factors for post-ES bleeding. Primary outcome was defined as the incidence, type and severity of post-ES bleeding.Results:There was no statistical difference in age, sex, indication for ERCP, comorbid diseases, technical characteristics or results of therapeutic ERCP between the 2 groups. The incidence of post-ES bleeding was 3.9% in the SSRIs group and 3% in the non SSRIs group, a difference not statistically significant (P=0.754). Likewise, there was no difference in type (P=0.145) or severity of bleeding (P=0.754) between the 2 groups. Multivariate analysis showed the precut technique as the only independent risk factor for post ES hemorrhage (odds ratio 2.56, 95% confidence interval 1.23-3.63; P=0.001).Conclusion:This study found that SSRIs, alone or combined with ASA or NSAIDs, had no influence on the incidence or the severity of post-ES bleeding.

Endoscopic Pancreato-Biliary Interventions

AbstractEndoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) play a critical role in the diagnosis and management of benign and malignant pancreatobiliary diseases. In the last several years, role of ERCP has evolved from just a diagnostic procedure to mostly a therapeutic procedure. It plays a key role in the diagnosis of indeterminate biliary strictures and evaluation of bile leaks. Therapeutic ERCP utilizes various techniques for the extraction of biliary and pancreatic stones, management of bile leaks, and the treatment of malignant and benign strictures. EUS plays a central role in tissue acquisition for diagnostic purposes. Therapeutic applications of EUS have significantly increased in the recent years and include management of pancreatic fluid collections, pancreatic necrosis, drainage of the biliary obstruction, gall bladder drainage, and EUS-assisted ERCP. These procedures have good efficacy and acceptable side effect profile when performed by expert endoscopists at tertiary care medical centers.

Trends in Post-Therapeutic Endoscopic Retrograde Cholangiopancreatography Gastrointestinal Hemorrhage, Perforation and Mortality from 2000 to 2012: A Nationwide Study

Background/Aims: Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates. Methods: First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012. Results: The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression. Conclusion: Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography.

AIMTo systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.METHODSSystematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.RESULTSAdvances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.CONCLUSIONThis systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

Hospital Teaching Status and the Effect on Endoscopic Retrograde Cholangiopancreatography Mortality and Complications in the United States

Introduction: There is limited data in the literature on the outcomes of patients that undergo Endoscopic Retrograde Cholangiopancreatography (ERCP) in teaching versus non-teaching hospitals. Since ERCP has the potential for numerous complications, our aim was to assess the differences in post-ERCP outcomes of infection rates, pancreatitis, gastrointestinal (GI) bleed, perforation and mortality in teaching versus nonteaching hospitals nationwide. We hypothesized that ERCP complication rates would be higher in teaching hospitals given the involvement of trainees and the greater complexity of patient populations. Methods: Data from the National Inpatient Sample (NIS), the largest national inpatient database, was used from the years 2008 to 2012. Individuals that underwent inpatient ERCPs were identified using the International Classification of Diseases, Ninth Edition (ICD-9) codes. NIS classifies hospitals as teaching urban, non-teaching urban, and rural. AMA-approved residency programs are required to qualify as teaching hospitals. Non-teaching urban and rural hospitals were grouped together for the analysis. We then identified hospital stays complicated by pancreatitis, infection, GI hemorrhage, perforation and mortality. Using ANOVA analysis in STATA, the differences in infection rates, pancreatitis, GI hemorrhage, perforation and mortality between teaching and non-teaching hospitals were calculated. Results: A total of 296,835 inpatient ERCPs was included in this study. 75,268 ERCPs were diagnostic, while 267,990 were therapeutic; 154,553 were performed at teaching hospitals and 142,282 at non-teaching hospitals. ERCP infection rates (Odds Ratio [OR] = 1.041, 95% Confidence Interval [CI]:1.012-1.071, p 1.095-1.071, p<0.001) were higher in teaching hospitals when compared to non-teaching hospitals. There was no difference observed among the rates of post-ERCP pancreatitis or GI perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to non-teaching hospitals (OR = 1.206 95% CI:1.068-1.362, p <0.001). Likewise, length of stay was increased in teaching hospitals (8.3 vs 7.2 days, p<0.05 for diagnostic and 6.5 vs 5.8 days, p<0.05 for therapeutic ERCPs). Conclusion: In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates for infection and GI hemorrhage. Additionally, length of stay was longer for patients that underwent inpatient ERCPs in teaching hospitals.782_A Figure 1. Differences in ratios of pancreatitis, GI hemorrhage, GI perforation, infection and mortality in inpatient diagnostic and therapeutic ERCPs among teaching versus non-teaching hospitals782_B Figure 2. Percentages of demographic variables among therapeutic and diagnostic ERCPs between teaching and non-teaching hospitals

Application of endoscopic retrograde cholangiopancreatography to common bile duct stones with periampullary diverticulum

Objective To explore the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones with periampullary diverticula (PAD). Methods Data of 2, 103 patients with common bile duct stones(CBD stones), who underwent therapeutic ERCP for the first time from April 2013 to March 2016, were prospectively analyzed. Patients were divided into two groups according to presence or absence of PAD (PAD group and non-PAD group). Success rate of ERCP, complete clearance rate of the CBD stones after the first attempt and difficult cannulation rate were compared between the two groups. Results The difficult CBD cannulation rate was 14.87%(117/787) in PAD group and 9.93% (123/1 239) in non-PAD group with significant difference (P=0.001). Successful CBD cannulation was achieved in 96.92% (787/812) patients in PAD group and 95.97% (1 239/1 291) in non-PAD group (P=0.156). The complete clearance rate of CBD stones after the first attempt was 85.39% (672/787) in PAD group and 87.09% (1 079/1 239)in non-PAD group (P=0.154). There was no significant difference between the two groups in the complication rate[26/812(3.20%) VS 33/1 291(2.56%), P=0.833]. Conclusion Although PAD increases the difficulty of ERCP, ERCP is an effective and safe method for patients of CBD stones with PAD. Key words: Cholangiopancreatography, endoscopic etrograde; Choledocholithiasis; Diverticulum

National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis.

Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations. We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane-Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors. There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01). There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.

Факторы риска острого панкреатита после лечебной эндоскопической ретроградной холангиопанкреатографии

Факторы риска острого панкреатита после лечебной эндоскопической ретроградной холангиопанкреатографии

Mo1333 THERAPEUTIC ERCP MAY NOT BE NECESSARY FOR ACUTE CHOLANGITIS OR BILIARY COLIC PATIENTS WITH ONLY BILE DUCT SLUDGE ON EUS

Recently, there have been several reports on the usefulness of endoscopic ultrasonography (EUS) before endoscopic retrograde cholangiopancreatography (ERCP) for patients with suspected acute cholangitis or biliary colic whose abdominal computed tomography (CT) or transabdominal ultrasonography (TAUS) are negative for biliary stenosis, tumors or stones. However, no sufficient investigations have yet been made on the outcomes of cases that do not have choledocholithiasis but do show only biliary sludge on EUS with conservative follow-up. Among patients that were clinically suspected to have experienced acute cholangitis or biliary colic, and showed negative CT scan and EUS for choledocholithiasis, those who did not undergo therapeutic ERCP and were conservatively followed up were selected. Their outcomes were then examined to reveal whether their clinical outcome including recurrent cholangitis or biliary colic would vary in the presence or absence of biliary sludge. The subjects were extracted from patients who were suspected to have acute cholangitis or biliary colic but were found to have no choledocholithiasis on abdominal CT and EUS in the reporting hospital between April 2012 and July 2017. Among them, 46 cases that did not undergo therapeutic ERCP and were conservatively followed up were examined. These patients were divided into two groups according to the presence or absence of biliary sludge in the common bile duct on EUS findings. A retrospective examination was performed according to the following aspects: the subjects' backgrounds, blood test results, CT findings, EUS findings (the diameter of the common bile duct and the presence or absence of thickening of the common bile duct wall), whether they had undergone cholecystectomy and the date of surgery when performed, and whether they had undergone treatment for subsequent acute cholangitis or biliary colic. Among the 46 cases, 6 (13%) had recurrence during the median follow-up period of 138 days (ranging from 2–1613 days) after undergoing EUS. The median time to recurrence was 31 days (ranging from 3–769 days). Among the 46 patients, 16 (35%) had biliary sludge in the common bile duct on EUS; among 6 cases that had recurrence, only 1 (6%) had biliary sludge. After conservative treatment, cholecystectomy was performed on 7 cases (18%), where 4 (27%) had biliary sludge, and 3 (13%) did not. Among the cases with clinically suspected biliary colic or acute cholangitis, which were negative for choledocholithiasis on CT and EUS and positive for sludge on EUS, acute cholangitis recurred in only 1 case (6%) even after conservative treatment. Though this is a pilot study, the addition of therapeutic ERCP might be considered unnecessary for a patient presenting with only biliary sludge.

No Superiority of Stents vs Balloon Dilatation for Dominant Strictures in Patients With Primary Sclerosing Cholangitis

Dominant strictures occur in approximately 50% of patients with primary sclerosing cholangitis (PSC). Short-term stents have been reported to produce longer resolution of dominant strictures than single-balloon dilatation. We performed a prospective study to compare the efficacy and safety of balloon dilatation vs short-term stents in patients with non-end-stage PSC. We performed an open-label trial of patients with PSC undergoing therapeutic endoscopic retrograde cholangiopancreatography (ERCP) at 9 tertiary-care centers in Europe, from July 2011 through April 2016. Patients found to have a dominant stricture during ERCP were randomly assigned to groups that underwent balloon dilatation (n= 31) or stent placement for a maximum of 2 weeks (n= 34); patients were followed for 24 months. The primary outcome was the cumulative recurrence-free patency of the primary dominant strictures. Study recruitment was terminated after a planned interim analysis because of futility and differences in treatment-related serious adverse events (SAEs) between groups. The cumulative recurrence-free rate did not differ significantly between groups (0.34 for the stent group and 0.30 for the balloon dilatation group at 24 months; P = 1.0). Most patients in both groups had reductions in symptoms at 3 months after the procedure. There were 17 treatment-related SAEs: post-ERCP pancreatitis in 9 patients and bacterial cholangitis in 4 patients. SAEs occurred in 15 patients in the stent group (45%) and in only 2 patients in the balloon dilatation group (6.7%) (odds ratio, 11.7; 95% confidence interval, 2.4-57.2; P= .001). In a multicenter randomized trial of patients with PSC and a dominant stricture, short-term stents were not superior to balloon dilatation and were associated with a significantly higher occurrence of treatment-related SAEs. Balloon dilatation should be the initial treatment of choice for dominant strictures in patients with PSC. This may be particularly relevant to patients with an intact papilla. ClinicalTrials.gov no. NCT01398917.

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.