Therapeutic ERCP In Patients Research Articles

Safety, Risk Stratification and Cost of ERCP in Patients with Cirrhosis

Introduction: Procedure related complications and cost of therapeutic ERCP in patients with cirrhosis were compared to patients without cirrhosis. Disease severity scores were used to stratify procedure risks. Patients and Methods: Outcome and complications of therapeutic ERCP were prospectively studied in patients with cirrhosis and compared to patients without cirrhosis undergoing ERCP. Patients with cirrhosis were evaluated using liver scores. Results: The study included 150 patients with cirrhosis (60% males, mean age 60+/-12.4 years), and 150 patients without cirrhosis (56% males, mean age 52.4+/-20.3 years). Biliary cannulation was successful in 98% and 98.3% of patients with and without cirrhosis. Clinical pancreatitis, perforation, bleeding and cardiopulmonary complications were not different in patients with and without cirrhosis (8% vs 9.3, 0% vs 2%, 3.3% vs 4%, and 4% vs 2% respectively), while cholangitis occurred more frequently in patients with cirrhosis (13.3% vs 1.3% respectively). Hospital stay was longer and mortality and costs were significantly higher among patients with cirrhosis. Patients with Child C cirrhosis developed more complications and had higher mortality. A MELD score cut off of ≥11.5 separated all mortalities. Conclusions: Patients with cirrhosis experienced more complications and costs, and patients with cirrhosis who developed moderate to severe complications were more likely to die.

Efficacy and safety of therapeutic ERCP in patients with cirrhosis: a large multicenter study

Patients with cirrhosis may be less than optimal candidates for ERCP because of underlying ascites, coagulopathy, encephalopathy, and other problems. Although the risks of surgery in patients with cirrhosis are well known, few data are available regarding ERCP in patients with cirrhosis. We performed a retrospective, multicenter study of ERCP in patients with cirrhosis to evaluate outcomes, efficacy, and safety. Multicenter retrospective study. A total of 538 ERCP procedures were performed on 328 patients with cirrhosis. A total of 229 patients had Child-Pugh (CP) class A, 229 patients had CP class B, and 80 patients had CP class C. Thrombocytopenia and coagulopathy were corrected before ERCP. The 30-day, procedure-related adverse events included post-ERCP pancreatitis (n = 25, 4.6%: 21 mild, 3 moderate, 1 severe), hemorrhage (n = 6, 1.1%), cholangitis (n = 15, 2.8%), perforation (n = 2, 0.4%), aspiration pneumonia (n = 5, 0.9%), bile leakage (n = 1, 0.2%), cholecystitis (n = 1, 0.2%), and death (n = 1, 0.2%). There was a higher incidence of adverse events in patients with CP class B and C disease when compared with those with CP class A disease (11.4%, 11.3%, and 6.1%, respectively; P = .048). There was no correlation between the risk of significant hemorrhage and the presence of coagulopathy or CP class, even in those who underwent a sphincterotomy. The presence of poorly controlled encephalopathy correlated with a higher overall adverse event rate (P = .003). Sub-analysis revealed that patients without primary sclerosing cholangitis had a significantly higher overall rate of adverse events, pancreatitis, bleeding, and cardiopulmonary adverse events after ERCP when compared with those with primary sclerosing cholangitis. Our study was performed on a large series of patients with cirrhosis undergoing ERCP. Overall, the adverse events seen in patients with cirrhosis are similar to those seen in the general population of patients undergoing ERCP, although patients with CP classes B and C have higher adverse event rates compared with those with CP class A. Patients with cirrhosis without primary sclerosing cholangitis had significantly greater adverse event rates when compared with patients with primary sclerosing cholangitis.

Artificial neural network predicts the need for therapeutic ERCP in patients with suspected choledocholithiasis

Selection of patients with the highest probability for therapeutic ERCP remains an important task in a clinical workup of patients with suspected choledocholithiasis (CDL). To determine whether an artificial neural network (ANN) model can improve the accuracy of selecting patients with a high probability of undergoing therapeutic ERCP among those with strong clinical suspicion of CDL and to compare it with our previously reported prediction model. Prospective, observational study. Single, tertiary-care endoscopy center. Between January 2010 and September 2012, we prospectively recruited 291 consecutive patients who underwent ERCP after being referred to our center with firm suspicion for CDL. Predictive scores for CDL based on a multivariate logistic regression model and ANN model. The presence of common bile duct stones confirmed by ERCP. There were 80.4% of patients with positive findings on ERCP. The area under the receiver-operating characteristic curve for our previously established multivariate logistic regression model was 0.787 (95% CI, 0.720-0.854; P < .001), whereas area under the curve for the ANN model was 0.884 (95% CI, 0.831-0.938; P < .001). The ANN model correctly classified 92.3% of patients with positive findings on ERCP and 69.6% patients with negative findings on ERCP. Only those variables believed to be related to the outcome of interest were included. The majority of patients in our sample had positive findings on ERCP. An ANN model has better discriminant ability and accuracy than a multivariate logistic regression model in selecting patients for therapeutic ERCP.

Mo1448 Utility of the Short Single-Balloon Enteroscope (Short-SBE) to Perform Therapeutic ERCP in Patients With Surgically Altered Anatomy

Digestive Disease Center, Soonchunhyang University, College of Medicine, Seoul, Republic of Korea Introduction Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, post-ESP pancreatitis is a common and serious complication. Since one prospective randomized controlled trial showed that pancreatic duct stent placement reduced post-ESP pancreatitis, almost physicians have tried to place pancreatic duct stent after EPS. Aims and Methods: The aim of this prospective, randomized trial is to compare the rates of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic duct stent placement. Consecutive patients who were to undergo ESP were randomized to pancreatic duct stent placement group (stent group) after endoscopic snare papillectomy or to no pancreatic duct stent placement group (no stent group). Result The groups were similar with regard to patient demographics. In total, 24 patients were enrolled. Fourteen patients were assigned to the stent group and 10 patients to the no stent group. Post-ESP pancreatitis developed in 5 patients (20.8 %, 5/24), 3 cases occurred in the stent group and 2 case occurred in the no stent group. One case of moderate grade pancreatitis developed in the stent group. The overall incidence of post-EPS pancreatitis was 21.4% (3/14) in the stent group and 20.0 % (2/10) in the no stent group (p 0.932). The rates of hyperamylasemia were 14.3% (2/14) in the stent group and 0.0% (0/10) in the no stent group (p 0.493). There was no significant difference in other complications (ex, bleeding and perforation etc.) between the groups. Conclusion: There was no significant difference in the occurrence of post-ESP pancreatitis and hyperamylasemia between patients with and without pancreatic duct stent placement after endoscopic snare papillectomy. Our findings suggest that a pancreatic duct stent placement after ESP did not confer a protective effect in reducing post-ESP pancreatitis. Therefore, more large scaled prospective, randomized controlled studies regarding the effectiveness of pancreatic duct stent placement to reduce the incidence rates of post-ESP pancreatitis are needed.

Su1453 Therapeutic ERCP in Patients With Surgically Altered Anatomy: Spiraling to Success

Su1453 Therapeutic ERCP in Patients With Surgically Altered Anatomy: Spiraling to Success

Su1423 Effective “Short” DBE for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

Su1423 Effective “Short” DBE for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

VHM14 Therapeutic ERCP in Patients with Surgically Altered Anatomy: Spiraling to Success

Reaching the papilla or bilio-enteric anastomosis in patients with surgically altered anatomy makes meaningful therapeutic endoscopic treatment technically challenging. At our center, spirus enteroscopy assisted ERCP (SE-ERCP) has been performed with favorable results. Here we present 3 cases for review. In all cases, an enteroscope was prepared with the Spirus overtube and this was used to examine the upper GI tract. Spirus enteroscopy performed until reaching the papilla or bilio-enteric anastomosis. In all cases, cannulation is performed with the Cotton cannulatome. Additional endoscopic procedures demonstrated include sphincterotomy, balloon dilation, stent placement into the bile duct as well as pancreatic duct and stone extraction. Spirus enteroscopy assisted ERCP is technically feasible and allows for the performance of therapeutic interventions in patients with surgically altered anatomy. At our center over the last year, 15 spirus enteroscopy ERCPs have been performed with an 80% success rate and no complications. Current limitations include the proper endoscopic tools that can be used with an enteroscope.

Successful Use of Single-Balloon Enteroscopy Assisting ERCP in Patients with Altered Small Bowel Anatomy

Purpose: ERCP becomes challenging and often unsuccessful in patients with altered small bowel anatomy. Single-balloon enteroscopy (SBE) allows deep intubation of the small bowel by using a single-balloon overtube to reduce and pleat the bowel over a standard enteroscope. We present a case of successful diagnostic and therapeutic ERC in a patient with Roux-en-Y anastomosis, with the use of SBE. A 66 y/o female presented to the ER with jaundice, fever, ascites and abdominal pain with similar episodes during the past year. She had history of breast cancer status post mastectomy in 1993, with right hepatectomy for metastasis. She also had a Roux-en-Y hepaticojejunostomy for presumed delayed complications from the segmental resection of the liver. Physical exam showed jaundice, and stigmata of chronic liver disease. Labs on admission revealed leukocytosis of 13.1 bil/L [4.8-11.8], platelets 135,000 bil/L [130-460], protein 7.3 gr/dL [6.3-8.2], albumin 3.4 gr/dL [3.8-5.2], AST 59 U/L [0-30], ALT 43 U/L [0-37], total bilirrubin 12.4 mg/dL [0-1.0], alkaline phosphatase 268 U/ L [37-132]. Abdominal US showed mild ascites, liver 12.7 cm, spleen 13.5 cm, and dilated intrahepatic ducts. Abdominal CT could not be performed due to allergy to Iodine, and a pacemaker precluded patient from having an MRCP. Based on the above data, patient was thought to have secondary biliary cirrhosis decompensated by ascites and complicated by recurrent episodes of cholangitis, likely due to narrow anastomosis vs. biliary stones. An initial ERCP attempt using a pediatric colonoscope was unsuccessful. ERCP assisted with single-balloon enteroscopy was performed. Using a pleating technique while inflating and deflating the balloon, the jejunum was carefully examined as the enteroscope was advanced. The scope was then advanced into the afferent limb and the biliary-enteric anastomosis was found. A cannula was advanced and cholangiogram showed an anastomosis consistent with choledocho-jejunostomy, dilated intrahepatic ducts, and multiple filling defects. The anastomosis was dilated with a 6-7-8 mm CRE balloon, followed by an 8-9-10 mm CRE balloon. A memory basket was then used to remove multiple large black pigmented stones. Finally, the anastomosis was dilated with a 10-11-12 mm CRE balloon, and an occlusion cholangiogram revealed no filling defects. SBE can be used to assist diagnostic and therapeutic ERCP in patients with altered anatomy. It was especially helpful in our patient, as cirrhosis and ascites excluded the possibility of elective surgery or percutaneous drain.

Spiral Enteroscopy for Therapeutic ERCP in Patients with Roux-en-Y Gastric Bypass

Spiral Enteroscopy for Therapeutic ERCP in Patients with Roux-en-Y Gastric Bypass

ERCP Using Spiral Enteroscopy in Patients with Altered Gastrointestinal Anatomy

Purpose: Endoscopic methods for accessing the biliary and pancreatic ducts in patients with surgically altered anatomy can be difficult. Spiral enteroscopy (SE) is a new technique that allows for visualization of the small bowel by using a rotating overtube to pleat small bowel on the enteroscope to advance through the lumen. This is the first reported case series using SE to access the biliary and pancreatic ducts in patients with surgically altered anatomy to perform diagnostic and therapeutic ERCP. Case Vignettes: A total of five cases were performed with SE-assisted ERCP. Patient demographics, procedural indications, findings and therapeutic interventions are listed in Table 1. All procedures were performed using an Olympus SIF-Q180 enteroscope and a Discovery Small Bowel (DSB) overtube, which were inserted through the mouth and advanced across the stomach into the small bowel, with careful attention to prevent gastric loop formation. The enteroscope was advanced to site of the native papilla or surgical anastomosis. A custom length 320 cm sphincterotome was used for cannulation of the native papilla in patients with Roux-en-Y anatomy. A wire-guided CRE balloon and hydrophilic guidewire was used to cannulate surgical pancreatic and biliary anastomses (Figure 1). Discussion: Patients with surgically-altered upper GI tract anatomy pose a challenge to endoscopic biliary interventions. Endoscopic treatments are preferable because they are less invasive than either transhepatic or surgical options. More patients are undergoing Roux-en-Y gastric bypass and the need for biliary and pancreatic interventions in these patients will likewise increase. Our case series is the first report of using spiral enteroscopy for accessing the native papilla or the desired surgical pancreatic or biliary anastomosis to perform diagnostic and therapeutic ERCP in patients with altered upper GI tract anatomy. In our small case series, the success rate was 80%. Additionally, SE-assisted ERCP appears to be easier to perform compared to other methods previously described and allows for stable positioning of the enteroscope to perform delicate therapeutic maneuvers. Spiral enteroscopy-assisted ERCP should be considered in patients with altered anatomy in whom the pancreatic and biliary ducts are beyond the reach of a standard side-viewing duodenoscope.Table 1: Patient characteristics, findings, and therapeutic interventionsFigure

T-tube assisted, non-endoscopic method for endobiliary drainage in a patient with Billroth II gastrectomy

Introduction: Several studies has shown that the rate to gain access to the main duodenal papilla and perform therapeutic ERCP in patients with previous Billroth II gastrectomy is only 60–70%. However, recent studies have reported better results using double balloon enteroscope, but its widespread use is limited. Now, we report a simple, less invasive and readily available method for treatment of extra hepatic biliary obstruction in a patient with previous Billroth II gastrectomy. Case report: The 90 year old male patient who suffered from number of chronic diseases presented with acute cholangitis caused by multiple CBD stones. We attempted ERCP several times by using either side viewing duodenoscope and/or gastroscope, but the intubation of the afferent limb failed. Eventually, open cholecystectomy, choledochotomy and T-tube drainage were carried out. T-tube cholangiogram performed post-operatively raised the suspicion of a retained stone of 5mm in size at the suprapapillary region of the CBD. Attempts to perform ERCP failed again. Ultimately, we introduced a standard papillotome loaded with a 0.036-inch J-tipped Teflon coated guide wire through the external opening of the T-tube. After having been reached the intracholedochal part of the tube, the tip of papillotome was maneuvered into the downward opening of the intracholedochal T-tube. The guide wire was passed through the descending limb of the tube into the distal part of the common bile duct and into the duodenum. Finally, a plastic stent of 7 F in diameter and 92mm in length was placed transpapillary through the guide wire using a 7 F pusher catheter. Following the procedure, a serial T-tube cholangiogram evidenced good contrast flow through the stent. The tube was removed 2 days later and the patient had a 6 months uneventful follow up. Conclusion: This simple, minimal invasive and not expensive method may be valuable in patients with Billroth II anatomy and previous T-tube placement who need endobiliary drainage.

The utility of a multibending endoscope for selective cannulation during ERCP in patients with a Billroth II gastrectomy (with video)

Selective cannulation in patients with a Billroth II gastrectomy is still challenging. To evaluate the usefulness of a multibending, forward-viewing endoscope (M-scope) for selective cannulation during diagnostic or therapeutic ERCP in patients with a Billroth II gastrectomy. Case series. Tertiary center. Fourteen patients having biliary disease with a Billroth II gastrectomy in whom selective cannulation failed when using a conventional forward-viewing endoscope. In all cases, we attempted selective biliary cannulation for ERCP with a single-bending, forward-viewing endoscope for 10 minutes. After failure with the conventional endoscope, we retried selective cannulation with the M-scope for 10 minutes. After cannulation, the diagnostic or therapeutic endoscopic procedures were performed. We assessed the success rate of selective cannulation, the possibility of therapeutic approaches, and procedure-related complications. In all cases, we successfully reached the ampulla of Vater with the M-scope. The overall success rate of selective cannulation with the M-scope was 92.9% (13/14). One patient developed mild pancreatitis. Therapeutic procedures such as sphincterotomy, balloon dilatation, stone removal, and biliary drainage were all possible. Small number of patients; uncontrolled, single-center study. The M-scope seems to be helpful for selective cannulation during ERCP in patients with a Billroth II gastrectomy. All diagnostic and therapeutic procedures were possible through the M-scope.

“Short” Double-Balloon Enteroscope for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

“Short” Double-Balloon Enteroscope for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

“Short” Double-Balloon Enteroscope for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

“Short” Double-Balloon Enteroscope for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy

EUS accurately predicts the need for therapeutic ERCP in patients with a low probability of biliary obstruction

Because of its inherent risks, ERCP should only be performed for purposes of treatment. EUS and MRCP have emerged as diagnostic alternatives before therapeutic ERCP. Our purpose was to test the accuracy of EUS in predicting the need for therapeutic ERCP in low-risk patients. Prospective, unblinded, single-center study. Academic center of the University of Witten/Herdecke. Fifty patients with clinical, laboratory, or transabdominal US findings suggestive of biliary obstruction were included. After clinical assessment and US, all patients underwent EUS. If EUS was conclusive, either ERCP with sphincterotomy (EST) was performed or the patients were followed up for 1 year. If EUS was inconclusive, MRCP was performed, followed by ERCP or a 1-year follow-up. After each diagnostic step, the examiner decided whether any biliary conditon was present and whether therapeutic ERCP was necessary. The decicions were compared with the results of ERCP with EST or the outcome after the 1-year follow-up. Accuracy of EUS in predicting the need for therapeutic ERCP. Nine patients had ERCP with EST. The final assessment classified 2 of these interventions as having been unnecessary. EUS was conclusive in 49 cases. After EUS, the accuracy of the decision on the presence of a biliary condition increased from 82% to 96% and on the need for therapeutic ERCP from 86% to 96%. Single-center experience. EUS accurately predicts the need for therapeutic ERCP in patients at low risk for biliary obstruction.

Complications after ERCP in patients with primary sclerosing cholangitis

There are conflicting data regarding the role of ERCP in patients with primary sclerosing cholangitis (PSC) and the risk of procedure-related complications. We compared the complication rate after ERCP in a consecutive series of patients with PSC compared with control patients with biliary strictures who did not have PSC. Retrospective cross-sectional study. A tertiary referral academic hospital. Incidence of complications after ERCP. A total of 85 ERCPs among 30 patients with PSC and 70 ERCPs among 45 control patients were reviewed. There was no significant difference in the overall complication rates between patients with and without PSC (11/85 [12.9%] vs 6/70 [8.6%], P = .45). Complications in PSC were more likely to occur after ERCP done to evaluate an acute sign or symptom than in elective cases (7/24 [29.2%] vs 4/61 [6.6%], P = .01). Patients with PSC who had complications had more total and acute ERCPs than did those without complications. There was no significant difference in the rate of complications in diagnostic versus therapeutic ERCPs nor between stent placement and dilation-only therapeutic ERCPs in the PSC population. Retrospective study design and limited power related to the small sample sizes. Elective ERCP is safe and carries a modest risk in patients with PSC; however, ERCP for acute indications greatly increases the probability of postprocedure complications. The overall complication rate after therapeutic ERCP in patients with PSC is similar to that in patients without PSC.

Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series

ERCP is technically challenging in patients who have had a long-limb Roux-en-Y surgical procedure. The recent introduction of the double-balloon endoscope permits the examination of a much longer segment of the small bowel compared with a standard endoscope and may be used to perform ERCP in these patients. To report successful use of double-balloon ERCP in patients who have had a Roux-en-Y surgical procedure. Fourteen patients with a history of either Roux-en-Y gastric bypass weight-reduction surgery or Roux-en-Y pancreatobiliary surgery required diagnostic and/or therapeutic pancreatobiliary intervention. Case report. Double-balloon ERCP. Fourteen patients underwent a total of 20 ERCPs with the double-balloon endoscopy system. The ampulla was successfully reached in 85% of total cases (100% of patients who have had Roux-en-Y weight reduction surgery), with adequate cannulation of either the biliary or pancreatic duct in 80% (88% of patients for weight reduction). Therapeutic intervention, including stone removal, pancreatobiliary-duct dilation, sphincterotomy, stent placement, and removal of previously placed stents, was performed successfully in 6 cases. The mean age was 47 years old. The mean (+/- standard deviation) total duration of the procedure was 99 +/- 48 minutes. There were no immediate or short-term complications. The double-balloon endoscopy system permits diagnostic and therapeutic ERCP in patients who have had long-limb surgical procedures. Our experience demonstrated that this procedure is well tolerated, safe, and has a high success rate.

Efficacy and safety of therapeutic ERCP in patients 90 years of age and older

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Retrospective study. Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

Hereditary pancreatitis: Clinical presentation, ERCP findings, and outcome of endoscopic therapy

Background: Hereditary pancreatitis (HP) is an autosomal dominant disorder characterized by the onset of recurrent attacks of acute pancreatitis in childhood and frequent progression to chronic pancreatitis. There are limited data on the role of diagnostic and therapeutic ERCP in patients with HP. The aims of this study were to describe the clinical presentation and findings on pancreatography and to evaluate the role of endoscopic and surgical intervention in patients with HP. Methods: Twenty-seven consecutive patients with HP were referred for ERCP at two centers in the midwest United States. Medical records and pancreatograms were reviewed. Results: Pancreatography was abnormal in all patients. The majority (70%) had severe (Cambridge Grade III) changes of chronic pancreatitis. Nineteen (70%) patients underwent endoscopic therapy and 8 (30%) surgical intervention. After endoscopic therapy (mean follow-up 32 months), 50% were symptom free, 38% had moderate improvement, and 12% had no or transient improvement in symptoms. After surgery (mean follow-up 32 months), 38% were symptom-free, 25% had moderate improvement, and 12% had transient improvement in symptoms. Two patients treated surgically died of pancreatic cancer. Conclusions: In the short-term, improving drainage of the pancreatic ductal system by endoscopic means effectively relieves pain and reduces the number of attacks of pancreatitis in the majority of patients with HP. (Gastrointest Endosc 2002;56:66-71.)

Therapeutic ERCP in patients with long-limb surgical bypass using a new oblique-viewing enteroscope

Therapeutic ERCP in patients with long-limb surgical bypass using a new oblique-viewing enteroscope