Therapeutic ERCP Research Articles

COMPLICATIONS OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN KURDISTANCENTER FOR GASTROENTEROLOGY AND HEPATOLOGY

Background 
 ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases.In this retrospective study, the overall complications rates for therapeutic ERCP were identified in Kurdistan Center for Gastroenterology and hepatology-Sulaimani-Kurdistan region-Iraq.
 Patients and Methods
 This retrospective case series was carried out in Kurdistan center for gastroenterology and hepatology in Sulaimani city-Iraq from January 2014 to January 2015. The records of 806 ERCP were evaluated to collect procedure related data and the overall complications rate for diagnostic and therapeutic ERCP.
 Results
 All cases examined by ERCP in the KCGH in Sulaimani over a period of one year (from January 2014 to January 2015) were 806, 471 females (58.43%) and 335 males (41.56%). Less than quarter of patients were referrals from Iraqi governorates other than Sulaimani governorate. The mean duration of ERCP procedure was 27.5 min. Deep cannulation was successful in 749 (92.92%) patients. There were 57 (7.07%) failure of cannulation. In cases who had successful cannulation a cholangiogram was obtained which showed bile duct dilatation. In cases of failed cannulation pancreatic stent deployed in 26 (3.22%). Endoscopic sphincterotomy was performed in 472 (58.56%) patients, followed by stone extraction in 341 (96.05%) patients, stenting of common bile duct in 422 (52.35%) ,stent removal in second session of ERCP. The overall complications rate was 9.42%. Post-ERCP pancreatitis was the most common and occurs in 34 patients (4.23%), Bleeding occurred in 19 patients (2.35%) and was related to a therapeutic procedure in all cases. Sixteen patients had cholangitis (1.98%), most cases being secondary to incomplete drainage. There were 4 perforations (0.49%). All other complications totaled 1.12%.
 Conclusion
 Despite the potential benefits of ERCP for the treatment of benign and malignant pancreaticobiliary diseases, it is associated with morbidity and risk of mortality. The most frequent ERCP-related complication was pancreatitis. Bleeding was second complication and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Patients’ comorbidities and therapeutic procedures can increase the risk of post-ERCP complications.Our interventions and their complications rates are comparable to those reported in other countries.

The Role of Endoscopic Cholangioscopy in an 8-Year-Old with Williams Syndrome and Recurrent Choledocholithiasis

FigureWe present an 8 year old with Williams Syndrome, supravalvular aortic stenosis and two previous episodes of choledocholithiasis complicated by acute pancreatitis. Both times he required a therapeutic ERCP. Findings on the previous ERCPs showed common bile duct dilatation along with biliary stones which were removed. After the second episode of choledocholithiasis he underwent a cholecystectomy. He presented again with acute pancreatitis secondary to choledocholithiasis. He again underwent a repeat ERCP, this time with direct visualization with a peroral cholangioscope. ERCP showed stones within the distal CBD, which were successfully swept free. Subsequent cholangioscopy showed high insertion of the pancreatic duct into the CBD and non-obstructive biliary web remnants. Actigall was started to improve biliary flow. There is potential need for a surgical choledochoduodenostomy if any further episodes; however the patient has been without any reoccurrence of his biliary issues. Cholangioscopy, developed in the 1970's, has been limited in its use due to technological restrictions, which have only been overcome recently. Our system is catheter based with a biopsy channel, optic channel and two irrigation channels. It has dual controls to navigate the biliary tree and passed via a duodenoscope working channel. The diameter of the cholangioscope is 3.3 mm, limiting use in smaller pediatric patients. Based on biliary duct size in relation to age, we postulate that our cholangioscope can be used in children 7 years of age or greater. In review of the literature, we were unable to find any reported cases with the use of cholangioscopy in a pediatric patient to date. We also identified two interesting findings; a biliary web remnant and a high insertion of the pancreatic duct into his CBD. Biliary webs are rare and previously diagnosed on imaging. Our patient has only a web remnant but might result in impaired biliary drainage and serve as a nidus for stone formation. In regards to the high insertion pancreatic duct, this is a novel finding. We theorize that this may play a role in his increased episodes of choledocholithiasis and place him at risk for additional episodes of acute pancreatitis. The use of the cholangioscopy resulted in the identification of our patient's biliary pathology, allowing for improved evaluation and treatment. Cholangioscopy should be considered in appropriately sized pediatric patients with recurrent choledocholithiasis.

Efficacy and safety of extracorporeal shock wave lithotripsy for chronic pancreatitis

Introduction: There is still uncertainty regarding the efficacy and optimal modalities of extracorporeal shock wave lithotripsy (ESWL) in the treatment of chronic pancreatitis. The aims of the present study were to assess the safety and the efficacy of ESWL, either alone or followed by therapeutic endoscopic retrograde cholangiopancreatography (adjuvant ERCP) and to determine predictive factors of efficacy, in a real-life setting.Patients and methods: This study included all consecutive patients who underwent an ESWL in a single University Hospital between 2001 and 2012. The indication for ESWL was obstructive stone(s) of the main pancreatic duct resulting in either painful chronic pancreatitis or recurrent acute pancreatitis. Success was defined by resolution of pain, no analgesic treatment, no acute pancreatitis and no surgical treatment for chronic pancreatitis 6 months after the ESWL.Results: One hundred and forty-six patients were studied; 6/146 (4%) had a complication of ESWL. Among the 132 patients in whom follow-up was completed, 91 (69%) had an adjuvant ERCP. After 6 months of follow-up, 100/132 (76%) patients achieved success. In multivariate analysis, the single significant predictive factor of the success of the ESWL treatment was chronic pain (p = 0.03). Patients who had chronic pain and needed opioid treatment had less chance of success than patients without chronic pain (OR 95%CI 0.31 [0.07–1.14]). We found no difference in the success rates between patients who underwent adjuvant ERCP and those who had ESWL only (p = 0.93).Conclusion: This study shows that the ESWL is a safe and effective treatment for patients with chronic pancreatitis and obstructive stones within the main pancreatic duct. Systematic association with therapeutic ERCP appears to provide no additional benefit and is therefore not recommended.

Therapeutic enteroscopy using a new single-balloon enteroscope: a case series.

Background and study aims: Balloon-assisted enteroscopy allows therapeutic intervention in the small bowel, and even of the biliopancreatic system in patients with altered anatomy. However, the conventional single-balloon enteroscope (SBE) has limited therapeutic use because of its small-caliber working channel and the lack of an additional water jet channel. The new single-balloon enteroscope prototype XSIF-180JY has been developed to overcome these problems. We present experience with use of the new SBE prototype during 14 therapeutic endoscopy procedures, which illustrates its advantages. Patients and methods: During a 2-month period, 16 SBE procedures were performed (2 antegrade, 2 retrograde and 12 ERCP procedures) using the XSIF-180JY prototype, 14 of which were done with therapeutic intent. Results: The XSIF-180JY SBE allowed deep enteroscopy with balloon dilation and multiple intestinal polypectomies. Moreover, 14 ERCP procedures were successfully performed in 12 patients with Roux-en-Y altered anatomy. Sphincterotomy, balloon dilation, stone extraction and 7 Fr plastic stent placement were performed through the 3.2-mm working channel. The additional water jet was useful for flushing away stone fragments from the intrahepatic bile ducts and the retrieval basket and for flushing away blood from a bleeding sphincterotomy. No complications related to the enteroscope were encountered. Conclusions: The new therapeutic XSIF-180JY SBE permitted therapeutic enteroscopy and ERCP through its 3.2-mm working channel and the additional water jet channel proved useful in flushing away biliary stones and blood without the need to clear the working channel. This newly developed SBE has the advantage of a larger working channel and an additional water jet, improving therapeutic enteroscopy.

What is the factor of post ERCP pancreatitis for cannulation by trainees in naïve papilla

Access to the pancreatic or the bile duct is paramount to the success of diagnostic and therapeutic ERCP. Selective cannulation may be difficult because of the small size of the papilla and anatomic factors such as peripapillary diverticulum and gastrectomy with Billroth-II anastomosis. Currently, one of the techniques for gaining access in such cases is the pre-cut technique with a catheter that has a thin wire at the tip (needle knife). A less well-described pre-cut technique involves initial cannulation of the pancreatic duct with a “traction-type” papillotome and then incision through the “septum” toward the bile duct. The aim of this randomized trial was to compare the success and the complication rates of needle-knife sphincterotomy and transpancreatic sphincterotomy in achieving cannulation of an otherwise inaccessible bile duct.Sixty-three consecutive patients with inaccessible bile ducts underwent pre-cut sphincterotomy either by needle-knife sphincterotomy (n = 34) or transpancreatic septotomy (n = 29). In patients with an accessible pancreatic duct who undergo needle-knife sphincterotomy, a short (2-3 cm) stent (5F-7F) was placed in the pancreatic duct to act as a guide and to reduce the risk of post-procedure pancreatitis. All patients were hospitalized overnight for observation after pre-cut sphincterotomy. The outcomes measured were success rate and complications. Indications for pre-cut sphincterotomy were the following: suspected choledocholithiasis, 11 patients (17.5%); obstructive jaundice with negative CT findings, 19 patients (29.2%), or with positive CT findings, 13 patients (20.6%); abdominal pain with elevated biochemical tests of liver function, 15 patients (23.8%); and miscellaneous, 5 patients (7.9%).In 55 of 63 (87%) patients, the bile duct was selectively cannulated after pre-cut sphincterotomy. On a pre-protocol basis, the bile duct was cannulated in 29 of 29 (100%) patients randomized to transpancreatic septotomy sphincterotomy and 26 of 34 (77%) patients who underwent needle-knife sphincterotomy (p = 0.01). There were 7 complications, including bleeding (n = 2) and acute pancreatitis (n = 5). Complications were less frequent in the transpancreatic septotomy sphincterotomy group (1/29; 3.5%) compared with the needle-knife sphincterotomy group (6/34; 17.7%).Transpancreatic pre-cut sphincterotomy can be performed with a high degree of success in patients with inaccessible obstructed bile ducts. Compared with standard needle-knife sphincterotomy, transpancreatic septotomy sphincterotomy has a significantly higher rate of bile duct cannulation and a lower complication rate.

Suppository naproxen reduces incidence and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial.

To determine the efficacy of rectally administered naproxen for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). This double-blind randomized control trial conducted from January 2013 to April 2014 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 324 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients received a single dose of Naproxen (500 mg; n = 162) or a placebo (n = 162) per rectum immediately before ERCP. The overall incidence of PEP, incidence of mild to severe PEP, serum amylase levels and adverse effects were measured. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and elevation of the serum amylase level to > 3 × the upper normal limit (60-100 IU/L) within 24 h after ERCP. The severity of PEP was classified according to the duration of therapeutic intervention for PEP: mild, 2-3 d; moderate 4-10 d; and severe, > 10 d and/or necessitated surgical or intensive treatment, or contributed to death. PEP occurred in 12% (40/324) of participants, and was significantly more frequent in the placebo group compared to the naproxen group (P < 0.01). Of the participants, 25.9% (84/324) developed hyperamylasemia within 2 h of procedure completion, among whom only 35 cases belonged to the naproxen group (P < 0.01). The incidence of PEP was significantly higher in female sex, in patients receiving pancreatic duct injection, more than 3 times pancreatic duct cannulations, and ERCP duration more than 40 min (Ps < 0.01). There were no statistically significant differences between the groups regarding the procedures or factors that might increase the risk of PEP, sphincterotomy, precut requirement, biliary duct injection and number of pancreatic duct cannulations. In the subgroup of patients with pancreatic duct injection, the rate of pancreatitis in the naproxen group was significantly lower than that in the placebo (6 patients vs 23 patients, P < 0.01, RRR = 12%, AR = 0.3, 95%CI: 0.2-0.6). Naproxen reduced the PEP in patients with ≥ 3 pancreatic cannulations (P < 0.01, RRR = 25%, AR = 0.1, 95%CI: 0.1-0.4) and an ERCP duration > 40 min (P < 0.01, RRR = 20%, AR = 0.9, 95%CI: 0.4-1.2). Single dose of suppository naproxen administered immediately before ERCP reduces the incidence of PEP.

The Usefulness of Early Endoscopic Ultrasonography in Acute Biliary Pancreatitis with Undetectable Choledocholithiasis on Multidetector Computed Tomography.

EUS can detect bile duct stones (BDS) that are undetectable on multidetector computed tomography (MDCT). BDS associated with acute biliary pancreatitis (ABP) are small and tend to be excreted spontaneously. This study evaluated the usefulness of early EUS in patients with ABP and undetectable BDS on MDCT. Forty-one patients with ABP and undetectable BDS on MDCT underwent EUS within 24 hours of admission and were diagnosed with BDS, sludge, dilated common bile duct (CBD), or normal CBD. ERCP was performed in patients with BDS, sludge, or clinical deterioration. The diagnostic yield and the effects of early EUS on morbidity, mortality, and the length of hospitalization were evaluated. EUS detected BDS or sludge in 48.8% of patients examined. BDS was the diagnosis in 13 patients, sludge in seven, and neither for 21 patients. ERCP was performed in 20 patients with BDS or sludge, in two patients with coexisting cholangitis, and in one patient with worsening liver function tests. ERCP identified BDS in 12 patients and sludge in seven. No lesions were diagnosed in four patients by ERCP. All patients improved, and the length of hospitalization in patients with ERCP was 9.0 days, without ERCP 7.1 days. Two patients with major complications by ERCP were hospitalized for a prolonged time. Early EUS may be useful to select patients for therapeutic ERCP in cases of suspected ABP with undetectable BDS on MDCT.

Acute Recurrent Pancreatitis; Relative Risk Factors, Etiology ,Diagnosis Procedure And Treatment In the Pancreatic disease Institute of Wuhan Union Hospital Of China

This study describes the relative risk factors, etiology and treatment option of recurrent acute pancreatitis. The data of 71 patients with acute recurrent pancreatitis were retrospectively studied from January 2010 to December 2014. Of 71 patients, 41 were male and 30 were female with a sex ratio of 1.4:1 with a mean age of 49 years. Their age ranged from 14 to 85 years. After reviewing the clinical data, the risk factors were analyzed using univariate and multivariate analysis. The etiology was investigated in each case using specialized laboratory analysis, ERCP, EUS and MRCP. Their pain was labeled severe, moderate and mild by using the Analgesic Ladder by World Health Organization. Subsequent to the investigation reports, therapeutic ERCP and endoscopic sphincterotomy were performed. Of the 71 patients, 52 cases were biliary pancreatitis, 13 were idiopathic pancreatitis, 3 were alcohol induced pancreatitis and 3 were hyperlipidemia pancreatitis. The univariate analysis showed easy recurrence with obstructive jaundice, hepatic function injury and local complication of pancreas (P=0.016< 0.05 P= 0.003<0.05 and P= 0.024< 0.05 correspondingly). Multivariate analysis showed no single factor related to recurrence. Upon definition of etiology, there were 33 cases of common bile duct stones, 14 cases of pancreatic duct stones, 5 cases of gallbladder stones, 3 cases of pancreas divisum, 2 cases of ampullary tumor, 4 cases of sphincter of Oddi dysfunction, 6 cases of chronic pancreatitis, 1 cases of post liver transplant complication and 3 cases of duodenal diverticulum. The 71 patients performed ERCP followed by either endoscopic sphincterotomy in 69 cases or endoscopic resection in 2 cases. The procedure was curative and successfully performed. A complication rate of 2.8% with no mortality was observed. Post-therapy, a decline in pain intensity was observed in 56 cases of the patients. ERCP and endoscopic sphincterotomy has a curative effect in diverse etiology of acute recurrent pancreatitis.

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.

Clinical observation of therapeutic endoscopic retrograde cholangiopancreatography in 1482 cases

Objective To analyze the clinical observation and incidences of complications of therapeutic postendoscopic retrograde cholangiopancreatography(ERCP). Methods The clinical information of 1 482 cases of therapeutic ERCP was analyzed retrospectively. Results Among them,468 cases had nasal biliary drainage,532 cases had pancreatic or bile duct stent after endoscopic procedure and the other 482 case hadn't.For the drainage group,there were 396 cases of biliary stone,36 cases of simple dilatation of common bile duct,8 cases of biliary cyst,6 cases of strictured papilla,18 cases of inflammatory stricture of common bile duct,2 cases of sclerosing cholangitis and 2 cases of autoimmune pancreatitis. For the pancreatic or bile duct stent group, there were 483 cases of malignant biliary obstruction,13 cases of biliary stone,28 cases of pancreatic duct stone,3 cases of sclerosing cholangitis and 5 cases of inflammatory stricture of common bile duct.And there were 385 cases of biliary stone,36 cases of simple dilatation of common bile duct,38 cases of inflammatory stricture of common bile duct,11 cases of strictured papilla,9 cases of pancreatic duct stone and 3 cases of biliary cyst for un-drainage group.The incidences of acute pancreatitis and acute cholangitis(4.4%,2.6%)were higher in un-drainage group than the nasal biliary drainage group(1.5%,0.6%,P 0.05)and the stent group(0.4%,0.8%,P>0.05). The incidences of 4 kinds of complications were not significantly different between the nasal biliary drainage group and the stent group. Conclusion Endoscopic nasal biliary drainage or stent can prevent and treat some of therapeutic ERCP complications effectively. Key words: Endoscopic retiograde cholangiopancreatgraphy; Nasal biliary drainage; Pancreatic or bile duct stent; Complication; Prevent and treat

EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos)

Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study. EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation. The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20). EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates.

PWE-438 Cholecystectomy audit: waiting time, readmissions and complications

<h3>Introduction</h3> 15% of the UK adult population have gallstones. In those with symptomatic gallstone disease, laparoscopic cholecystectomy is the gold standard management.¹There continues to be debate over whether patients should undergo definitive management at presentation or it should be delayed until inflammation has subsided. Guidelines suggest patients with acute cholecystitis should be offered cholecystectomy within 1 week¹, while those with gallstone pancreatitis should receive therapeutic ERCP within 72 h followed by cholecystectomy within the same hospital admission, or within 2 weeks.² <h3>Method</h3> A retrospective audit of all cholecystectomies at the trust over a 1-year period was performed. Data extracted from electronic medical records (Medicorr) was collated using Microsoft Excel. Patient demographics, diagnosis at initial presentation, time to surgery, and rate and cause of readmission of those awaiting elective surgery were recorded. Chi-Squared analysis was performed to assess for a significant difference between elective and emergency lap-open conversion and complication rates. <h3>Results</h3> 477 patients were included. The median age was 51 years and 80% were female. The most common indications for cholecystectomy were biliary colic (69%) and cholecystitis (23%). The median wait for surgery was 81 days. The median wait for patients with acute cholecystits and gallstone pancreatitis was 69 and 62 days respectively. 8% of patients were readmitted while waiting. Those discharged after presenting with complicated gallstone disease (common bile duct stones or gallstone pancreatitis) were most likely to require readmission (27% and 24% respectively). Acute cholecystitis was the most common diagnosis on readmission (56%). 5 patients were readmitted with gallstone pancreatitis. The laparoscopic to open conversion rate was not significantly greater in emergency operations compared to elective (p &gt; 0.05). The complication rate of emergency operations, however, was significantly greater compared to elective (p &lt; 0.05). <h3>Conclusion</h3> Guidelines for performing urgent cholecystectomy for patients with gallstone pancreatitis and acute cholecystitis were not met for the majority of patients. A significant proportion were admitted to hospital while awaiting cholecystectomy, some with serious complications of gallstones. It appears that patients with complicated gallstones disease are more likely to be readmitted. We are continuing to collect data to attempt to identify high-risk patients. There may be a role for “elective-emergency” lists for such patients, to prevent complications developing. We plan to re-audit in one year to identify improvement. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> NICE Clinical Guidance 188 – Gallstone Disease British Society of Gastroenterology: UK guidelines for the management of acute pancreatitis. Gut 2005;54;1–9

PWE-196 Factors predicting mortality in acute severe gallstone pancreatitis

Introduction The British Society of Gastroenterology (BSG) guidelines state that “Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gall stone aetiology who satisfy the criteria for predicted or actual severe pancreatitis”. The Cochrane review in 2012 suggested that ERCP does not affect morbidity and mortality and some patients with gallstones in the CBD will pass spontaneously. Aim The aim of this study was to assess predictive factors of mortality and the need for ERCP in severe gallstone pancreatitis. Method Data for patients who presented with acute severe biliary pancreatitis between January 2012 and April 2014 was collected. Data collected included predicted severity (Modified Glasgow score), liver function tests, white cell count, USS, ERCP and MRCP reports. Overall 90 day mortality was also recorded. Results 123 patients had predicted severe pancreatitis. On US 21 patients had a dilated CBD and 16 had CBD stone. 51% of patients (n = 63) had MRCP of which 22 patients had CBD stones. 60 patients had ERCP. In 17% (n = 21) no stone was found. 2 patients (3%) developed post ERCP pancreatitis.11% (n = 14)of the patients admitted with predicted severe acute pancreatitis died. On univariate analysis albumin (p = 0.003), alanine transaminase (ALT) (p= Conclusion Low serum albumin and ALT predicts mortality in severe GSP but ERCP does not and may precipitate further attacks of pancreatitis. Patients who have severe gallstone pancreatitis without deteriorating LFTs or cholangitis should have an MRCP to confirm stones in the CBD prior to ERCP. Disclosure of interest None Declared.

Papillary obstruction with/or without biliary pancreatitis can be dissolved by low doses of theophylline(Theo) and nitroglycerin(NO) to postpone therapeutic ERCP.

Papillary obstruction with/or without biliary pancreatitis can be dissolved by low doses of theophylline(Theo) and nitroglycerin(NO) to postpone therapeutic ERCP.

Consideration of Endoclips to Help Cannulate an Ampulla Hidden in a Duodenal Diverticulum at ERCP

We thank Drs. Nadir and Chuang for their thoughtful letter [1] in response to our recent single case report [2] of successful deployment of two endoclips at ERCP to expose an ampulla of Vater, initially inaccessible due to the ampulla lying within a large diverticulum, with consequent successful cannulation, sphincterotomy, and stone retrieval. They report one case in which an endoclip was deployed to evert and expose an ampulla that was initially inaccessible within a large duodenal diverticulum, and deployed a second endoclip for stabilization that inadvertently caused greater instability of the ampulla. Despite this difficulty, they were able to use the sphincterotome to evert the ampullary opening and successfully cannulate for therapeutic ERCP. We have two comments. First, despite their difficulties, the outcome was successful cannulation after multiple unsuccessful attempts before deploying the endoclips. Second, we experienced a similar problem of instability during cannulation after deploying one endoclip which resolved after deploying a second endoclip. This finding argues for carefully placing endoclips to achieve stability. Endoclips should currently be considered only when (1) cannulation is otherwise impossible due to ampulla location within a diverticulum, (2) ERCP is required for potentially life-saving endoscopic therapy, and (3) the endoscopist is highly skilled in both ERCP and endoclip deployment. This technique should currently be considered experimental with use restricted to these circumstances due to insufficient outcomes data.

Su1593 Long-Term Outcome of Endoscopic Transpapillary Gallbladder Drainage: a Single-Center Experience

Su1592 Whether a Wait-and-See Policy or Add on Therapy With Choleretics Is Effective in Gallbladder in Situ Without Definite Stones Following Complete Removal of Biliary Stones? a Prospective Multicenter Observational Study Tae Hoon Lee*, Hyun Jong Choi, Joung-Ho Han, Yong Seok Kim, Seok Jeong, Yun Nah Lee, Yunho Jung, Young Sin Cho, Dong Hee Koh, Jong Ho Moon, Sang-Heum Park Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea (the Republic of); Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea (the Republic of); Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea (the Republic of); Internal Medicine, Konyang University School of Medicine, Daejeon, Korea (the Republic of); Internal Medicine, Inha University School of Medicine, Incheon, Korea (the Republic of); Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea (the Republic of) Background/Aims: In patients with acalculous gallbladder in situ after complete removal of common bile duct (CBD) stones, there is no definite guideline for the management of remnant gallbladder. Elective cholecystectomy for acalculous gallbladder following removal of CBD stones is still controversial. We aimed to evaluate whether a wait-and-see policy or add on therapy with choleretics is justified in gallbladder in situ without definite stones following complete removal of CBD stones by ERCP. Patients and Methods: In this prospective comparative study in five tertiary referral centers, patients who underwent therapeutic ERCP to removal of CBD stones were randomized to a group received choleretic agents during 3 months (UDCA 600 mg or Terpene derivatives 300 mg per day) or just wait-and-see group after complete clearance of CBD stones. All patients did not have definite gallstones in gallbladder except sludges. The primary outcome was further developed biliary complications needed cholecystectomy or therapeutic ERCP between an add on therapy group with choleretics and a wait-and-see policy group during long-term observational period. Results: Two hundred eighteen patients entered into the trial; 110 of 218 patients were randomized to a choleretics medication group and others were randomized to a just wait-and-see group after complete removal of CBD stones by ERCP. Number of CBD stones, CBD dilatation, and mean sessions of ERCP for complete CBD clearance were not different between two groups. There was no definite gallbladder stones in both group, but gallbladder sludges were detected in 30 (27.3%) and 22 (20.4%) patients, respectively (PZ0.232). Median follow-up was 701 days (range, 105-1523) in choleretics medication group and 565 days (93-1229) in a wait-and-see group, respectively. During a median follow-up of approximately 2 years, recurrent biliary events needed surgical cholecystectomy or therapeutic ERCP were not different statistically (PZ0.376). Eleven patients (10%) in choleretics medication group returned with further biliary events (cholecystitis needed cholecystectomy, nZ2; cholangitis needed ERCP, nZ9). Among those with wait-and-see group, 15 (13.9%) returned with further biliary events (cholecystitis needed cholecystectomy, nZ2; cholangitis needed ERCP, nZ13). There was no cholereticsrelated complications needed additional therapy or withdraw. Median biliary eventsfree survival was also not different between two groups (636 vs. 402 days, Log-rank PZ0.066). Conclusions: During observational period, biliary complications needed operation or therapeutic ERCP were more frequent in a wait-and-see group without statistical difference. More long-term follow up is required to distinguish the statistical difference.

430 Treatment of Refractory Bleeding Post-Sphincterotomy and Post-Papillectomy With Endoscopic Fibrin Glue Injection. Results in a Large Series

Bleeding is one of the most common complication after therapeutic ERCP. Endoscopic hemostasis can be achieved by epinephrine, hemoclip, thermal coagulation or combining these options. In case of failure, the last options were radiological or surgical treatment. Fibrin glue injection has been proposed for endoscopic hemostasis in this subgroup of patients. Results of endoscopic injection of fibrin glue, for refractory post-sphincterotomy and post-papillectomy bleeding, were analyzed in a large series.

Mo1446 Endoscopic Ultrasound-Guided Rendezvous for Difficult Biliary Cannulation: a Multicenter Prospective Pilot Study

Biliary cannulation is indispensable step in therapeutic ERCP for biliary disorder. Although the reported success rate of biliary cannulation is high, there are still cases with difficult biliary cannulation. EUS guided rendezvous (EUS-RV) can salvage failed cannulation. Aims: To determine the safety and efficacy of EUS-RV with a standardized algorithm in terms of a scope position in a prospective cohort undergoing therapeutic ERCP.

P0070 : Efficacy of therapeutic ercp in biliary complications following liver transplant: 10-Years experience

P0070 : Efficacy of therapeutic ercp in biliary complications following liver transplant: 10-Years experience

Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla.

Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.