Time Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Predictors of Jaundice Resolution and Survival After Endoscopic Treatment of Primary Sclerosing Cholangitis.

The benefit of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of primary sclerosing cholangitis (PSC) remains controversial. To identify predictors of jaundice resolution after ERCP and whether resolution is associated with improved patient outcomes, we conducted a retrospective cohort study of 124 patients with jaundice and PSC. These patients underwent endoscopic biliary balloon dilation and/or stent placement at an American tertiary center, with validation in a separate cohort of 102 patients from European centers. Jaundice resolved after ERCP in 52% of patients. Median follow‐up was 4.8 years. Independent predictors of jaundice resolution included older age (P = 0.048; odds ratio [OR], 1.03 for every 1‐year increase), shorter duration of jaundice (P = 0.059; OR, 0.59 for every 1‐year increase), lower Mayo Risk Score (MRS) (P = 0.025; OR, 0.58 for every 1‐point increase), and extrahepatic location of the most advanced biliary stricture (P = 0.011; OR, 3.13). A logistic regression model predicted jaundice resolution with area under the receiver operator characteristic curve of 0.67 (95% confidence interval, 0.5‐0.79) in the validation set. Independent predictors of death or transplant during follow‐up included higher MRS at the time of ERCP (P < 0.0001; hazard ratio [HR], 2.33 for every 1‐point increase), lower total serum bilirubin before ERCP (P = 0.031; HR, 0.91 for every 1 mg/dL increase), and persistence of jaundice after endoscopic therapy (P = 0.003; HR, 2.30). Conclusion: Resolution of jaundice after endoscopic treatment of biliary strictures is associated with longer transplant‐free survival of patients with PSC. The likelihood of resolution is affected by demographic, hepatic, and biliary variables and can be predicted using noninvasive data. These findings may refine the use of ERCP in patients with jaundice with PSC.

Next-generation sequencing of bile cell-free DNA for the early detection of patients with malignant biliary strictures

ObjectiveDespite significant progresses in imaging and pathological evaluation, early differentiation between benign and malignant biliary strictures remains challenging. Endoscopic retrograde cholangiopancreatography (ERCP) is used to investigate biliary strictures, enabling the...

ERCP improves mortality in acute biliary pancreatitis without cholangitis.

Background and study aims Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. The necessity for endoscopic retrograde cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. The aim of this study was to evaluate the association of ERCP and its performance during admission with mortality and length of stay (LOS) in patients with AGPNC. Patients and methods We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis or concurrent cholangitis, and those who were transferred from elsewhere for treatment. Our primary outcome measure was inpatient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results We identified 491,011 records eligible for analysis. Of the patients, 30.6 % (150,101) had AGPNC. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (± 6.38) days with a median stay of 4 days (range, 3–7). When adjusted for age, Elixhauser Comorbidity Index, and severe pancreatitis, patients with ERCP during admission were 43 % less likely to die. ERCP performed between Days 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion ERCP performed during inpatient admission for AGPNC was associated with decreased mortality. These data support early ERCP in patients with acute gallstone pancreatitis without cholangitis.

Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction

BackgroundThere is a lack of studies regarding the optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in patients with cholangitis caused by distal malignant biliary obstruction (MBO). This study aims to investigate the optimal timing of ERCP in patients with acute cholangitis associated with distal MBO with a naïve papilla.MethodsA total of 421 patients with acute cholangitis, associated with distal MBO, were enrolled for this study. An urgent ERCP was defined as being an ERCP performed within 24 h following emergency room (ER) arrival, and early ERCP was defined as an ERCP performed between 24 and 48 h following ER arrival. We evaluated both 30-day and 180-day mortality as primary outcomes, according to the timing of the ERCP.ResultsThe urgent ERCP group showed the lowest 30-day mortality rate (2.2%), as compared to the early and delayed ERCP groups (4.3% and 13.5%) (P < 0.001). The 180-day mortality rate was lowest in the urgent ERCP group, followed by early ERCP and delayed ERCP groups (39.4%, 44.8%, 60.8%; P = 0.006). A subgroup analysis showed that in both the primary distal MBO group, as well as in the moderate-to-severe cholangitis group, the urgent ERCP had significantly improved in both 30-day and 180-day mortality rates. However, in the secondary MBO and mild cholangitis groups, the difference in mortality rate between urgent, early, and delayed ERCP groups was not significant.ConclusionsIn patients with acute cholangitis associated with distal MBO, urgent ERCP might be helpful in improving the prognosis, especially in patients with primary distal MBO or moderate-to-severe cholangitis.

Optimal Timing of Endoscopic Intervention After Extracorporeal Shock-Wave Lithotripsy in the Treatment of Chronic Calcified Pancreatitis.

The interval between extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) may cause differences in cannulation and stone removal. This study was to investigate the optimal timing of ERCP after ESWL. Patients with chronic calcified pancreatitis, who underwent ESWL and subsequent ERCP in Changhai Hospital from February 2012 to February 2015, were retrospectively analyzed. The interval between ESWL and ERCP was used to divide patients into groups A (<12 hours), B (12-36 hours), and C (>36 hours). Cannulation success, stone clearance, and post-ESWL/ERCP complications were compared. A total of 507 patients were enrolled. There were no significant differences regarding the successful cannulation and stone removal rates between the 3 groups. In patients without prior ERCP, the successful cannulation rates were 71.4%, 81.9%, and 90.9% (P = 0.004), and the successful clearance rates were 76.2%, 85.1%, and 90.9% (P = 0.031) for these 3 groups, respectively, showing significant differences. There were no differences in the successful cannulation and stone extraction rates for patients with prior ERCP. The interval between ESWL and ERCP in chronic calcified pancreatitis patients with prior ERCP is not relevant, while delaying endoscopic intervention is recommended in those with native papilla.

Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low-volume Endoscopists.

Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP. We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High-volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low-volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year. Three hundred eighty-five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age <4 years or >16 years at the time of ERCP (P < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT. Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) can safely and effectively manage postsurgical or traumatic bile duct leaks (BDLs). Standardized guidelines are lacking regarding effective management of BDLs. Our aim was to evaluate the efficacy, clinical outcomes, and complications of different ERCP techniques and intervention timing using a nationwide database. Patients and methods We performed a retrospective analysis of the IBM Explorys database (1999–2019), a pooled, national, de-identified clinical database of over 64 million unique patients across the United States. ERCP timing after BDL was classified as emergent (< 1 day), urgent (1–3 days) or expectant (> 3 days). ERCP technique was classified into sphincterotomy, stent or combination therapy. ERCP complications were defined as pancreatitis, duodenal perforation, duodenal hemorrhage, and ascending cholangitis within 7 days of the procedure. Results Expectant ERCP had a decreased risk of adverse events (AEs) compared to emergent and urgent ERCP ( P = 0.004). Rehospitalization rates also were lower in expectant ERCP ( P < 0.001). Patients with COPD were more likely to have an AE if the ERCP was performed emergently compared to expectantly ( P = 0.002). Combination therapy had a lower rate of ERCP failure compared to placement of a biliary stent ( P = 0.02). There was no statistically significant difference in rates of ERCP failure between biliary stent and sphincterotomy ( P = 0.06) or sphincterotomy and combination therapy ( P = 0.74). Conclusion Our study suggests that ERCP does not need to be performed emergently or urgently for management of BDLs. Combination therapy is superior to stenting but not sphincterotomy; however, future prospective studies are needed to validate these findings.

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography.

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure. A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis. The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group. ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study.

BackgroundThe timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort.MethodsThe cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the 2 cohorts.ResultsOverall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis.ConclusionsThe increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician’s suspicion about the severity of disease.

Impact of the COVID-19 pandemic on endoscopic retrograde cholangiopancreatography: a single center experience.

the COVID-19 pandemic has impacted on several aspects of health care services worldwide. The aim of the study was to determine its influence on the case volume, success rate and complication rate of endoscopic retrograde cholangiopancreatography (ERCP). all patients who underwent ERCP one-year before and after applying COVID-19 safety measures at the Qena University Hospital were included. Data were collected from the patients' records, analyzed and compared. a total of 250 patients underwent ERCP between April 1st, 2019 and March 31st, 2021, and the mean age of participants was 52 ± 18 years. There was a 5 % increase in case volume after applying COVID-19 safety measures (128 vs 122) and the total procedure time was significantly shorter (42 vs 46 minutes, p = 0.04). There was no significant difference in the overall success rate and complication rate. Procedure success significantly correlated with cannulation attempts and total procedure time in both groups, and serum bilirubin and cannulation time in the pre-COVID-19 patients and alkaline phosphatase (ALP) in post-COVID patients. ERCP-related complications significantly correlated with cannulation attempts in both groups, and ALP, international normalized ratio (INR), cannulation time and total procedure time in pre-COVID-19 patients, and platelet count and amylase in post-COVID patients. Two patients were confirmed COVID-19 cases at the time of ERCP; therapeutic targets were achieved in both with a smooth post-ERCP recovery. Three out of nine ERCP team members caught a mild to moderate COVID-19 infection and recovered after receiving proper management. our result show that there was no negative impact of using COVID-19 safety measures and precautions on the case-volume, indications, overall outcome or complication rate of ERCP.

Long-term follow-up after fetal radiation exposure during endoscopic retrograde cholangiopancreatography.

Background and study aims The main concern about endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy is the risk of radiation exposure to the fetus. The potential exists not only in the short-term, but also in the long-term and includes growth and development problems and the possibility of childhood cancer. Little is known about the long-term effects of fetal radiation exposure at the time of ERCP. The aim of the study was to report the long-term outcome of babies born after radiation exposure to mothers who underwent ERCP during pregnancy. Patients and methods This was a single-center retrospective cohort study. We included 24 consecutive pregnant patients who underwent ERCP due to choledocholithiasis and their children, between June 1997 and June 2015. All patients and their babies were followed up until birth to assess their short-term outcome. To assess long-term outcomes, from September 2014 to September 2015, a comprehensive medical interview was conducted with the mothers and their children. We also evaluated medical records, lab tests, school report cards, and the families completed a questionnaire inquiring about perceived health status of the children. Results Fifteen patients had full-term pregnancies. One patient had a preterm delivery (32 weeks) due to preeclampsia. There were no cases of miscarriage, stillbirth or fetal malformations. Long-term follow-up was performed at a mean age of 11.08 years (range 1–18) for the children, with no developmental delays, poor school performance, or malignancies found. Conclusions Long-term outcome in children born after radiation exposure during ERCP was unremarkable.

Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions.

BACKGROUNDThe management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.AIMTo assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.METHODSWe enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.RESULTSHybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.CONCLUSIONHybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.

S0113 The Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Biliary Pancreatitis Without Cholangitis: A Nationwide Inpatient Cohort Study

INTRODUCTION: Endoscopic Retrograde Cholangiopancreatography (ERCP) is recommended within 24 hours for patients with Acute biliary pancreatitis (ABP) with signs of cholangitis. In the absence of cholangitis, the impact of the timing of ERCP remains unclear. We aimed to analyze the timing of ERCP in ABP patients without cholangitis. METHODS: This is a retrospective, longitudinal study of patients from 2005 to 2014, who presented to the US hospitals with diagnosis of ABP and received ERCP within first 24 hours (urgent ERCP) or within 24 to 72 hours (early ERCP). Study cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the two cohort. RESULTS: Overall, 105,433 admissions were evaluated. There was a significant P-trend (P < 0.001) increase in urgent ERCP performed over the 10-year study period (Figure 1). Predictors of urgent ERCP in ABP patients utilizing multivariate regression model are shown in Figure 2. Older patients, males, patients with comorbidities, African American and Hispanic patient population were significantly less likely to receive ERCP urgently. Intermediate ERCP volume hospitals were more likely to perform urgent ERCP in ABP patients. Additionally, teaching hospitals and hospitals in the Midwest and West were more likely to perform urgent ERCP. Use of abdominal imaging modalities prior to ERCP resulted in 50% decrease in the utilization of urgent ERCP. There were no differences in mortality rates or the complications rates between the two cohorts (Table 1). The composite variable encompassing all the complications was not significant between the two groups. There were significant differences in length of stay and healthcare cost analysis. CONCLUSION: We performed a retrospective study of patients with ABP (but without cholangitis) that showed an increasing trend of urgent ERCP over the study period without clinically significant benefit in mortality, length of stay and healthcare cost analysis. Further, urgent ERCP utilization is not uniform across various demographic and hospital cohorts. Hence, early ERCP may be over-utilized, and it may be reasonable to perform early ERCP (within 24–72 hours) instead of urgent ERCP in ABP patients in the absence of cholangitis.Figure 1.: Trends of urgent ERCP utilization in Acute Biliary Pancreatitis patients without signs of cholangitis across a 10-year period from 2005 to 2014.Figure 2.: Multivariate regression model predicting demographic and hospital factors affecting urgent ERCP utilization in Acute Biliary Pancreatitis without signs of cholangitis.Table 1.: Mutivariate Hazard Ratios and Regression Coefficients of various outcome factors based on patients receiving urgent ERCP in Acute Biliary Pancreatitis patients without signs of cholangitis compared to patients receiving early ERCP

Which scope is appropriate for endoscopic retrograde cholangiopancreatography after Billroth II reconstruction: An esophagogastroduodenoscope or a colonoscope?

BACKGROUNDRecently, with the advent of more advanced devices and endoscopic techniques, endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II (B-II) patients has been increasingly performed. However, the procedures are difficult, and the techniques and strategies have not been defined.AIMTo reveal the appropriate scope for ERCP in B-II patients.METHODSSixty ERCP procedures were performed on B-II patients between June 2005 and May 2018 at Fukushima Medical University Hospital, and in 44 cases, this was the first ERCP procedure performed by esophagogastroduodenoscopy (EGDS) or colonoscopy (CS) after B-II gastrectomy. These cases were divided into two groups: 17 cases of ERCP performed by EGDS (EGDS group) and 27 cases of ERCP performed by CS (CS group). The patient characteristics and ERCP procedures were compared between the EGDS and CS groups.RESULTSThe procedural time was significantly shorter in the EGDS group than in the CS group [median (range): 60 (20-100) vs 90 (40-128) min, P value < 0.01]. CS was an independent factor of a longer ERCP procedural time according to the univariate and multivariate analyses (odds ratio: 3.97, 95%CI: 1.05-15.0, P value = 0.04).CONCLUSIONCompared to CS, EGDS shortened the procedural time of ERCP in B-II patients.

National trends and outcomes in timing of ERCP in patients with cholangitis

IntroductionGuidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term “early” remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. MethodsThe 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. ResultsOf 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). ConclusionThere has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Su1518 EFFECT OF POST-ERCP CHOLECYSTECTOMY VS. PRIMARY ERCP ALONE ON THE RATE OF RECURRENT COMMON BILE DUCT STONES

Gallstone diseases have a high prevalence in western populations and pose a large burden to health care systems. While endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment of choice for common bile duct stones (CBDS), post-ERCP cholecystectomy (CCY) is often performed to prevent recurrent gallstone disease. The effect of post-ERCP CCY compared to primary ERCP alone on the rate of recurrent CBDS has not been described in a general population over a prolonged period of time. Our aim was to investigate the effect of post-ERCP CCY compared to primary ERCP alone on the rate of recurrent CBDS during 5-year follow-up from time of intervention. Using an internal ERCP database at Odense University Hospital, we identified all patients that underwent ERCP for CBDS between January 1 1995 and August 31 2019. Patients with known hepatobiliary or pancreatic malignancies at the time of ERCP were excluded. Patient characteristics, clinical presentation and information on endoscopic procedures were retrieved from the ERCP database. Information on comorbidities, recurrent CBDS and performance of post-ERCP CCY were retrieved from the Danish National Patient Registry (in ICD-10 and SKS codes). The effect of post-ERCP CCY compared to ERCP alone on the rate of recurrent CBDS was investigated using logistic regression, with adjustment for age and comorbidities (Charlson Comorbidity Index, CCI). During the study period 1,768 consecutive patients that underwent ERCP for CBDS fulfilled the inclusion criteria. Among these, 635 patients received post-ERCP CCY (within half a year after primary ERCP) and 1,133 received ERCP alone. Differences between the CCY and no CCY group were observed in age (p<0.01) and gender (p<0.01). The rate of recurrent CBDS during 1-year follow-up was 16% (n=104) in the CCY group and 18% (n=209) in the no CCY group (p=0.30). During 5-year follow-up the rate of recurrent CBDS was 23% (n=149) in the CCY group and 21% (n=239) in the no CCY group (p=0.27). Neither age or gender were independently associated with risk for recurrent CBDS at 5-year follow-up (p>0.1 for both). Performance of CCY was not associated with reduced risk of recurrent CBDS during 5-year follow-up – in both univariate analysis (OR [95% CI]: 1.15 [0.91-1.45]; p=0.25) and multivariate analysis (OR [95% CI]: 1.07 [0.82-1.41]; p=0.61) after adjustment for age (OR [95% CI]: 1 [0.99-1.00]; p=0.51) and CCI (OR [95% CI]: 0.52 [0.27-0.97]; p=0.04). Our results indicate that post-ERCP CCY is not associated with reduced rates of recurrent CBDS compared to ERCP alone during a prolonged follow-up period of 5 years from the time of intervention.

Reduced risk of post ERCP pancreatitis in statin users

BackgroundOne of the most feared complications of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence of 3.5 to 15%, is post ERCP pancreatitis (PEP). Given the role of statins in the reduction of systemic and pancreatic intraluminal inflammation, we hypothesized that the use of statins may lower the risk of PEP.MethodsA retrospective cohort study of all patients undergoing ERCP at West Virginia University during the years 2016 and 2017 was performed. Possible association of collected variables with PEP was assessed with Univariate tests and multivariable logistic regression analyses.ResultsA total of 1162 ERCPs were included. Mean age was 60.12 years (SD: 17.5). 51.3% of the participants were female. Two hundred and sixty-three participants underwent more than one ERCP during the study period.Seven hundred and ninety-nine ERCPs (78.8%) were conducted in participants who were not taking a statin medication at the time of ERCP, while 363 participants were on statin medications at the time of ERCP; 118 and 245 participants were taking high dose statins (atorvastatin 40–80 mg or rosuvastatin 20 mg), and low/medium dose statins (all other statin regimens) at the time of the procedure, respectively.The overall incidence of PEP in the cohort was 7.3%. In the non-statin and statin groups, 9.5 and 3.4% of participants developed PEP, respectively. On univariate analysis, young age, no statin use, history of PEP, and endoscopic sphincterotomy were found to be significantly associated with the development of PEP. In a binary logistic regression model, young age (P = 0.033), history of PEP (P = 0.0001, OR 2.41, 95% CI: 1.05–5.51) and endoscopic sphincterotomy (P = 0.038, OR 2.85, 95% CI: 1.7–4.78) were found to be associated with increased risk of PEP. Statin usage was found to be protective against PEP, (OR 0.35, 95% CI: 0.18–0.69).ConclusionChronic statin usage is protective against post ERCP pancreatitis, and our findings suggest a potential role of these drugs as prophylactic agents. Randomized controlled trials are needed to establish any potential clinical application.

Common bile duct metastasis from recurrent adenocarcinoma of lung: A case report

AbstractObstructive jaundice caused by metastasis of lung cancer to distal common bile duct (CBD) is extremely rare. Here, we report a 70‐year‐old man presented with progressive jaundice and generalized weakness for 1 month. He had a medical history of stage IIB (pT2N1M0) lung adenocarcinoma, for which he had undergone surgical treatment and subsequent adjuvant chemotherapy 3 years ago. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a distal CBD stricture. Histopathological examination of the biopsy specimen taken from the stricture site demonstrated adenocarcinoma with positive for cytokeratin‐7 and thyroid transcription factor‐1 on immunohistochemistry. The findings confirmed the diagnosis of metastasis of recurrent lung adenocarcinoma to the CBD. The patient's jaundice improved after insertion of an endoscopic retrograde bile duct (ERBD) drainage plastic stent at the time of ERCP. He was then started on target therapy with afatinib after discharge. The ERBD stent was removed 3 months later. He had remained in stable condition without jaundice during the 1‐year follow‐up period. In conclusion, obstructive jaundice caused by metastatic adenocarcinoma to the CBD is a rare manifestation of lung cancer. An accurate diagnosis is crucial in further treatment for such a patient.

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

A 49-year-old woman presented with exercise-induced chest discomfort during long-distance running that was occasionally present during rest. Significant coronary artery disease was excluded and a diagnosis of “painful left bundle branch block (LBBB) syndrome” was made after correlation of LBBB aberrancy with symptoms during Holter monitoring. The patient underwent confirmatory testing consisting of rapid atrial pacing below and above 130 beats per minute, the rate cut-off for LBBB manifestation. His bundle pacing implantation was performed resulting in both non-selective and selective morphologies depending on output, both of which manifested with a painless narrow QRS regardless of rate. She was rendered completely pain free during long-distance running and remains so 6-months later. Her pain at rest, now thought to be due to severe anxiety secondary to her painful LBBB, has also subsided. Exercise-induced, painful LBBB is a rare phenomenon that manifests as chest discomfort when LBBB is present. This disease is frequently misdiagnosed as coronary angina, has limited medical treatment options, and can be disabling. HBP is an attractive treatment for this syndrome in an effort to avoid electromechanical dyssynchrony, the presumed mechanism of discomfort. This case report adds to the growing literature of painful LBBB syndrome and its effective treatment with HBP, with the added caveat that it can present with persistent symptoms at rest, in the setting of enhanced anxiety. HBP should be considered early on in the treatment of such patients.

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BackgroundIndication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging. AimsIn this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers. MethodsClinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed. ResultsThere were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)]. ConclusionOptimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.