Utility Of ERCP Research Articles

Endoscopic retrograde cholangiopancreatography for the management of choledocholithiasis in older patients.

older adults are increasing in number and frequently seek hospital care for acute illness. This study aimed to measure the utilization and safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 85 and older in our hospital. a single-site, retrospective, observational and descriptive study was performed. Data about admissions and ERCP utilization was obtained from our hospital database. Medical and procedural records of patients aged 85 or older who underwent ERCP for choledocholithiasis between 2013 and 2019 were reviewed. Technical and medical adverse events after ERCP were evaluated. four hundred and ninety-four ERCP due to choledocholithiasis were performed during the study period and 154 (31 %) patients were aged 85 or older; 567 (4.8 %) admissions due to biliary tract diseases were identified in the older population, and 27 % of cases required ERCP. In older patients, the rate of technical adverse events was around 10 %. There was no statistical difference between the older and younger groups regarding technical complications (8.8 vs 9.7 %; p = 0.7). Furthermore, in 36 % of cases, a medical event, decompensated comorbidity or geriatric syndromes appeared after ERCP. The overall mortality for any cause at six months was nearly 20 %, and the survival rate was significantly lower in patients who developed adverse events (technical or medical). in our hospital, ERCP is frequently used for patients aged 85 and older. Although technical adverse event rates are similar to those of younger adults, medical events appear frequently. We plan to strengthen our care plans for older adults and hope to reduce the medical complications experienced post-ERCP.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) Utilization of Trends Among Interventional Endoscopists.

Endoscopic ultrasound-directed transgastric ERCP (EDGE) has become standard-of-care therapy at many centers for pancreaticobiliary disease in patients with Roux-en-Y Gastric Bypass. In this study, we aimed to evaluate the opinions and practices of endoscopists who perform EDGE. A 22-question utilization of EDGE survey was sent to 36 advanced endoscopists at tertiary care centers in the United States. The two-section survey included questions regarding advanced endoscopy volume and training at the respective facilities, and questions on specific details of EDGE utilization. Among 36 interventional endoscopists (IE) surveyed, 14 (39%) reported performing > 1000 ERCPs annually. Thirty (83%) offered EDGE as an option for Roux-en-Y gastric bypass patients with previous cholecystectomy. Other options offered included: 19 (53%) offered Laparoscopy-assisted ERCP (LA-ERCP), 7 (19%) offered Single-Balloon ERCP (SBE), and 10 (28%) offered percutaneous drainage (PTC). Twenty (56%) IE performed 10 or less EDGE procedures, while 16 (44%) performed 11 or more. Single-session EDGE was performed by 7 (19%) IE, while 15 (42%) performed dual session, and 13 (36%) performed both. 19 (53%) actively closed fistulas while 17 (47%) let them close spontaneously. Thirty one (86%) reported a technical success rate of 91% to 100%. The most frequently reported immediate adverse event post-procedurally was abdominal pain, reported by 17IE (47%). Weight gain was reported by 2IE (6%). EDGE continues to gain in popularity as an option for Roux-en-Y gastric bypass patients requiring pancreaticobiliary interventions, with 24/36IE (67%) believing that it should be the new standard. In addition, most report a low frequency of post-procedural weight gain. ClinicalTrials.gov Identifier NCT05041608.

Advancements in Endoscopic Biliary Interventions by Gastroenterology.

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.

Comparison of idiopathic recurrent acute pancreatitis [IRAP] and recurrent acute pancreatitis with genetic mutations

BackgroundIdiopathic recurrent acute pancreatitis (IRAP) describes frequent episodes of pancreatitis without an etiology found using current testing. We compared the natural history of IRAP with recurrent acute pancreatitis with genetic mutations. MethodsRetrospective cohort of patients with recurrent acute pancreatitis (≥2 episodes) and negative conventional testing. All patients had ≥1 episode after cholecystectomy and completed genetic testing. Primary outcomes were chronic pancreatitis incidence, pancreatic cancer, and mortality. Secondary outcomes included opioid and ERCP utilization. Results128 patients met criteria for presumed IRAP. 35 patients met criteria for true IRAP. 12 patients had recurrent acute pancreatitis with gene mutations. Chronic pancreatitis developed in 27 (77.1%) IRAP patients over a median of 6 years. Chronic pancreatitis incidence was similar in IRAP and CFTR mutation carriers; but developed later in SPINK1 carriers. No patients developed pancreatic cancer or died from pancreatic-related causes. Patients were frequently treated with oral opioids and ERCP, without significant differences within or between groups. ConclusionIRAP and pancreatitis in mutation carriers is associated with chronic pancreatitis. Important differences in natural history were observed, but no association was found with cancer or pancreas-related mortality. Efforts to understand the genetic contributions to IRAP, minimize opioids and unnecessary ERCPs are encouraged.

44 Trends in ERCP Utilization for Sphincter of Oddi Dysfunction: The Real World Impact of EPISOD and Rome IV

INTRODUCTION: The widespread clinical adaptation of landmark clinical trials and practice guidelines is often unclear. The EPISOD trial, a randomized, sham-controlled trial, demonstrated that endoscopic sphincterotomy in patients with Type III Sphincter of Oddi dysfunction (SOD) did not result in clinical improvement. The results of this study were presented at the 2013 National Meeting of the American College of Gastroenterology and published in May 2014. Subsequently, the updated 2016 Rome IV criteria removed Type III SOD from the functional biliary disorder classification. Though patients with Type III SOD make up a minority of all SOD patients, we aimed to assess the utilization of ERCP for patients with SOD in a large population database from 2012–2017. METHODS: We searched electronic health record (EHR)-based disparate data from a cloud-based dataset which incorporates over 300 individual hospitals in the United States (Explorys Inc, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a first-ever diagnosis of “disorder of Sphincter of Oddi” or “spasm of Sphincter of Oddi” annually from 2012–2017. Because the dataset uses SNOMED codes, it was not feasible to sub-classify the types of SOD. Stratified by year, we identified the proportion of patients undergoing ERCP with sphincterotomy and those receiving tricyclic antidepressants (TCA). A Mantel-Haenszel test was used. RESULTS: The number of index cases of SOD and rates of ERCP utilization are outlined in Table 1. From 2013 (the presentation of EPISOD data) to 2016, there was a significant trend demonstrating lower rates of ERCP for newly-diagnosed SOD (P = 0.018). A divergent increase in TCA utilization was concomitantly seen from 2013–2015, but the trend was not statistically significant (P = 0.29). Following the publication of the ROME IV criteria, rates of ERCP utilization for newly-diagnosed SOD significantly increased (P = 0.048) (Figure 1). CONCLUSION: Following the presentation of the EPISOD data, there was a significant 3-year linear decrease in ERCP utilization for all-comers newly-diagnosed with SOD. Concomitantly, a divergent yet insignificant increase in TCA usage was observed. In 2016, after the Rome IV criteria narrowed the diagnosis of SOD, an expected increase in ERCP utilization was observed. These findings call for ongoing observation to see if these trends are durable.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

The utility of ERCP in pediatric pancreatic trauma

Background/purposeEndoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes. MethodsA retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests. ResultsERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7–211) vs 7 (4–12) days; p=0.55], similar hospital days: [12 (8–20) vs 11 (6–19) days, p=0.63], and similar time on parenteral nutrition: [17 (10–40) vs 10 (6–18) days; p=0.19] compared to patients who were only observed. ConclusionsIn children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed. Study typeRetrospective Study; Treatment Study. Level of evidenceIII.

Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013

Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States. We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures. Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures hasincreased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals. Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of theincreased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Largeurban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

Utility of ERCP in the Treatment of Biliary Stricture Combined With Bile Duct Stone After Liver Transplantation

Utility of ERCP in the Treatment of Biliary Stricture Combined With Bile Duct Stone After Liver Transplantation

Diagnostic utility of ERCP for biliary stricture

Diagnostic utility of ERCP for biliary stricture

Multicenter Evaluation of the Clinical Utility of Laparoscopy-Assisted ERCP in Patients with Rouxen-Y Gastric Bypass (RYGB)

Introduction: RYGB is the most common weight loss procedure in the United States. Standard ERCP is not feasible and enteroscopy assisted ERCP tends to be technically challenging with low success rate in these patients. Laparoscopy-assisted (lap-assist) ERCP has been proposed through small, single-center, case series. Therefore we conducted a multicenter, nationwide study to evaluate the feasibility, safety and outcomes of this approach. Methods: This is an IRB approved, retrospective study that included adult patients with RYGB undergoing lap-assist ERCP in 22 centers in the United States and 2 in Brazil. A standardized data entry form was distributed across all the centers to collect information about demographics, indications, operative details, success rate, and complications. Severity of complication was classified using the American Society for Gastrointestinal Endoscopy lexicon. Results: We included 388 patients with median age of 51 (Interquartile range (IQR) 41-60) and 84% females. Indication for lap-assist ERCP was biliary in 92% (stones 50%) and pancreatic in 8% (acute pancreatitis 94%). Success in reaching the papilla was achieved in 98%, cannulating the desired duct in 98%, and performing the desired intervention in 97%. Success in the disease state resolution after the intervention was 94%. The most common therapeutic interventions were biliary sphincterotomy (97%), stone extraction (45%), pancreatic stent placement (15%), and biliary stent placement (7%). Median total procedure time (laparoscopy + ERCP) was 152 (IQR 112-210) and median ERCP time was 39 (IQR 27-55) minutes. Median length of stay in the hospital was 2 (IQR 1-3) days. Complications were reported in 16% of the cases (9% laparoscopy and 6% ERCP related). Most common complications were pancreatitis (5%), infections (5%), cholangitis (1%) and perforation (1%). Majority (13.4%) were classified as mild, whereas 1.5% was classified as severe and one death was reported. Conclusion: Our large multicenter study indicates that lap-assist ERCP in patients with RYGB is highly successful with success rates compatible to standard ERCP in patients with normal upper GI tract anatomy. ERCP related complication rates appear comparable to conventional ERCP, but the overall complication rate was higher due to the added laparoscopy associated complications. Note: There are a total of 53 authors from 24 participating centers. Only 25 authors listed due to the abstract submission system limitation on the maximum authors number.

Racial and Insurance Status Disparities in ERCP Utilization in Acute Pancreatitis

Racial and Insurance Status Disparities in ERCP Utilization in Acute Pancreatitis

Prospective Evaluation of the Clinical Utility of Laparoscopy-Assisted ERCP in Patients With Roux-en-Y Gastric Bypass

Prospective Evaluation of the Clinical Utility of Laparoscopy-Assisted ERCP in Patients With Roux-en-Y Gastric Bypass

Safety and Yield of Diagnostic ERCP in Liver Transplant Patients with Abnormal Liver Function Tests

Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8–48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48–62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic.

Su1138 Dramatic Decline in Bile Duct Surgery Rates With Increased Utilization of Therapeutic ERCP in the United States: Population-Based National Data Over 19 Years (1993-2011)

Su1138 Dramatic Decline in Bile Duct Surgery Rates With Increased Utilization of Therapeutic ERCP in the United States: Population-Based National Data Over 19 Years (1993-2011)

Su1730 The Utilization of Diagnostic ERCP in the Last Decade: Changing Indications in a Tertiary Referral Center

Since the advent of less invasive tests the utilization of diagnostic ERCP has reduced. Previous data showed a reduction in diagnostic ERCP to early 2000, while there has been a steady rise in therapeutic ERCP utilization nationwide. The role of diagnostic ERCP in the last decade is unclear.

Su1675 Utility and Problems of EUS and ERCP At One Session for Clinical Management of Acute Cholangitis

Since acute cholangitis(AC) is sudden onset syndrome and has risk for developing severe infection that can be fatal, we usually need to provide appropriate medical care at early stage. ERCP or EUS are indispensable for prompt diagnosis and treatment for AC. Some reports have indicated the superiority of linear array EUS in detection of biliary tract lesions and contribute correct diagnosis for because of the high resolution of images. In this study we evaluated the utility and problems of EUS and ERCP at one session.

Su1671 Utility and Problems of Linear Array EUS and ERCP for Diagnosis and Treatment of Acute Cholangitis in Over 80 Years High Elderly Patients

Su1671 Utility and Problems of Linear Array EUS and ERCP for Diagnosis and Treatment of Acute Cholangitis in Over 80 Years High Elderly Patients

Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study

Comprehensive, population-based data on ERCP use over the last 30 years in North America are lacking. To establish crude and age-adjusted population-based rates of ERCP, evaluate for changing indications for ERCP, and evaluate for interactions between cholecystectomy technique and ERCP use from 1984 to 2009. Retrospective, comprehensive, population-based study. All inpatient and outpatient ERCPs and cholecystectomies in Manitoba, Canada from 1984 to 2009. All residents of Manitoba, Canada with a history of ERCP and/or cholecystectomy. None. Yearly crude and age-adjusted rates of ERCP (diagnostic and therapeutic) and cholecystectomy (open, laparoscopic, and with open bile duct exploration), and patient and/or procedure demographics. The rate of ERCP/10,000 people increased from 7.70 (1984) to 13.86/10,000 (2009) (P = .001). Diagnostic ERCP declined from 7.28/10,000 (1984) to 1.11/10,000 (2009), and therapeutic ERCP increased from 0.42/10,000 (1984) to 12.75/10,000 (2009) (P < .001). ERCPs were more common in women (62%) and in older populations (60-79 years, >80 years), with rates of therapeutic ERCP reaching 62.58/10,000 in the elderly. The primary indication for ERCP has changed over time, with biliary indications increasing from 50.3% to 67.3% and pancreatic indications decreasing from 18.3% to 8.1% (P < .05). The rate of therapeutic ERCP increased during the transition from open to laparoscopic cholecystectomy (1991-1994), whereas open bile duct exploration (OBDE) decreased from 2.0 to 0.18/10,000 (P < .001). Retrospective analysis, administrative data. ERCP use increased steadily from 1984 to 2009, and changed from a diagnostic modality to a therapeutic one. Changes in cholecystectomy technique may have influenced therapeutic ERCP use and likewise, the availability of therapeutic ERCP has decreased the need for OBDE.

Trends in Utilization and Complications of ERCP in Primary Sclerosing Cholangitis: A Tertiary Center Experience

Trends in Utilization and Complications of ERCP in Primary Sclerosing Cholangitis: A Tertiary Center Experience