Complications of endoscopic biliary sphincterotomy

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

Steerable catheter based on wire-driven seamless artificial blood vessel tube for endoscopic retrograde transpapillary interventions

PURPOSE

Current steerable catheters (SCs) for endoscopic retrograde cholangiopancreatography (ERCP) have performance limitations caused by an asymmetric multiple-slit tube design with a small maximum bend angle, lesser curvatures, and insufficient durability. We propose a wire-driven SC for balanced bidirectional bending using artificial blood vessel material to overcome these limitations. We assess the SC prototype's steerability using phantom and animal models.

METHODS

The SC prototype employed a slit-less and multiple-lumen seamless tube with a polytetrafluoroethylene (PTFE) body with stretch-retractable porous expanded PTFE at the distal end, and loop-formed control wires. We evaluated the wire routing design using a static model. The bending performance was compared with conventional SCs. Feasibility studies were performed, including major duodenal papilla insertions and ductal branch selections in desktop phantoms and a mini-pig model.

RESULTS

The proposed design reduced the wire contact force by 48% compared to the single wire configuration. The maximum bend angle was 162°, almost twofold larger than that for conventional SCs. The lateral tip position in the bent shape was maximally 56% smaller. The tip flexibility was comparable to conventional SCs, and the insertion resistance was similar to the passive catheters. Phantom studies showed that the SC prototype could perform the large and protuberant papilla insertions and fine ductal branch selections without breaking; the animal study was completed successfully.

CONCLUSION

We propose a wire-driven SC design for ERCP using a multi-lumen seamless tube and two loop-formed control wires, different from the conventional SC design with a multiple-slit tube and single control wire. The SC prototype records balanced bidirectional bending with a maximum bending angle of ± 162° without breakage risk. The phantom and animal studies show that the prototype performance potentially facilitates papilla cannulations and intrahepatic ductal branch seeking.

ERCP for bile duct stones across a national service, demonstrating a high requirement for repeat procedures

Background and study aims  Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods  Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results  In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions  In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.

A case of delayed pancreatic fistula after covered self-expandable metallic stent deployment for pancreatic head cancer

A 69-year-old man was referred to our hospital with obstructive jaundice. A tumor with poor contrast enhancement was found in the pancreatic head, but there was no evidence of pancreatic atrophy, irregular stenosis, or dilation of the main pancreatic duct. He was diagnosed with borderline resectable pancreatic cancer with distal malignant biliary obstruction. After plastic stent placement, serum bilirubin levels improved, and chemotherapy was started. However, he developed cholangitis; thus, the plastic stent was replaced with a covered self-expandable metallic stent. He subsequently developed a delayed pancreatic fistula due to main pancreatic duct disruption. An endoscopic nasopancreatic duct drainage tube was placed to bridge the main pancreatic duct disruption after removing the covered self-expandable metallic stent. In addition, endoscopic ultrasound-guided transmural drainage was performed for the infected fluid collection caused by the pancreatic fistula, and the clinical symptoms quickly improved. This case presents the possibility of a delayed pancreatic fistula due to self-expandable metallic stent deployment. The need for considering such delayed complications when placing self-expanding metallic stents is highlighted.

Endoscopic Management Using Novel Haemostatic Agents for Immediate Bleeding during Endoscopic Retrograde Cholangio-Pancreatography

Bleeding after endoscopic sphincterotomy (ES) remains as a major challenge during ERCP procedure. Standard endoscopic haemostatic procedures have demonstrated good performance for bleeding control. Novel endoscopic haemostatic agents have also been widely used in gastrointestinal bleeding management. Regardless, there is still a paucity of high-quality evidence evaluating the practicality of these agents in ERCP. This case series study was performed on the patients who underwent ERCP procedure in a tertiary referral private hospital within 2 years period. Post-ES immediate bleeding is defined as the onset of bleeding at the time of sphincterotomy. Treatment groups for post-ES bleeding are divided into (1) standard haemostatic methods and (2) novel haemostatic agents. There were 40 patients who received standard haemostatic treatment and 60 patients who received novel haemostatic agents. Initial haemostasis was achieved in all patients. Two patients who received standard haemostatic treatment had rebleeding. Meanwhile, no patients in novel haemostatic treatment group had rebleeding. In conclusion, novel haemostatic agent can be considered as an easy and practical method in daily practice, especially when an ERCP procedure is performed. Further studies with larger sample size which, if possible, can also include a cost-effectiveness analysis are still required to implement these agents as a standard procedure in clinical practice. (This abstract has been presented at the American College of Gastroenterology meeting October 2021).

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

Risk of post-sphincterotomy bleeding in patients with thrombocytopenia

Background

Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Objective

The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES.

Design

Retrospective observational cohort study.

Methods

Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review.

Results

A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not.

Conclusion

In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.

EUS-guided biliary drainage in malignant distal biliary obstruction: An international survey to identify barriers of technology implementation

Background and Objectives

EUS-guided biliary drainage (EUS-BD) is a promising alternative to ERCP in malignant distal biliary obstruction (MDBO). Despite accumulating data, however, its application in clinical practice has been impeded by undefined barriers. This study aims to evaluate the practice of EUS-BD and its barriers.

Methods

An online survey was generated using Google Forms. Six gastroenterology/endoscopy associations were contacted between July 2019 and November 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers. The primary outcome was the uptake of EUS-BD as a first-line modality, without previous ERCP attempts, in patients with MDBO.

Results

Overall, 115 respondents completed the survey (2.9% response rate). Respondents were from North America (39.2%), Asia (28.6%), Europe (20%), and other jurisdictions (12.2%). Regarding the uptake of EUS-BD as first-line treatment for MDBO, only 10.5% of respondents would consider EUS-BD as a first-line modality regularly. The main concerns were the lack of high-quality data, fear of adverse events, and limited access to EUS-BD dedicated devices. On multivariable analysis, lack of access to EUS-BD expertise was an independent predictor against the use of EUS-BD, odds ratio 0.16 (95% confidence interval, 0.04-0.65). In salvage situations following failed ERCP, most favored EUS-BD (40.9%) over percutaneous drainage (21.7%) in unresectable cancer. In borderline resectable or locally advanced disease, however, most favored the percutaneous approach due to fear of EUS-BD complicating future surgery.

Conclusions

EUS-BD has not reached widespread clinical adoption. Identified barriers include lack of high-quality data, fear of adverse events, and lack of access to EUS-BD dedicated devices. Fear of complicating future surgery was also identified as a barrier in potentially resectable disease.

Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis

Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).

Risk factors for post-endoscopic retrograde cholangiopancreatography cholangitis in patients with hepatic alveolar echinococcosis-an observational study

BACKGROUND

Hepatic alveolar echinococcosis (HAE) is considered to be one of the most deadly chronic parasitic diseases in the world. We have shown that the incidence of cholangitis in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) was increased significantly. On this finding, we carried out, a preliminary study on the risk factors for cholangitis after ERCP.

AIMS

To retrospectively detect the risk factors for post-ERCP cholangitis in patients with biliary tract affected by HAE.

METHODS

The study included data from 51 cases of AE who had undergone therapeutic ERCP between January 2015 and December 2019. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of post-ERCP cholangitis was evaluated using a collected database.

RESULTS

There were five cases of mild cholangitis after ERCP (Tokyo criteria), and no moderate or severe cholangitis occurred. The incidence rate of cholangitis after ERCP was 9.8%. Univariate analysis showed hilar bile duct stenosis (p = .016), endoscopic retrograde biliary drainage (p = .007), a stent diameter ≥8.5 Fr (p = .000) and single stent implantation (p = .010) were risk factors for post -ERCP cholangitis. All cases of cholangitis improved under conservative treatment.

CONCLUSION

Patients with hilar bile duct compression or endoscopic retrograde biliary drainage appeared to be more likely to develop post-ERCP cholangitis. The number and diameter of biliary stents may influence post-ERCP cholangitis. Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors for screening. KEY MESSAGESMany studies reported the post-ERCP complications in patients with hepatic alveolar echinococcosis and found that the incidence of post-ERCP cholangitis was significantly high. Therefore, we conducted a preliminary study on the risk factors of postoperative cholangitis in patients who underwent ERCP.The incidence rate of cholangitis after ERCP was 9.8%. We found that hilar bile duct stenosis, and endoscopic retrograde biliary drainage, were risk factors for cholangitis, and stent diameter and the number of stent implantation may influence the incidence rate of cholangitis after ERCP.Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors of screening.

Post-ERCP Complication Analysis of an Experienced Center

BACKGROUND/AIM

Post-ERCP pancreatitis (PEP), post-sphincterotomy bleeding (PSB), and Post-ERCP perforation are the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Identification of risk factors for post-ERCP complications is critical for postoperative follow-up. This study aimed to evaluate the most common post-ERCP complication risk factors in an experienced center.

METHODS/DESIGN

The sample consisted of 1288 patients with naive papillae. Demographic characteristics, patient-related risk factors, procedure-related risk factors and postoperative complications were recorded.

RESULTS

Patients had a mean age of 61.5±18.4 years. The prevalence of PEP, PSB, and post-ERCP perforation was 7.9%, 11.9%, and 0.5%, respectively. Among patient-related factors, female sex (OR 1.672 95% Cl 1.046 to 2.672) and narrowing of the choledochal diameter (OR 2.910 95% Cl 1.830 to 4.626) were associated with PEP. From procedure-related factors; precut sphincterotomy (OR 2.172 95% Cl 1.182 to 3.994), difficult cannulation (OR 5.110 95% Cl 2.731 to 9.560), pancreatic cannulation (OR 5.692 95% Cl 0.994 to 32.602) and postprocedure residual stone (OR 2.252 95% Cl 1.403 to 3.614) were found to be associated with PEP. The successful procedure (OR 0.378 95% Cl 0.204 to 0.699) had a protective effect on PEP. Choledocholithiasis indication (OR 3.594 95% Cl 1.444 to 8.942) and small papilla (OR 2.042 95% Cl 1.170 to 3.562) were associated with the development of PSB. Choledochal stenosis, periampullary-diverticulum, oral anticoagulant, and oral antiaggregant use were not associated with the development of PSB. Of the patients with post-ERCP perforation, 85.7% had difficult cannulation, 57.1% had precut sphincterotomy, and 28.6% had periampullary-diverticulum.

CONCLUSION

Female sex, biliary stricture, precut sphincterotomy, difficult cannulation, pancreatic cannulation, and postoperative residual stone were associated with PEP. Choledocholithiasis indication and the presence of small papilla were associated with PSB.

Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study

BACKGROUND

Evidence supporting the feasibility of single-stage stone removal in patients with a moderate grade of acute cholangitis remains insufficient. The maximal size of a common bile-duct stone suitable for removal during a single-stage ERCP in a moderate grade of acute cholangitis is unknown.

METHODS

We prospectively enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis. For eligible patients, single-stage treatment involved stone removal at initial ERCP.

RESULTS

A total of 123 patients were included in the final analysis. The success rate of complete stone extraction was similar between patients with mild and moderate grades of acute cholangitis (89.2% vs. 95.9%; p = 0. 181). Complication rates were comparable between the two groups. In the moderate grade of the cholangitis group, among patients who underwent early single-stage ERCP, the length of hospitalization declined as short as the patients in the mild grade of cholangitis (10.6 ± 6.2 vs. 10.1 ± 5.1 days; p = 0.408). In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤10 days) (odds ratio (OR), 3.981; p = 0.001). A stone size less than 1.5 cm presented a high success rate (98.0%) for complete stone removal.

CONCLUSIONS

Single-stage retrograde endoscopic stone removal in mild and moderate grades of acute cholangitis may be safe and effective, which can obviate the requirement for a second session, thus reducing medical expenses.

CLINICALTRIALS

gov: NCT03754491.

Outcomes of Endoscopic Retrograde Cholangiopancreatography in End-Stage Renal Disease Patients Undergoing Hemodialysis: A Systematic Review and Pooled Analysis

Background/Aims: The adverse events associated with endoscopic retrograde cholangiopancreatography (ERCP) in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) have not been sufficiently evaluated. This study aimed to review the morbidity and mortality associated with ERCP in ESRD patients on HD using a systematic review and pooled analysis. Methods: A systematic review and pooled analysis were conducted on studies that evaluated the clinical outcomes of ERCP in patients on HD. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for nonrandomized studies. The publication bias was assessed. Results: A total of 239 studies were identified, and 12 studies comprising 7921 HD patients were included in the analysis. The pooled estimated frequency of bleeding associated with ERCP in HD patients was 5.8% (460/7921). In the subgroup analysis of seven comparative studies, the ERCP-related bleeding rate was significantly higher in HD patients than in non-HD patients (5.5% (414/7544) vs. 1.5% (6734/456,833), OR 3.84; 95% CI 4.26−25.5; p < 0.001). The pooled frequency of post-ERCP pancreatitis was 8.3%. The pooled frequency of bowel perforation was 0.3%. The pooled estimated mortality associated with ERCP was 7.1% The publication bias was minimal. Conclusion: This pooled analysis showed that ERCP-related morbidity and mortality are higher in HD patients than in non-dialysis patients.

One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations.

Methods

We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program.

Results

The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend.

Conclusion

This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.

Practice patterns and adherence to society guidelines for suspected choledocholithiasis: A comparison of academic and community settings from a large US healthcare system

Background

The American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting.

Methods

A total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients’ demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative.

Results

A total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (p-value: &lt; 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, p-value: &lt; 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (p-value: &lt; 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (p-value: 0.02).

Conclusion

Our study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.

Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study

BACKGROUND

Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations.

METHODS

A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses.

RESULTS

Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines.

CONCLUSIONS

Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.

The risk of aspirin induced postoperative hemorrhage: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Current guidelines recommend aspirin maintenance for high-risk endoscopic procedures. Some Asian physicians noticed increasing postoperative bleeding in patients taking aspirin. We aimed to explore whether risk of postoperative hemorrhage due to aspirin differs in the East and the West.

METHODS

PubMed, EMBASE and Cochrane library database were systematically reviewed. We only included trials that met our criteria.

RESULTS

There is significant association between aspirin and postoperative bleeding (P < 0.001), especially in Eastern population (data from Japan, Korea, Turkey and China, P < 0.001). Result from the West (data from America, Canada and Australia) had no statistical significance (P = 0.07). For Easterners, aspirin increased bleeding risk after endoscopic submucosal dissection (ESD) and endoscopic sphincterotomy (EST). For Westerners, aspirin increased bleeding risk post endoscopic mucosal resection (EMR). For patients undergoing ESD, those who continued to receive aspirin had higher bleeding risk than patients who interrupted it for more than 7 days (P = 0.005).

CONCLUSION

Aspirin increases risk of postoperative hemorrhage. Easterners are more likely to suffer from bleeding after aspirin administration than Westerners. Stopping aspirin for more than 7 days may be advisable to control bleeding post ESD for patients with low risk of thrombosis.

The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study

Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.

Post-ERCP Pancreatitis: Prevention, Diagnosis and Management

Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.

A Prospective Cohort Study Evaluating PAN-PROMISE, a Patient-reported Outcome Measure to Detect Post-ERCP Morbidity

BACKGROUND & AIMS

The Cotton Consensus (CC) criteria for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) may not capture post-ERCP morbidity. PAN-PROMISE, a patient-reported outcome measure (PROM), was developed to quantify acute pancreatitis-related morbidity. This study aims to determine the value of PAN-PROMISE in independently defining ERCP-related morbidity.

METHODS

We conducted a prospective cohort study of patients undergoing ERCP at 2 academic centers from September 2021 to August 2022. We administered PAN-PROMISE and assessed quality of life and work productivity at baseline, 48 to 72 hours, 7 days, and 30 days following ERCP. PEP was defined by a 3-physician committee using the CC criteria. We defined high morbidity following ERCP (elevated PROM) by an increase of PAN-PROMISE score of >7 at 7 days post-procedure. The McNemar test assessed discordance between PEP and elevated-PROM.

RESULTS

A total of 679 patients were enrolled. Choledocholithiasis (30%) and malignant biliary obstruction (29%) were the main indications for ERCP. Thirty-two patients (4.7%) developed PEP. One hundred forty-seven patients (21.6%) had an elevated PROM, whereas only 20 of them (13.4%) had PEP by the CC criteria (P < .001 for discordance). An elevated PROM strongly correlated with lower physical quality of life and increased direct and indirect health care costs ($80 and $25 per point increase in PAN-PROMISE, respectively). Patients with pancreatic cancer (odds ratio, 4.52; 95% confidence interval, 1.68-10.74) and primary sclerosing cholangitis (odds ratio, 1.79; 95% confidence interval, 1.29-2.45) had the highest odds of elevated PROM.

CONCLUSIONS

A substantial number of patients experience significant morbidity after ERCP despite not developing PEP or other adverse events. Future studies are needed to characterize better the reasons behind this increase in symptoms and potential interventions to reduce the symptom burden post-ERCP.

CLINICALTRIALS

gov number, NCT05310409.

Safety of Nonagenarians Receiving Therapeutic ERCP, Single Center Experience

(1) Background: The complication rates for nonagenarians receiving therapeutic endoscopic retrograde cholangiopancreatography (ERCP) remain poorly understood. We aimed to determine whether nonagenarians were at an increased risk of ERCP-related complications. (2) Methods: We performed a retrospective study on therapeutic ERCP in nonagenarians from 2011 to 2016 at Taichung Veterans General Hospital. A control group comprising patients aged 65 to 89 years was used to compare demographic data and the outcomes of therapeutic ERCP with the nonagenarians. The risk factors for complications were determined by logistic regression model. (3) Results: There were 35 nonagenarians and 111 patients in the control group. Overall, complication rates were not statistically different between the two groups. However, advanced age was an independent predictor of complications in the multivariate analysis (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.01-1.12; p = 0.049). End stage renal disease (ESRD) was another independent predictor of complications (OR = 4.87; 95% CI = 1.11-21.36; p = 0.036). Post-ERCP pancreatitis and bleeding were more common in ESRD patients than patients without ESRD. (4) Conclusions: Although nonagenarians receiving ERCP did not have more complications compared to elderly patients younger than 90 years, advanced age and comorbidity still affect the outcome of therapeutic ERCP in the elderly patients.

The risk of variceal bleeding during endoscopic retrograde cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely performed procedure. However, the risk of variceal bleeding during ERCP has rarely been assessed. This study aims to evaluate the risk of variceal bleeding in patients with esophageal varices (EV) undergoing ERCP.

METHODS

From October 2010 to November 2017, the study retrospectively enrolled 75 cirrhotic patients who received elective ERCP. The patient's risk of gastrointestinal (GI) and variceal bleeding and other procedure-related adverse events within 30 days of ERCP were evaluated.

RESULTS

Among the 75 patients, 45 patients (60.0%) had EV. Most of the patients were males (65.3%), and there were high rates of viral hepatitis B-related cirrhosis (36.0%), Child-Pugh B (49.3%), and an indication of choledocholithiasis (40.0%). Thirty-three of 45 (73.3%) patients had high-risk EV, and nine (20.0%) patients had concomitant gastric varices. There was no esophageal variceal bleeding; however, one patient had gastric variceal bleeding after ERCP. Nonvariceal significant GI bleeding occurred in three patients with EV and one without EV ( p = 0.529). Post-ERCP pancreatitis occurred in three patients with EV and five without EV ( p = 0.169). No perforation or procedure-associated mortality was noted.

CONCLUSION

The risk of esophageal variceal bleeding within 30 days of ERCP is neglectable, except for a patient who suffered from gastric variceal bleeding. Other complications, such as nonvariceal bleeding and pancreatitis, are also no higher in patients with EV. Therefore, ERCP is generally a safe procedure for a patient with high-risk esophageal varices.

Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

The reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post-ERCP pancreatitis (PEP).

METHODS

Patients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs.

RESULTS

A total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP-related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire-assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post-ERCP administration of non-steroidal anti-inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla.

CONCLUSIONS

In patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP.

REGISTRATION

This study was registered in the University Hospital Medical Information Network (UMIN000024820).

Post-ERCP pancreatitis: Frequency and risk stratification from four tertiary care referral hospitals in South East Asia

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a dreaded complication. But the frequency of this complication varies widely (1%-40%) among the literature and across geographical regions. With uncertainty in the estimation of occurrence and having no accepted, safe, effective method to prevent it, identification of its frequency and predictable risk factors is very crucial in a local or regional setting. The aim of this study was to identify the frequency of PEP and its risk factors from 4 tertiary care referral centers from a country in the South East Asia Region. This cross-sectional study was done on 1042 consecutive ERCP in adult patients (age >18 years) with baseline serum amylase levels less than 3 times the upper level of standard value. On the basis of clinical features and the amylase level at 24 hours (the next morning), the procedure was evaluated to confirm PEP. The frequency of PEP was calculated and procedure, patient, or operator-related independent risk factors for occurring PEP were analyzed using univariate and multivariate analyses. The study found 204 (19.6%) cases of PEP. In multivariate regression analysis, young age, suspected Sphincter of Oddi Dysfunction, recurrent pancreatitis, needle papillotomy, and pancreatic sphincterotomy were significant risk factors. The univariate analysis also found difficult cannulation and pancreatic duct injection with contrast as significant risk factors. Both patient-related and procedure-related risk factors acted independently for the development of PEP, which occurred in 19.6% of cases. This multicenter assessment of the frequency and risk factors for PEP in our patients would be extremely beneficial for future prevention of this complication.

The preventive effect of tacrolimus on patients with post-endoscopic retrograde cholangiopancreatography pancreatitis

Background/Aims

In patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), calcineurin activates zymogen, which results in pancreatitis. In this study, we aimed to determine the efficacy of tacrolimus, a calcineurin inhibitor, in preventing post-ERCP pancreatitis (PEP).

Methods

This was a prospective pilot study in which patients who underwent ERCP received tacrolimus (4 mg in two divided doses); this was the Tac group. A contemporaneous cohort of patients was included as a control group. All patients were followed-up for PEP. PEP was characterized by worsening abdominal pain with an acute onset, elevated pancreatic enzymes, and a duration of hospital stay of more than 48 hours. Serum tacrolimus levels were measured immediately before the procedure in the Tac group.

Results

There were no differences in the baseline characteristics between the Tac group (n=48) and the control group (n=51). Only four out of 48 patients (8.3%) had PEP in the Tac group compared to eight out of 51 patients (15.7%) who had PEP in the control group. The mean trough tacrolimus level in patients who developed PEP was significantly lower (p<0.05).

Conclusions

Oral tacrolimus at a cumulative dose of 4 mg safely prevents PEP. Further randomized controlled studies are warranted to establish the role of tacrolimus in this context.

Antiplatelet Monotherapy Is Associated with an Increased Risk of Bleeding After Endoscopic Sphincterotomy

BACKGROUND

Clinical guidelines recommend continuing antiplatelet monotherapy with aspirin and, in certain situations, other antiplatelet agents in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.

AIMS

Given the scant evidence supporting this recommendation, our primary objective was to determine if the risk of post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy.

METHODS

We performed a systematic search of Cochrane Library, Ovid Embase, Ovid Medline, Pubmed, Scopus, and Web of Science Core Collection databases. Inclusion criteria were adult patients undergoing ERCP and sphincterotomy on antiplatelet monotherapy with the comparator of no antithrombotic therapy. Our primary outcome was post-sphincterotomy bleeding. Methodological quality was assessed with the ROBINS-I tool and the Newcastle-Ottawa Scale. Meta-analysis with random-effects model was performed.

RESULTS

The search identified 4676 unique citations, with six cohort studies meeting our inclusion criteria. Post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy: OR = 1.53 (95% CI 1.03-2.28) without substantial heterogeneity (I² = 0%). The number needed to harm (the number of patients who would have to receive antiplatelet monotherapy for one additional patient to have a post-sphincterotomy bleeding episode) was 185(95% CI 80-2272). All included studies had methodological shortcomings.

CONCLUSION

Antiplatelet monotherapy was associated with a modestly increased risk of post-sphincterotomy bleeding in our systematic review and meta-analysis. More high-quality studies are needed to improve certainty regarding the estimated effect size.

REGISTRATION

PROSPERO CRD42020153019.

ERCP-Related Adverse Events in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

While endoscopic retrograde cholangiopancreatography (ERCP) is a valuable diagnostic and therapeutic tool in primary sclerosing cholangitis (PSC), there is conflicting data on associated adverse events. The aims of this systematic review and meta-analysis are to (1) compare ERCP-related adverse events in patients with and without PSC and (2) determine risk factors for ERCP-related adverse events in PSC.

METHODS

Embase, PubMed, and CENTRAL were searched between January 1, 2000, and May 12, 2021. Eligible studies included adults with PSC undergoing ERCP and reported at least one ERCP-related adverse event (cholangitis, pancreatitis, bleeding, and perforation) or an associated risk factor. The risk of bias was assessed with the Newcastle-Ottawa scale and Cochrane Risk of Bias 2. Raw event rates were used to calculate odds ratios (ORs) and then pooled using random-effects models.

RESULTS

Twenty studies met eligibility criteria, of which four were included in a meta-analysis comparing post-ERCP adverse events in patients with PSC (n = 715) to those without PSC (n = 9979). We found a significant threefold increase in the 30-day odds of cholangitis in PSC compared to those without (OR 3.263, 95% CI 1.076-9.896; p=0.037). However, there were no significant differences in post-ERCP pancreatitis (PEP), bleeding, or perforation. Due to limitations in primary data, only risk factors contributing to PEP could be analyzed. Accidental passage of the guidewire into the pancreatic duct (OR 7.444, 95% CI 3.328-16.651; p < 0.001; I ² = 65.0%) and biliary sphincterotomy (OR 4.802, 95% CI 1.916-12.033; p=0.001; I ² = 73.1%) were associated with higher odds of PEP in a second meta-analysis including five studies.

CONCLUSIONS

In the context of limited comparative data and heterogeneity, PSC patients undergoing ERCP have higher odds of cholangitis despite the majority receiving antibiotics. Additionally, accidental wire passage and biliary sphincterotomy increased the odds of PEP. Future studies on ERCP-related risks and preventive strategies are needed.

Multimodal treatments of “gallstone cholangiopancreatitis”

Gallstone cholangiopancreatitis is a potentially life-threatening pathology which requires quick intervention involving endoscopists, interventional radiologists, anesthesiologists and surgeons in relation to clinical conditions. Treatment possibilities are varied, especially with current progress in advanced endoscopy, interventional radiology, and minimally invasive surgery. The following treatments are available: endoscopic sphincterotomy (ES) with stone extraction followed by laparoscopic cholecystectomy; simultaneous endoscopic stone extraction with laparoscopic cholecystectomy (rendezvous technique); combined laparoscopic cholecystectomy and common bile duct (CBD) exploration; open CBD exploration; ES post-cholecystectomy; percutaneous placement of biliary drains for unstable patients, followed by percutaneous cholangioscopy; and lithotripsy with different approaches, including a laser and balloon dilation of the sphincter of Oddi. Each technique has its strengths and weaknesses, and there is great discussion in the literature on choosing the ideal approach based on the patient’s clinical conditions.

Impact of guidewire caliber on ERCP outcomes: Systematic review and meta-analysis comparing 0.025- and 0.035-inch guidewires

Background and study aims  The impact of guidewire caliber on endoscopic retrograde pancreatography (ERCP) outcomes are not clear. Recent studies have compared two guidewires, 0.035- and 0.025-inch, in randomized controlled trials (RCTs). We performed a systematic review and meta-analysis of available RCTs to assess if different caliber would change the outcomes in ERCP. Patients and methods  A systematic search of PubMed/Medline, Embase, Cochrane, SciELO, Global Index Medicus and Web of Science was undertaken through November 23, 2021 to identify relevant RCTs comparing the two guidewires. Binary variables were compared using random effects model and DerSimonian-Laird approach. For each outcome, risk-ratio (RR), 95 % confidence interval (CI), and P values were generated. P  < 0.05 was considered significant. Results  Three RCTs with 1079 patients (556 in the 0.035-inch group and 523 in the 0.025-inch group) were included. The primary biliary cannulation was similar in both groups (RR: 1.02, CI: 0.96-1.08, P  = 0.60). The overall rates of PEP were also similar between the two groups (RR: 1.15, CI: 0.73-1.81, P  = 0.56). Other outcomes (overall cannulation rate, cholangitis, perforation, bleeding, use of adjunct techniques) were also comparable. Conclusions  The results of our analysis did not demonstrate a clear benefit of using one guidewire over other. The endoscopist should consider using the guidewire based on his technical skills and convenience.

Long-term outcomes of endoscopic papillary large-balloon dilation (12-15 mm) with or without limited sphincterotomy for removal of bile duct stones

BACKGROUND

Limited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12-15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones.

METHODS

Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed.

RESULTS

Basic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up was 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357-6.640; P = 0.007) was an independent risk factor for stone recurrence.

CONCLUSIONS

The application of a large balloon (12-15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.

No Significant Difference in Post-ERCP Bleeding Rates Between Dual Antiplatelet Agents and Aspirin Alone: A Systematic Review and Meta-analysis

BACKGROUND

Several professional society guidelines suggest holding antiplatelet agents before high-risk procedures. However, there is lack of high-grade evidence to support the recommendation as most of the studies have been single center with small sample sizes. We aimed to perform the first systematic review and meta-analysis comparing dual antiplatelet therapy (DAPT) versus aspirin alone in terms of postendoscopic retrograde cholangiopancreatography (ERCP) bleeding.

METHODS

Three independent reviewers performed a comprehensive review of all original articles published from inception to May 2020, evaluating the post-ERCP bleeding rate in setting of DAPT. Primary outcomes were the overall post-ERCP bleeding rate with the use of dual antiplatelet therapy; comparison of post-ERCP bleeding rate in patients with DAPT versus aspirin alone. Secondary outcomes were comparison of immediate and delayed post-ERCP bleeding outcomes in the 2 cohorts.

RESULTS

Six studies were included after a thorough search was concluded using the key words. The pooled analysis of studies revealed an overall post-ERCP bleeding rate of 5.7% (95% confidence interval: 3-10.6) on sustained DAPT. Post-ERCP bleeding in DAPT Cohort was not significantly higher as compared with aspirin only Cohort (odds ratio: 1.14, 95% confidence interval: 0.46-2.81). The immediate bleeding and delayed bleeding rates cannot be generalized due to low number of studies.

CONCLUSIONS

The first systematic review and meta-analysis showed that post-ERCP bleeding rates are not significantly higher in DAPT cohort as compared with aspirin alone. Therefore, the risk of bleeding is less likely related to the antiplatelet agents and more likely related to the procedure itself.

Effects of antithrombotic therapy on bleeding after endoscopic sphincterotomy: A systematic review and meta-analysis

Background and study aims  Bleeding is a common complication of following endoscopy sphincterotomy (EST), and antithrombotic therapy use during the procedure often increases risk of it. Although several guidelines have been released regarding the use of antithrombotic agents during EST, many issues about it remain controversial. We carried out a systematic review and meta-analysis to evaluate the effect of antithrombotic medication on the risk of EST bleeding. Methods  A structured literature search was carried out in Web of Science, EMBASE, PubMed, and Cochrane Library databases. RevMan 5.2 was used for meta-analysis to investigate the rate of post-EST bleeding. Results  Seven retrospective articles were included. Compared with patients who had never taken antithrombotic drugs, patients who discontinued antithrombotic drugs 1 day before the procedure had a significantly increased risk of post-EST bleeding (OR, 1.95; 95 %CI, 1.57-2.43), particularly for severe bleeding (OR, 1.83; 95 %CI, 1.44-2.34). In addition, compared with patients who discontinued antithrombotic therapy for at least 1 day, patients who continued taking antithrombotic drugs did have an increased risk of post-EST bleeding (OR, 0.70; 95 %CI, 0.40-1.23). Conclusions  The use of antithrombotic drugs may increase the bleeding rate of EST, but discontinuing therapy 1 day before endoscopy does not significantly reduce the bleeding rate.

A novel machine learning model and a public online prediction platform for prediction of post-ERCP-cholecystitis (PEC)

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment for common bile duct (CBD) stones. Post- ERCP cholecystitis (PEC) is a known complication of such procedure and there are no effective models and clinical applicable tools for PEC prediction.

METHODS

A random forest (RF) machine learning model was developed to predict PEC. Eligible patients at The First Hospital of Lanzhou University in China with common bile duct (CBD) stones and gallbladders in-situ were enrolled from 2010 to 2019. Logistic regression analysis was used to compare the predictive discrimination and accuracy values based on receiver operation characteristics (ROC) curve and decision and clinical impact curve. The RF model was further validated by another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126.

FINDINGS

A total of 1117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy as the top six predictive factors and has a sensitivity of 0.822, specificity of 0.853 and accuracy of 0.855, with the area under curve (AUC) value of 0.890. A separate logistic regression prediction model was built with sensitivity, specificity, and AUC of 0.811, 0.791, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model.

INTERPRETATION

The results suggest that the proposed RF model based on the top six PEC risk factors could be a promising tool to predict the occurrence of PEC.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

BACKGROUND AND AIMS

Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL.

METHODS

Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors.

RESULTS

1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89).

CONCLUSION

Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

The effect of nafamostat mesilate infusion after ERCP for post-ERCP pancreatitis

Background

Nafamostat mesilate decreases the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, no studies have administered nafamostat mesilate after ERCP. So we investigated if the infusion of nafamostat mesilate after ERCP can affect the post-ERCP pancreatitis (PEP) in high-risk patients.

Methods

In a tertiary hospital, 350 high-risk patients of PEP were reviewed retrospectively. Among them, 201 patients received nafamostat mesilate after ERCP. Patient-related and procedure-related risk factors for PEP were collected. We performed a propensity score matching to adjust for the significant different baseline characteristics. The incidence and severity of PEP were evaluated according to the infusion of nafamostat mesilate. The risk factors of PEP were also analyzed by multivariate logistic regression.

Results

The baseline characteristics were not different after the matching. The PEP rate (17.4% vs. 10.3%, P = 0.141) was insignificant. Among the PEP patients, mild PEP was significantly higher in the nafamostat mesilate group (85.7% vs. 45.5%, P = 0.021). Only one patient in the nafamostat mesilate group developed severe PEP. Although young age (odds ratio [OR] 3.60, 95% CI 1.09–11.85, P = 0.035) was a risk factor, nafamostat mesilate (odds ratio [OR] 0.30, 95% CI 0.09–0.98, P = 0.047) was a protective factor for moderate to severe PEP.

Conclusions

The administration of nafamostat mesilate after ERCP in high-risk patients was not effective in preventing PEP, but may attenuate the severity of PEP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02345-3.

Evaluation of the American Society of Gastrointestinal Endoscopy 2019 and the European Society of Gastrointestinal Endoscopy guidelines' performances for choledocholithiasis prediction in clinically suspected patients: A retrospective cohort study

Background and Aim

The American Society of Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have published guidelines for choledocholithiasis. However, the guidelines were formulated using data from a large number of patients with no to low risk of common bile duct (CBD) stones. This study aimed to assess the guidelines' predictive performance in a population with a high frequency of stones.

Methods

Data for three choledocholithiasis standard reference tests were retrospectively reviewed from January 2019 to June 2021. Clinical parameters were used to categorize patients into risk groups according to the guidelines, and then the guidelines' predictive abilities were calculated.

Results

Among 1185 patients, 521 were included. The stone prevalence was 61.0% (n = 318). Twelve (2.3%), 146 (28.0%), and 363 (69.7%) patients were classified into low‐, intermediate‐, and high‐risk groups according to the ASGE guidelines, and 30 (5.8%), 149 (28.6%), and 342 (65.6%) according to the ESGE guidelines. Focusing on the high‐risk group, the ASGE guidelines had a positive predictive value of 73.6 and a positive likelihood ratio of 1.78. The ESGE guidelines had a positive predictive value of 73.7 and positive likelihood ratio of 1.79. Both guidelines had equivalent areas under the receiver operating characteristic curve of 0.69 (95% confidence interval [CI]: 0.65–0.73) and 0.68 (95% CI: 0.64–0.72), respectively.

Conclusion

In the high‐risk group, the guidelines increased the chance of detecting choledocholithiasis by approximately 10% (61.0% prevalence to 73.6 and 73.7% positive predictive value). However, statistically, the guidelines had marginal discriminative performance in a population with high stone prevalence.

Adverse Event Fatalities Related to GI Endoscopy

BACKGROUND

Death after endoscopy is rare, under-reported, and has variable causes. This study aimed to evaluate the incidence and causes of fatal endoscopic adverse events (AEs) across two academic medical centers and to identify patient-, procedure-, and sedation-related risk factors.

METHODS

This is a retrospective cohort study of fatal adverse events causally related to endoscopy at Denver Health Medical Center and the University of Colorado Hospital from 2011 to 2020. Fatal AEs were retrieved from the physician-reported database. Electronic medical records were then reviewed to determine medical history, procedure details, subsequent treatments, and time and cause of death.

RESULTS

From January 2011 to January 2020, 146,010 GI endoscopy procedures were performed. Median patient age was 70 [51-78] and 57% were male. Thirty-one deaths were identified, 28 of which were attributed to endoscopy, yielding a procedure-related fatality rate of 0.018%. Procedures included 11 EGDs, one colonoscopy, two flexible sigmoidoscopies, six ERCPs, seven upper EUS, and one PEG-J tube placement. Specific causes of death included aspiration in four patients (14%); cardiac arrest or myocardial infarction in seven patients (25%); perforation in nine patients (32%); bleeding in four patients (14%); cholangitis or sepsis without perforation in three patients (11%); and acute pancreatitis in one patient (3.6%).

CONCLUSIONS

Fatal endoscopic AEs were rare but tended to occur in older patients with major comorbidities. Most deaths occurred from aspiration pneumonia, cardiac arrest, or perforation-related sepsis within 1 week of the procedure.

US Nationwide Insight Into All-cause 30-day Readmissions following Inpatient Endoscopic Retrograde Cholangiopancreatography

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data.

METHODS

Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission.

RESULTS

A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52,P<0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10,P=0.008).

CONCLUSION

All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.

ACCURACY OF ABBREVIATED PROTOCOL OF MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY IN THE DIAGNOSIS OF CHOLEDOCHOLITHIASIS

BACKGROUND

Abbreviated magnetic resonance imaging protocols have emerged to reduce the examination time of the long protocols eliminating unnecessary pulse sequences to answer a targeted clinical question, without compromising diagnostic information.

OBJECTIVE

The objective of this study was to evaluate the diagnostic accuracy of an abbreviated magnetic resonance cholangiopancreatography (A-MRCP) protocol in patients with suspected choledocholithiasis.

METHODS

This retrospective study evaluated patients (ages 10 + years) that performed consecutive MRCP examination from October 2019 to June 2020, with the clinical suspicion of choledocholithiasis. Readers first evaluated the biliary tree using a four-sequence A-MRCP protocol and later reviewed the entire conventional eleven-sequence MRCP. Presence of choledocholithiasis, stone size, common bile duct caliber, and additional findings were evaluated.

RESULTS

A total of 148 patients with MRCP were included (62.8% female, mean 50.9 years). The prevalence of choledocholithiasis was 32.2%. The accuracy of the abbreviated MRCP protocol for choledocholithiasis was 98.7%. There was no difference between the performance of the abbreviated and conventional MRCP image sets for detection of choledocholithiasis (kappa=0.970), with a sensitivity of 98% and a specificity of 99%. There was excellent inter-reader agreement evaluating for choledocholithiasis on both imaging sets of MRCP protocols (kappa values were 0.970).

CONCLUSION

An abbreviated MRCP protocol to evaluate for choledocholithiasis provides similar diagnostic over the conventional MRCP protocol, offering potential for decreased scanning time and improved patient tolerability.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Nonagenarians: A Systematic Review and Meta-Analysis

BACKGROUND

Recent advances in modern medicine have translated into increase in life expectancy in the USA and with that, a rise in the demand for invasive procedures in elderly patients. Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for managing various benign and malignant pancreatobiliary conditions and can be associated with various adverse events.

AIM

We performed a systematic review and meta-analysis to evaluate outcomes of ERCP in nonagenarians.

METHODS

A comprehensive literature search was performed in Embase, MEDLINE, Web of Science, and Cochrane Review library until July 2020. Our primary outcomes were the rate of technical success and adverse events in nonagenarians. Secondary outcomes were comparison of technical success and adverse events compared with younger patients.

RESULTS

The initial search revealed 4933 studies, of which 24 studies with 5521 patients met our inclusion criteria. Pooled technical success rate of ERCP in nonagenarians was 92%, and pooled adverse event rate was 7.8%. There was no significant difference in technical success rate and overall rate of adverse events comparing ERCP outcomes in nonagenarians with a relatively younger population. The risk of post-ERCP bleeding was significantly higher in nonagenarians compared to younger patients with OR = 1.986 [1.113-3.544], I2 = 0. ERCP-related mortality was also significantly higher in nonagenarians compared to younger patients with OR = 4.720 [1.368-16.289], I2 = 0.

CONCLUSION

There was no significant difference in technical success rate and risk of adverse events related to ERCP in nonagenarians compared to younger patients. However, the risk of bleeding and procedure-related mortality was significantly higher.

Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

BACKGROUND

Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP.

OBJECTIVES

To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases.

SEARCH METHODS

For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis.

MAIN RESULTS

15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.

New common bile duct morphological subtypes: Risk predictors of common bile duct stone recurrence

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment for removing common bile duct (CBD) stones. The risk factors for CBD stone recurrence after ERCP have been discussed for many years. However, the influence of CBD morphology has never been noticed.

AIM

To evaluate CBD morphology and other predictors affecting CBD stone recurrence in average patients.

METHODS

A retrospective analysis of 502 CBD stone patients who underwent successful therapeutic ERCP for stone extraction at our centre from February 2020 to January 2021 was conducted. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.

RESULTS

CBD morphology (P < 0.01), CBD diameter ≥ 1.5 cm [odds ratio (OR) = 2.20, 95%CI: 1.08-4.46, P = 0.03], and endoscopic biliary sphincterotomy with balloon dilation (ESBD) (OR = 0.35, 95%CI: 0.17-0.75, P < 0.01) are three independent risk factors for CBD stone recurrence. Furthermore, the recurrence rate of patients with the S type was 6.61-fold that of patients with the straight type (OR = 6.61, 95%CI: 2.61-16.77, P < 0.01). The recurrence rate of patients with the polyline type was 2.45-fold that of patients with the straight type (OR = 2.45, 95%CI: 1.14-5.26, P = 0.02). The recurrence rate of S type patients was 2.70-fold that of patients with the polyline type (OR = 2.70, 95%CI: 1.08-6.73, P = 0.03). Compared with no-ESBD, ESBD could decrease the risk of recurrence.

CONCLUSION

CBD diameter ≥ 1.5 cm and CBD morphology, especially S type and polyline type, were associated with increased recurrence of CBD stones. In addition, ESBD was related to decreased recurrence. Patients with these risk factors should undergo periodic surveillance and standard prophylactic therapy.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists’ experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists’ experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting

INTRODUCTION

Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital.

METHODS

We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes.

RESULTS

We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines.

CONCLUSION

Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.