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Benavides-Salgado DE, Jiménez-Castillo RA, Cuéllar-Monterrubio JE, Jáquez-Quintana JO, Garza-Galindo A, Cortes-Hernández C, Maldonado-Garza HJ, García-Compeán D, González-González JA. Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:237-242. [PMID: 37689502 DOI: 10.1016/j.rgmxen.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/04/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. MATERIAL AND METHODS Patients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. RESULTS Of the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). CONCLUSION Papilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.
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Affiliation(s)
- D E Benavides-Salgado
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - R A Jiménez-Castillo
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - J E Cuéllar-Monterrubio
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - J O Jáquez-Quintana
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - A Garza-Galindo
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - C Cortes-Hernández
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - H J Maldonado-Garza
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - D García-Compeán
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - J A González-González
- Servicio de Gastroenterologia y Endoscopía, Hospital Universitario «Dr. E. González», Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico.
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Meng ZW, Ruan Y, Fisher S, Bishay K, Chau M, Howarth M, Cartwright S, Chen Y, Dixon E, Heitman SJ, Brenner DR, Forbes N. Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis. DEN OPEN 2024; 4:e355. [PMID: 38529515 PMCID: PMC10962486 DOI: 10.1002/deo2.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024]
Abstract
Background Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables. Methods Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation. Results Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003. Conclusions We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.
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Affiliation(s)
- Zhao Wu Meng
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Yibing Ruan
- Department of OncologyCumming School of MedicineUniversity of CalgaryCalgaryCanada
- Department of Cancer Epidemiology and Prevention ResearchCancer Care Alberta, Alberta Health ServicesCalgaryCanada
| | | | - Kirles Bishay
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Millie Chau
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Megan Howarth
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Shane Cartwright
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Yen‐I Chen
- Department of Medicine, Division of Gastroenterology and HepatologyMcGill University Health CentreMontrealCanada
| | - Elijah Dixon
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of SurgeryUniversity of CalgaryCalgaryCanada
| | - Steven J. Heitman
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
| | - Darren R. Brenner
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of OncologyCumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Nauzer Forbes
- Department of Community Health SciencesUniversity of CalgaryCalgaryCanada
- Department of MedicineDivision of Gastroenterology and HepatologyUniversity of CalgaryCalgaryCanada
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Tari E, Gagyi EB, Rancz A, Veres DS, Váncsa S, Hegyi PJ, Hagymási K, Hegyi P, Erőss B. Morphology of the papilla can predict procedural safety and efficacy of ERCP-a systematic review and meta-analysis. Sci Rep 2024; 14:7341. [PMID: 38538734 PMCID: PMC10973369 DOI: 10.1038/s41598-024-57758-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024] Open
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary therapeutic procedure for pancreaticobiliary disorders, and studies highlighted the impact of papilla anatomy on its efficacy and safety. Our objective was to quantify the influence of papilla morphology on ERCP outcomes. We systematically searched three medical databases in September 2022, focusing on studies detailing the cannulation process or the rate of adverse events in the context of papilla morphology. The Haraldsson classification served as the primary system for papilla morphology, and a pooled event rate with a 95% confidence interval was calculated as the effect size measure. Out of 17 eligible studies, 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I papilla (26%), while the highest one was observed in the case of type IV papilla (41%). For post-ERCP pancreatitis, the event rate was the highest in type II papilla (11%) and the lowest in type I and III papilla (6-6%). No significant difference was observed in the cannulation failure and post-ERCP bleeding event rates between the papilla types. In conclusion, certain papilla morphologies are associated with a higher rate of difficult cannulation and post-ERCP pancreatitis.
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Affiliation(s)
- Edina Tari
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Endre Botond Gagyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, Budapest, Hungary
| | - Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Szilárd Váncsa
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Péter Jenő Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Krisztina Hagymási
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Surgery, Transplantation, and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary.
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary.
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Ishikawa-Kakiya Y, Maruyama H, Fujiwara Y. Endoclip with traction band-assisted traction method for endoscopic retrograde cholangiopancreatography with long oral protrusion of papilla. Dig Endosc 2024; 36:246-247. [PMID: 38105656 DOI: 10.1111/den.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
Watch a video of this article.
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Affiliation(s)
- Yuki Ishikawa-Kakiya
- Department of Gastroenterology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Benavides-Salgado D, Jiménez-Castillo R, Cuéllar-Monterrubio J, Jáquez-Quintana J, Garza-Galindo A, Cortes-Hernández C, Maldonado-Garza H, García-Compeán D, González-González J. Morfología de la papila de Vater como factor que influye en el éxito en canulación durante el entrenamiento del Residente en Endoscopia Avanzada. Estudio clínico prospectivo. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2023. [DOI: 10.1016/j.rgmx.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/09/2023]
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Rivas A, Pherwani S, Mohamed R, Smith ZL, Elmunzer BJ, Forbes N. ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management. Expert Rev Gastroenterol Hepatol 2023; 17:1101-1116. [PMID: 37899490 DOI: 10.1080/17474124.2023.2277776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs. AREAS COVERED This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023. EXPERT OPINION Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.
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Affiliation(s)
- Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simran Pherwani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Estela EL, Tovar NR, Maldonado FA, Tisoc LM, Goicochea-Lugo S, Rossell MC. Association between type of major duodenal papilla and difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography in adults: a cross-sectional study with bootstrap method. Ann Gastroenterol 2023; 36:216-222. [PMID: 36864942 PMCID: PMC9932863 DOI: 10.20524/aog.2023.0775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/14/2022] [Indexed: 02/05/2023] Open
Abstract
Background The type of major duodenal papilla could be associated with difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography (ERCP) in adults. Methods This retrospective cross-sectional study included patients undergoing ERCP for the first time by an expert endoscopist. We defined the type of papilla according to the endoscopic classification of Haraldsson in type 1-4. The outcome of interest was difficult biliary cannulation, defined according to the European Society of Gastroenterology. To assess the association of interest, we calculated crude and adjusted prevalence ratios (PRc and PRa, respectively) and their respective 95% confidence intervals (CI) using Poisson regression with robust variance models, employing bootstrap methods. For the adjusted model we included the variables age, sex, and indication for ERCP, according to an epidemiological approach. Results We included 230 patients. The most frequent type of papilla was type 1 (43.5%), and 101 (43.9%) of the patients presented difficult biliary cannulation. The results were consistent between the crude and adjusted analyses. After adjusting for age, sex, and ERCP indication, the prevalence of difficult biliary cannulation was highest in patients with papilla type 3 (PRa 3.66, 95%CI 2.49-5.84), followed by patients with papilla type 4 (PRa 3.21, 95%CI 1.82-5.75), and patients with papilla type 2 (PRa 1.95, 95%CI 1.15-3.20) compared to patients with papilla type 1. Conclusion In adults undergoing ERCP for the first time, patients with papilla type 3 had a greater prevalence of difficult biliary cannulation than patients with papilla type 1.
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Affiliation(s)
- Evelyn León Estela
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima (Evelyn León Estela, Natali Ravelo Tovar, Lucinda Moran Tisoc, Miguel Chávez Rossell)
| | - Natali Ravelo Tovar
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima (Evelyn León Estela, Natali Ravelo Tovar, Lucinda Moran Tisoc, Miguel Chávez Rossell)
| | | | - Lucinda Moran Tisoc
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima (Evelyn León Estela, Natali Ravelo Tovar, Lucinda Moran Tisoc, Miguel Chávez Rossell)
| | - Sergio Goicochea-Lugo
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima (Sergio Goicochea-Lugo), Peru
| | - Miguel Chávez Rossell
- Servicio de Gastroenterología, Hospital Nacional Arzobispo Loayza, Lima (Evelyn León Estela, Natali Ravelo Tovar, Lucinda Moran Tisoc, Miguel Chávez Rossell)
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