Complications of ERCP

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography: A case report and review of literature

BACKGROUND

Splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication. The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.

CASE SUMMARY

This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting. The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct. The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography. The patient was successfully treated with percutaneous transhepatic cholangial drainage, endoscopic pyloric stent placement, and conservative management. The causes of splenic injury following ERCP are discussed.

CONCLUSION

ERCP has the potential to cause splenic injury. If a patient experiences symptoms such as abdominal pain, decreased blood pressure, and altered hematology after the procedure, it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

The safety of not implementing endoscopic nasobiliary drainage after elective clearance of choledocholithiasis: a systematic review and meta-analysis

BACKGROUND

Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis.

METHODS

Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures.

RESULTS

Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60).

CONCLUSION

It appears safe to no- ENBD after elective clearance of choledocholithiasis.

The Embolization of the Segmental Branch of Hepatic Artery Pseudoaneurysm Following Endoscopic Retrograde Cholangiopancreatography: A Case Report

Endoscopic retrograde cholangiopancreatography (ERCP) remains the main therapeutic modality towards the management of common bile duct (CBD) stones and dilatation of strictures. It also has varied diagnostic roles including brush biopsy. The procedure still is associated with side effects and increased morbidity and mortality. One side effect is bleeding. This may be associated with procedural trauma or bleeding following post-traumatic pseudoaneurysm delayed-onset bleeding. Although it may be argued that inflammation surrounding the biliary duct area and in particular the pancreas could also contribute to the delayed bleeding along the ampullary region, we present a case of delayed pseudoaneurysm bleeding that was successfully managed post-ERCP via interventional radiology-guided embolization.

A Study on the Spectrum of Imaging Findings of Post-ERCP-Specific Complications: A Retrospective Descriptive Study

Aim  The aim of this study was to examine the imaging manifestations of post-endoscopic retrograde cholangiopancreatography (ERCP) specific complications by computed tomography to aid in its early and successful diagnosis and timely intervention. Method  Forty-one cases of imaging having post-ERCP were complications were retrospectively collected and the spectrum of complications and their key imaging features and methods to improve their detection were analyzed. Result  The most common complication detected in computed tomography (CT) post-ERCP was the presence of intra-abdominal collections seen in 21 patients (51.2%). Pancreatitis was seen in 20 of 41 patients (48.7%), while bowel perforation was present in 9 patients (21%). Pleural effusion was present in 8 patients (19.5%), liver abscess in 6 patients (14.6%), cholangitis in 4 patients (9.7%), gallbladder perforation in 4 patients (9.7%), displaced common bile duct stent in 3 patients (7.3%), possibility of main pancreatic duct cannulation in 2 patients (4.8%), vascular injury resulting in right hepatic artery pseudoaneurysm in 1 patient (2.4%), thrombosis of portal vein or its branches in 2 patients (4.8%), superior mesenteric vein thrombosis in 1 patient (2.4%), right hepatic vein thrombosis in 1 patient (2.4%), pulmonary thromboembolism in 2 patients (4.8%), duodenal inflammation in 1 patient (2.4%), bowel ileus in 4 patients (9.6%), and bowel obstruction in 1 patient (2.4%). Conclusion  Complications after ERCP can cause significant morbidity and mortality if not diagnosed early and treated appropriately. Familiarity with normal findings post-ERCP and knowledge of the imaging appearance of these complications are vital in the early management of these conditions.

Post-endoscopic Retrograde Cholangiopancreatography Hemorrhagic Pancreatitis in a Young Female: A Case Report

Hemorrhagic pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is an adverse event that has received limited attention in medical studies. We describe a 28-year-old female who was admitted with symptoms of abdominal pain, nausea, and vomiting, along with tenderness in the right upper quadrant upon physical examination. CT abdomen revealed the presence of a gallstone obstructing the common bile duct. The patient underwent an ERCP procedure, which included a biliary sphincterotomy and the balloon-assisted removal of the obstructing stone. Unfortunately, the procedure was complicated with acute pancreatitis characterized by fluid accumulation in the abdomen, suggestive of hemorrhagic pancreatitis. There was a notable decrease in hemoglobin levels and hypotension, indicating the need for a higher level of care. Patients were managed conservatively with hydration and pain control. Follow-up in the clinic confirmed the resolution of symptoms and stabilization of the hemoglobin. Prompt recognition of post-ERCP hemorrhagic pancreatitis is crucial and warrants a high index of suspicion. Furthermore, the discussion explored the various risk factors and pathological events behind post-ERCP pancreatitis to understand the mechanisms of the disease. Various previously used intervention and prevention strategies were critically discussed for the awareness of future researchers and healthcare practitioners.

Effectiveness of the pharmacological therapy to prevent post ERCP acute pancreatitis: a network meta-analysis

OBJECTIVE

To determine the effectiveness of the different pharmacological agents in preventing post-ERCP acute pancreatitis.

METHODS

We included clinical trials of pharmacological interventions for prophylaxis of acute post-ERCP pancreatitis. The event evaluated was acute pancreatitis. We conducted a search strategy in MEDLINE (OVID), EMBASE, and Cochrane Central Register of Controlled Trials from inception to nowadays. We reported the information in terms of relative risks (RR) with a 95% confidence interval. We assessed the heterogeneity using the I2 test.

RESULTS

We included 84 studies for analysis (30,463 patients). The mean age was 59.3 years (SD ± 7.01). Heterogeneity between studies was low (I2 = 34.4%) with no inconsistencies (p = 0.2567). Post ERCP pancreatitis was less in prophylaxis with NSAIDs (RR 0.65 95% CI [0.52 to 0.80]), aggressive hydration with Lactate Ringer (RR 0.32 95% CI [0.12-0.86]), NSAIDs + isosorbide dinitrate (RR 0.28 95% CI [0.11-0.71]) and somatostatin and analogues (RR 0.54 [0.43 to 0.68]) compared with placebo.

CONCLUSIONS

NSAIDs, the Combination of NSAIDs + isosorbide dinitrate, somatostatin and analogues, and aggressive hydration with lactate ringer are pharmacological strategies that can prevent post-ERCP pancreatitis when compared to placebo. More clinical trials are required to determine the effectiveness of these drugs.

A Review on Endoscopic Management of Acute Cholecystitis: Endoscopic Ultrasound-Guided Gallbladder Drainage and Endoscopic Transpapillary Gallbladder Drainage

A percutaneous cholecystostomy tube (PCT) is the conventionally favored nonoperative intervention for treating acute cholecystitis. However, PCT is beset by high adverse event rates, need for scheduled reintervention, and inadvertent dislodgement, as well as patient dissatisfaction with a percutaneous drain. Recent advances in endoscopic therapy involve the implementation of endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are increasingly preferred over PCT due to their favorable technical and clinical success combined with lower complication rates. In this article, we provide a comprehensive review of the literature on EUS-GBD and ETP-GBD, delineating instances when clinicians should opt for endoscopic management and highlighting potential risks associated with each approach.

Endoscopic Management of Malignant Biliary Obstruction

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for managing malignant biliary obstruction; however, it is impossible if the endoscope cannot reach the ampulla of Vater, and it carries a risk of procedure-related pancreatitis. Percutaneous approach is a traditional rescue method when ERCP fails and can be useful in advanced malignant hilar biliary obstruction; however, it is invasive and carries risks of tube dislodgement, recurrent infection, and tract seeding. Endoscopic ultrasound approach may be attempted if ERCP fails and is free from the risk of pancreatitis; however, it is only possible in limited centers, and training is still difficult. Malignant biliary obstruction should be managed by leveraging the complementary strengths of these methods.

Determining the Risk Factors of Complications Due to Endoscopic Retrograde Cholangiopancreatography

Background and objective The effective use of endoscopic retrograde cholangiopancreatography (ERCP) has been on the rise in diagnosing and treating benign and malignant pathologies of the common bile duct and pancreas. ERCP, a complex procedure requiring high knowledge, skills, and practice, differs from other endoscopic applications as it involves the use of different techniques and equipment and the occurrence of more complications. The most commonly observed complications of ERCP are pancreatitis, bleeding, perforation, and infections. In this study, we aimed to assess the incidence of post-ERCP complications to identify the associated risk factors and indications. Methodology In this study, 181 ERCP procedures performed on 122 consecutive patients in the endoscopy unit of Istanbul Training Hospital were prospectively evaluated by using an observational method to determine the frequency of and risk factors for post-ERCP complications. The patients were followed up in the course of the ERCP procedure and for 30 days after the procedure; the complications and clinical developments were recorded. Results The mean age of the cohort was 59.7 ± 17.7 (19-97) years; 40.9% were female and 59.1% were male. The cannulation success was achieved in 77.3% of the ERCP procedure performed. Among the ERCP procedures applied, 89% were performed for therapeutic purposes, and choledocholithiasis (60.2%) was the most common indication for ERCP. Major complications were detected in 25.4% of the patients after ERCP. The most common major complication was cholangitis (9.9%), followed by pancreatitis (7.2%), cholecystitis (5.5%), bleeding (3.9%), and perforation (1.1%). It was observed that sphincterotomy was associated with an increase in all complications. The incidence of cholangitis decreased in the presence of dilated bile ducts unrelated to obstruction. The increased incidence of pancreatitis was associated with the female gender, the use of sphincterotomy and basket, inexperienced endoscopists, and inpatient admissions. The incidence of cholecystitis, on the other hand, was found to be linked with sphincterotomy and inexperienced endoscopists. Conclusions ERCP is a complex endoscopic procedure that requires high technical knowledge and skill and can cause serious complications. For endoscopists to perform clinically effective and accurate ERCP, it is important that they correctly determine the indications for the procedure, know its potential complications, and refrain from practices that will create complications and are unnecessary as much as possible.

Clinical outcomes and predictors for 30-day readmissions of endoscopic retrograde cholangiopancreatography in the United States

BACKGROUND/OBJECTIVES

We aimed to assess 30-day readmissions of endoscopic retrograde cholangiopancreatography (ERCP) in the United States.

METHODS

The National Readmission Database was utilized from 2016 to 2020 to identify 30-day readmissions of ERCP. Hospitalization characteristics and outcomes were compared between index hospitalizations and readmissions. Predictors of 30-day readmission and mortality were also identified.

RESULTS

Between 2016 and 2020, 885 416 index hospitalizations underwent ERCP. Of these, 88 380 (10.15%) were readmitted within 30 days. Compared to index hospitalizations, 30-day readmissions had higher mean age (63.76 vs 60.8 years, P < 0.001) and proportion of patients with Charlson Comorbidity Index (CCI) score ≥3 (48.26% vs 29.91%, P < 0.001). Sepsis was the most common readmission diagnosis. Increasing age, male gender, higher CCI scores, admissions at large metropolitan teaching hospitals, cholecystectomy on index hospitalization, biliary stenting, increasing length of stay (LOS) at index admission, post-ERCP pancreatitis, post-ERCP hemorrhage, and gastrointestinal tract perforation were independent predictors of 30-day readmissions. Furthermore, 30-day readmissions had higher odds of inpatient mortality (4.42% vs 1.66%, aOR 1.9, 95% CI: 1.79-2.01, P < 0.001) compared to index hospitalizations. However, we noted a shorter LOS (5.78 vs 6.22 days, mean difference 1.2, 95% CI: 1.12-1.28, P < 0.001) and lower total hospital charge ($71 076 vs $93 418, mean difference $31 452, 95% CI: 29 835-33 069, P < 0.001) for 30-day readmissions compared to index hospitalizations. Increasing age, higher CCI scores, increasing LOS, biliary stenting, and post-ERCP hemorrhage were independent predictors of inpatient mortality for 30-day readmissions.

CONCLUSION

After index ERCP, the 30-day remission rate was 10.15%. Compared to index hospitalizations, 30-day readmissions had higher odds of inpatient mortality.

Practical application of the modification in endoscopic retrograde cholangiopancreatography treated common bile duct stones in patients with Billroth II gastroenterostomy in Vietnam

Objective

Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Billroth II gastroenterostomy (B-II GE) has been challenging, requiring flexibility in technical approaches during execution. The study aims to assess the effectiveness of enhanced techniques in performing ERCP on this patient group in Vietnam.

Method

A total of 42 Vietnamese patients with B-II GE performed an ERCP using a duodenoscope or a modification of ERCP equipment (a cap-fitted regular forward-viewing endoscope) if the former failed. The effectiveness and safety of the ERCP technique were assessed, particularly in patients who underwent the forward-viewing endoscope method.

Result

A total of 39 out of 42 patients had the Vater's papilla identified, among whom 12 patients (30.8%) achieved successful cannulation into the bile duct using a side-viewing endoscope, significantly lower than the success rate using a forward-viewing endoscope (25/27, counted 92.6%, with p < 0.001). After successful cannulation, the rate of stone clearance, the procedural time, and the hospitalization duration of the patients were equivalent between the two methods and were not dependent on the number or size of the stones. On the other hand, post-ERCP complications in patients utilizing forward-viewing endoscopy included acute pancreatitis (22.2%), post-sphincterotomy bleeding (3.7%), septicemia (4.8%), and perforation (0%). These complications were mild and amenable to conservative endoscopic and medical management, and no mortality was observed. The rates of complications and adverse events after ERCP are comparable between the two treatment methods, even though the end-viewing endoscope is used after the failure of the side-viewing endoscope.

Conclusion

Alter ERCP utilizing a cap-fitted forward-viewing endoscope can be a primary choice for treating common bile duct stones in patients with a Billroth II gastric resection history because of high efficacy and acceptable complications. It requires a high level of procedural expertise that requires multiple training sessions.

Safety and efficacy of endoscopic retrograde cholangiopancreatography in previously treated liver cancer patients: a survival analysis

Background and Aim

The prognosis and medication response for liver malignancies are both dismal and highly heterogeneous. For this diverse malignancy, multimodality therapies such as drugs, surgical management, and/or l+iver transplantation are available. Biliary complications remain a major problem after liver cancer treatment especially in those patients who undergo liver transplantation for their end stage liver disease. Although, most biliary complications can be successfully managed with endoscopic retrograde cholangiopancreatography. However, biliary complications still considered an important factor influencing long-term results in liver cancer treatment patients. The aim of this study was to evaluate the effect of biliary complications on the overall patient's survival rate after the endoscopic retrograde cholangiopancreatography.

Patients and Methods

We retrospectively analyzed data of consecutive patients who were treated for liver cancer at our tertiary care hospital from January 2015 to July 2020. We focused on the biliary complications and procedural data, including post-endoscopic retrograde cholangiopancreatography complications, survival rate, and complementary or alternative treatments to endoscopic retrograde cholangiopancreatography.

Results

We identified 967 cases (mean age 49; range 11-75), 84% men. During the mean follow up of 25 months (range 1 to 66 months), 102 patients developed biliary complications; 68/102 underwent 141 therapeutics endoscopic retrograde cholangiopancreatography procedures. The rest 34/102 patients were managed with percutaneous transhepatic cholangiography, conservative management, and/or surgery. Post- endoscopic retrograde cholangiopancreatography complications occurred in 79.4%, including anastomotic strictures in 25, non-anastomotic strictures in 5, stones in 5, cholangitis in 4, post-sphinctretomy bleeding in 3, pancreatitis in 2, and bile leakage in 1 patient. Seven (13.0%) patients died after ERCP due to multiple organ dysfunction syndrome. Although the survival rate of patients who underwent ERCP and those without ERCP was similar, patients with biliary complications fared significant worse.

Conclusion

Although endoscopic retrograde cholangiopancreatography is useful for the management of post liver cancer treatment biliary complications; the need for multiple rounds of endoscopic retrograde cholangiopancreatography and even post endoscopic retrograde cholangiopancreatography complications is relatively high, and often results in increased mortality. However, the survival following endoscopic or surgical therapy in liver cancer treatment patients is similar.

Application of a novel M-NED in ENBD patients: A case series report

RATIONALE

The traditional methods for exchanging the endoscopic nasobiliary drainage (ENBD) tube from the mouth to the nose, such as the guidewire method, sponge holding forceps method, and finger method, have significant drawbacks including pharyngeal stimulation symptoms, high incidence of epistaxis, low success rate, and potential bite injuries to the operator.

PATIENT CONCERNS

A case series of 9 patients who underwent ENBD at Shenzhen Second People's Hospital from January 2021 to December 2021 was collected.

DIAGNOSES

The study included 9 patients diagnosed with choledocholithiasis, with 3 males and 6 females, with an average age of (55 ± 9.798) years (range 43-71).

INTERVENTIONS

The M-NED was used to exchange the ENBD tube, and the success rate, operation time, and complications were recorded.

OUTCOMES

All patients successfully completed the operation in one go with an average mouth-nose exchange time of (44.67 ± 13.388) seconds (range 28-65). Two patients had mild adverse events, one of which was controllable bleeding caused by nasal mucosal injury with an estimated blood loss of 1 mL. The other patient had nausea during the operation, which improved after completion.

LESSONS

The novel M-NED is an effective and safe method for exchanging the ENBD tube from the mouth to the nose with a high success rate and low incidence of complications. It is a device with potential clinical application value.

Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders.

GOALS

Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients.

STUDY

In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 μg somatostatin followed by an infusion of 500 μg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11).

RESULTS

A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred.

CONCLUSIONS

In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.

Imaging of benign biliary pathologies

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes.

Prevention of post-ERCP pancreatitis: current strategies and novel perspectives

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.

An artificial intelligence difficulty scoring system for stone removal during ERCP: a prospective validation

BACKGROUND

A computer-assisted (CAD) system was developed to assess, score, and classify the technical difficulty of common bile duct (CBD) stone removal during endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of the CAD system was subsequently assessed through a multicenter, prospective, observational study.

METHOD

All patients who met the inclusion criteria were included. Based on cholangiogram images, the CAD system analyzed the level of difficulty of stone removal and classified it into "difficult" and "easy" groups. Subsequently, differences in clinical endpoints, including attempts at stone extraction, stone extraction time, total operation time, and stone clearance rates were compared between the two groups.

RESULTS

173 patients with CBD stones from three hospitals were included in the study. The group classified as difficult by CAD had more extraction attempts (7.20 vs. 4.20, P < 0.001), more frequent machine lithotripsy (30.4 % vs. 7.1 %, P < 0.001), longer stone extraction time (16.59 vs. 7.69 minutes, P < 0.001), lower single-session stone clearance rate (73.9 % vs. 94.5 %, P < 0.001), and lower total stone clearance rate (89.1 % vs. 97.6 %, P = 0.019) compared with the group classified as easy by CAD.

CONCLUSION

The CAD system effectively assessed and classified the degree of technical difficulty in endoscopic stone extraction during ERCP. In addition, it automatically provided a quantitative evaluation of CBD and stones, which in turn could help endoscopists to apply suitable procedures and interventional methods to minimize the possible risks associated with endoscopic stone removal.

Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important method to diagnose and treat biliary-pancreatic diseases. Perforations are infrequent but serious complications can occur during ERCPs. However, it is unclear which patients are suitable for surgery and when these patients should receive surgery.

Aim

To analyze the outcome of 45 patients with endoscopic retrograde cholangiopancreatography (ERCP) related perforation.

Materials and methods

We retrospectively reviewed all 45 patients with ERCP-related perforation between January 2003 and December 2017, and observed the location and causes of perforation, treatment strategies, and mortality.

Results

Twenty thousand four hundred and seventy-nine patients received ERCP procedures from January 2003 to December 2017 in our digestive endoscopy center. Forty-five patients suffered from ERCP-related perforations. The incidence rate of ERCP-related perforations was 0.22%. Twenty-six patients suffered from periampullary perforations, 15 patients suffered from duodenal wall perforations, 1 patient suffered from a fundus perforation, 1 patient suffered from a residual gallbladder duct perforation, 1 patient suffered from a papillary diverticulum perforation, and 1 patient suffered from an intrahepatic bile duct perforation. Six patients with duodenal perforations underwent surgery, and the other patients received conservative treatment. One patient with a duodenal perforation and ERCP-related pancreatitis died of heart failure, and all the other patients recovered. The mortality rate was 2.2%.

Conclusion

Endoscopic closure is seen as the first method for treating Stapfer type I perforations in the early phase, and surgery is seen as a remedial method when local treatment was failed. The Stapfer type II to type IV perforations can recover by conservative treatment.

Fatal Venous Gas Embolism During Endoscopic Retrograde Cholangiopancreatography After Simultaneous Deployment of 2 Self-Expandable Metallic Stents

Gas embolisms are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). While there have been multiple reports of ERCP-associated air embolisms, only 2 case reports using oral cholangioscopy and CO₂ insufflation have been reported in the literature. We present a unique case of a fatal CO₂ venous air embolism during ERCP without using cholangioscopy and with no intentional CO₂ insufflation of the biliary tree.

YouTube as a source of information on endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) carries a higher risk of adverse events than standard endoscopy. Internet media platforms such as YouTube has emerged as a medical information source. Therefore, study aimed to identify whether YouTube videos provide appropriate information on ERCP to the general population. The YouTube search was performed using the terms "endoscopic retrograde cholangiopancreatography" and "ERCP". The top 50 results of both searches, sorted by relevance and view count, were collected. After filtering according to a set of inclusion and exclusion criteria, a total of 26 videos were eligible for the final analysis. For quality assessment, we created a scoring system called ERCP Data Quality score (E-DQS), based on a colonoscopy education video available on the American Society of Gastrointestinal Endoscopy website. Healthcare professionals uploaded 14 (53.8%) videos, and 10 (38.6%) uploaded by medical websites. Only one video was uploaded by a layperson and one by a TV channel. The overall median E-DQS score for enrolled videos was 6.5 out of 20. The majority of videos did not describe the unique features of ERCP. Only 50% of videos informed viewers that patients would be irradiated and only six videos described at least one adverse event related to ERCP. ERCP videos on YouTube provide inadequate information regarding ERCP. Considering the unique characteristics of this procedure, professionals and academic societies need to be vigilant and proactive in producing and promoting high-quality videos.

Rectal nonsteroidal anti-inflammatory drugs, glyceryl trinitrate, or combinations for prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: A network meta-analysis

BACKGROUND

Acute pancreatitis is the most common and severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Recent evidence suggests that combinations based on rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are more beneficial in preventing post-ERCP pancreatitis (PEP). Randomized controlled trials (RCTs) have also demonstrated the efficacy of glyceryl trinitrate (GTN). We conducted a network meta-analysis to compare NSAIDs and GTN for prevention of PEP and to determine whether they are better in combination.

AIM

To compare NSAIDs and GTN for prevention of PEP and to determine whether they are better in combination.

METHODS

A systematic search was done for full-text RCTs of PEP in PubMed, Embase, Science Citation Index, and the Cochrane Controlled Trials database. Inclusion and exclusion criteria were used to screen for eligible RCTs. The major data were extracted by two independent reviewers. The frequentist model was used to conduct this network meta-analysis and obtain the pairwise OR and 95%CI. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

Twenty-four eligible RCTs were selected, evaluating seven preventive strategies in 9416 patients. Rectal indomethacin 100 mg plus sublingual GTN (OR: 0.21, 95%CI: 0.09–0.50), rectal diclofenac 100 mg (0.34, 0.18–0.65), sublingual GTN (0.34, 0.12–0.97), and rectal indomethacin 100 mg (0.49, 0.33–0.73) were all more efficacious than placebo in preventing PEP. The combination of rectal indomethacin and sublingual GTN had the highest surface under the cumulative ranking curves (SUCRA) probability of (92.2%) and was the best preventive strategy for moderate-to-severe PEP with a SUCRA probability of (89.2%).

CONCLUSION

Combination of rectal indomethacin 100 mg with sublingual GTN offered better prevention of PEP than when used alone and could alleviate the severity of PEP.

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.

Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures?

Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.

Cystic duct cyst in adults: a systematic review of the sixth entity

Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani's classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3 years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.

Complications of Endoscopic Retrograde Cholangiopancreatography in Patients With Previous Bariatric Surgery: A National Inpatient Sample Analysis, 2007-2013

BACKGROUND

Bariatric surgery (BS) has been proven to be effective in the treatment of obesity and weight-related diseases, but the anatomic changes after BS make endoscopic retrograde cholangiopancreatography (ERCP) technically challenging. This study aims to assess the safety and clinical outcomes of ERCP in patients with previous BS.

MATERIALS AND METHODS

The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with procedure diagnoses of ERCP. Those with prior BS were selected as cases and those without BS as controls. Case-control matching at a ratio of 1 case to 2 controls was performed based on sex, age, race, comorbidities, and obesity. The primary outcomes were inpatient mortality and ERCP-related complications. Multivariate regression analysis was used to identify independent risk factors associated to the primary outcomes.

RESULTS

A total of 1,068,862 weighted hospitalizations with ERCP procedure codes were identified. Of these, 6689 with BS were selected as cases, and 13,246 were matched as controls. The reason for hospital admission was most often biliary stone disease (60.7% vs. 55.5%), followed by malignancy (3.5% vs. 12.1%) and cholangitis (7.7% vs. 4.5%) with and without BS, P<0.05. The BS group had lower rates of post-ERCP pancreatitis (0.1% vs. 1.3%), cholecystitis (0.1% vs. 0.3%), bleeding (1.0% vs. 1.4%), and inpatient mortality (0.2% vs. 0.5%), but had higher rates of cholangitis (5.0% vs. 3.7%) and systemic infections (6.2% vs. 4.8%), all P<0.05.

CONCLUSIONS

BS group had lower post-ERCP pancreatitis, cholecystitis and bleeding while had more cholangitis, and systemic infection compared with those without BS. Also, BS was independently associated with reduced inpatient mortality after adjusted for age, race, and comorbidity.

Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal

Background and aim

The number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age.

Methods

This was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications.

Results

A total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005).

Conclusions

ERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.

Radiocontrast agent and intraductal pressure promote the progression of post-ERCP pancreatitis by regulating inflammatory response, cellular apoptosis, and tight junction integrity

OBJECTIVE

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication following ERCP and the mechanism is not fully understood. This study evaluated the changes in the inflammatory response, cellular apoptosis, and tight junction integrity in a rat model of pancreatitis to explore the underlying mechanism.

METHODS

PEP was induced in rats by retrograde biliopancreatic ductal infusion of contrast agents or saline. Pancreatic tissues were harvested and evaluated by histopathologic, immunohistochemical, immunofluorescence, and Western blot analyses. In addition, amylase and proinflammatory cytokines in plasma were quantified by ELISA assay.

RESULTS

PEP rats developed more severe acute pancreatitis than the sham group after injection of the contrast agent or isotonic saline. PEP rats exhibited increased tissue damage, plasma amylase, proinflammatory cytokines, necrosis, inflammatory infiltrates, apoptosis, and tight junction disruption. At the molecular level, contrast agent and isotonic saline-injected PEP rats demonstrated elevated NF-κB p65 and STAT3 pathways activation, altered expression and activation of apoptosis-related proteins, and suppressed expression of tight junction molecules. However, the contrast agent concentration had no effect on these changes.

CONCLUSIONS

In models of acute pancreatitis induced using contrast agent and hydrostatic pressure, the contrast agent and high hydrostatic pressure easily induced the inflammatory response, apoptosis, and tight junction disruption. It is noteworthy that no significant difference in damaged pancreatic acinar cells was observed with different concentrations of the contrast agent.

Role of Percutaneous Transhepatic Biliary Drainage as an Adjunct to Endoscopic Retrograde Cholangiopancreatography

Background

There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis.

Methods

Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed.

Results

Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17 ng/mL after one week of the PTBD.

Conclusion

PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

Analysis of Risk Factors in Endoscopic Retrograde Cholangiopancreatography-Related Immediate and Delayed Hemorrhage

BACKGROUND/AIMS

Hemorrhage is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP). However, there is a lack of comparative studies on immediate and delayed hemorrhage. The present study aims to explore the relevant risk factors of immediate and delayed hemorrhage of ERCP and compare the similarities and differences.

METHODS

ERCP cases conducted by our hospital between January 2017 and January 2020 were selected for retrospective analysis. Then age, gender, basic disease, laboratory examinations, and other relevant clinical information were collected for the analysis.

RESULTS

A total of 1009 ERCP cases were included in the present study. Among these cases, 76 patients were in the immediate hemorrhage group, 28 patients were in the delayed hemorrhage group, and 905 patients were in the non-hemorrhage group. The univariate analysis revealed that choledocholithiasis, pre-cut, and endoscopic papillary sphincterotomy (EST) were risk factors for immediate hemorrhage, while cholangitis, jaundice, coronary heart disease, pre-cut, high postoperative lipase at four hours and amylase at 24 h, high postoperative leukocyte, urea, bilirubin, low postoperative platelet counts and fibrinogen, and prolonged prothrombin time (PT) and thrombin time (TT) were risk factors for delayed hemorrhage. The logistic regression analysis revealed that EST, pre-cut, and activated partial thromboplastin time (APTT) were independent risk factors for immediate hemorrhage, while high amylase at 24 h after ERCP, high postoperative urea, prolonged TT, and coronary heart disease were independent risk factors for delayed hemorrhage.

CONCLUSIONS

Pre-cut was a common risk factor for immediate and delayed hemorrhage, while other risk factors were different.

The Incidence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review

Background

Existing literature on post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with liver transplant remains scarce and largely inconsistent. We therefore aimed to systematically review and analyze the literature on complication rates associated with ERCP in patients with liver transplant.

Methods

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through March 2020 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

Results

Fourteen studies with a total of 1,787 patients were analyzed. In total, 3,192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% confidence interval (CI): 0.035 - 0.075). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025 - 0.047), bleeding 1.1% (95% CI: 0.006 - 0.020), infections 0.2% (95% CI: 0.025 - 0.047), and cholangitis 0.8% (95% CI: 0.004 - 0.020). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455 - 3.653, P = 0.633, I² = 72.88%).

Conclusion

Post-ERCP complication rates in liver transplant patients are comparable to the general population and hence, peri-procedural evaluation and management may follow the current standards of care in this patient population.

Malpositioned endoscopically inserted biliary stent causing massive hematemesis managed with vascular plug and stenting

A 46-year-old man with a history of hepatitis B cirrhosis and hepatocellular carcinoma (HCC) status post liver transplantation two years ago complicated by HCC recurrence and biliary stenosis presented with hypovolemic shock and melena one month after endoscopic exchange of plastic biliary stents. During endoscopic retrograde cholangiopancreatography, patient was found to have hemobilia and developed uncontrollable bleeding after a common bile duct (CBD) sweep managed by insertion of a stent-graft across major papilla into presumed CBD. The bleeding continued with subsequent negative angiography, and a computed tomography angiography showed malpositioned stent-graft between major papilla and inferior vena cava (IVC). This was successfully managed by the deployment of a vascular plug inside the stent graft and excluding it by deploying a stent across the affected area in IVC.

Incidence, Risk Factors, and Treatment of Proximally Migrated Pancreatic Stents

AIM

The aim of this study was to investigate the incidence, risk factors, and treatment strategies of proximally migrated pancreatic stents.

MATERIALS AND METHODS

The data of 626 sessions of 421 patients with pancreatic duct stenting were retrospectively analyzed between 2010 and 2018, and patients with proximally migrated stents were included in the study.

RESULTS

Of 626 stents examined, 77 migrated proximally (12%). The migration rate (MR) was 16%, 2%, and 7%, respectively, in patients treated with chronic pancreatitis, malignancy, and pancreatic leakage indication. The MR was 14% in procedures with pancreatic duct stenosis, 21% in procedures with pancreatic sphincterotomy, and 27% in procedures performed from minor papillae. The MR of the 5, 7, and 10 Fr stents was 4%, 17%, and 10%, respectively. Of the 77 migrated stents, 64 were successfully removed (83%). This success rate (SR) was 84% in procedures with chronic pancreatitis indication, 83% in procedures with pancreatic duct stenosis, 79% in procedures with sphincterotomy, and 75% in procedures performed from minor papillae. The SR of the 5, 7, and 10 Fr stents was 100%, 79%, and 92%, respectively. It was also determined that 33 stents were fractured and migrated (43%). The SR of the fractured stents was 76%. Moreover, of the stents that were successfully removed, 35 were removed with forceps (55%) and 15 (23%) were removed with a balloon. Furthermore, in 47 cases, the stent was removed in the first session (73%). Acute pancreatitis occurred in 5 patients (8%) and perforation occurred in 1 patient (2%).

CONCLUSION

In this study, it was shown that proximal migration of pancreatic stents is frequent and most of these stents can be removed successfully.

How to Choose Between Percutaneous Transhepatic and Endoscopic Biliary Drainage in Malignant Obstructive Jaundice: An Updated Systematic Review and Meta-analysis

BACKGROUND/AIM

Malignant obstructive jaundice (MOJ) is a common condition caused by several primary and secondary cancers. We performed a systematic review and meta-analysis to investigate technical success rate and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) in MOJ.

MATERIALS AND METHODS

Relevant trials were identified by searching electronic databases and conference meetings. We included thirteen retrospective studies and four randomized controlled trials, with PTBD performed in 2353 patients and EBD in 8178 patients. Outcomes of interest included: technical success rate, overall complications, 30-day mortality rate and risk of bleeding, pancreatitis, cholangitis and tube dislocation.

RESULTS

The differences in technical success rate, total complications, 30-day mortality rate and tube dislocation were not statistically significant between the two groups. Patients receiving PTBD showed a lower risk of pancreatitis (OR=0.14, 95%CI=0.06-0.31) and cholangitis (OR=0.52, 95%CI=0.30-0.90) when compared to EBD while PTBD was associated with higher risk of bleeding (OR=1.78; 95%CI=1.32-2.39).

CONCLUSION

Our meta-analysis indicates the presence of some advantages and limits for both PTBD and EBD. We highlight the paucity of quality-of-life data, a vital element which should be carefully pondered in future studies and in choosing the optimal technique in patients with MOJ.

Aggressive hydration with lactated ringer solution in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

BACKGROUND

Acute pancreatitis is the most common complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). There was no conclusion on the prevention of Post-ERCP Pancreatitis (PEP) by Lactated Ringer Solution.

AIM

The purpose of this meta analyses is to determine whether aggressive hydration with Lactated Ringer Solution reduced the incidence of PEP.

METHODS

We retrieved randomized clinical trials comparing the preventive effects of aggressive hydration with Lactated Ringer Solution and standard hydration on PEP from PubMed, the Cochrane Library, Embase, the Web of Science, Clinical Trial.gov, Scopus database, CNKI, CQVIP and WanFang Data. Primary outcome was incidence of PEP. Secondary outcomes included incidence of hyperamylasemia, abdominal pain and adverse events.

RESULTS

Ten randomized controlled trials with 2200 patients were included in this meta-analysis. Meta-analysis showed that compared with standard hydration, aggressive hydration reduced the incidence of PEP (odds ratio [OR], 0.40; 95% confidence intervals [CI], 0.26-0.63; P < .0001). Compared with standard hydration, aggressive hydration also reduced the incidence of hyperamylasemia after ERCP (OR, 0.48; 95% CI, 0.38-0.60; P < .0001). There was significant difference between aggressive hydration and standard hydration in the incidence of abdominal pain (OR, 0.29; 95% CI, 0.11-0.73; P = .008). There was no difference in adverse events between aggressive hydration and standard hydration (OR, 0.93; 95% CI, 0.21-4.13; P = .93). Sensitivity analyses showed that neither alternative effect measures nor statistical models regarding heterogeneity affected the conclusions of this meta-analysis.

CONCLUSION

Aggressive hydration with Lactated Ringer Solution during perioperative period of ERCP can prevent PEP.

Characteristics and Outcomes of ERCP at a Canadian Tertiary Centre: Initial Results from a Prospective High-Fidelity Biliary Endoscopy Registry

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the management of pancreatic and biliary disease. While its role is firmly established, further well-designed prospective ERCP research is required, as a large portion of previous work has employed retrospective or administrative methodologies, both prone to potential biases. The aim of the Calgary Registry for Advanced and Therapeutic Endoscopy (CReATE) is to be a high-fidelity prospective multicentre registry.

METHODS

The study population consisted of consecutive adult ERCP patients from September 2018 to September 2019. Informed consent was acquired for each patient. All relevant preprocedural, procedural, peri-procedural and postprocedural data were captured in real time by a full-time third-party research assistant directly observing procedures. Outcomes were ascertained by comprehensive medical record review and patient phone interview 30 days after the index procedure.

RESULTS

Five endoscopists performed 895 ERCP procedures, 90.1% of which were deemed successful. Suspected choledocholithiasis was the most common indication for ERCP, followed by suspected or confirmed stricture(s), at 61.0% and 29.5%, respectively. 61.0% of procedures were performed on ERCP-naive patients. Post-ERCP pancreatitis occurred following 4.9% of procedures, with clinically significant bleeding or perforation occurring following 1.8% and 0.1% of procedures, respectively.

DISCUSSION

Through 12 months, CReATE captured 895 procedures prospectively, with each entry containing over 300 data fields. Active expansion to additional tertiary centres is underway, and this will enhance the existing data pool. CReATE has the potential to improve multiple facets of ERCP, including training, optimal procedural techniques, mitigation of adverse events and personalized patient care.

Serum microRNAs as Biomarkers for the Noninvasive Early Diagnosis of Biliary Tract Cancer

Background

Biliary tract cancers (BTCs) are aggressive malignancies with difficult early diagnosis and poor prognosis. Studies have shown that microRNAs (miRNAs) are expected to be biomarkers of the disease, which indicates that we can diagnose cancers according to the miRNAs that have significant changes. The aim of this study was to explore miRNA biomarkers of BTCs.

Methods

A total of 163 samples were collected and divided into the control group, the benign group and the malignant group. High-throughput low-density chips were used to screen miRNAs with significant changes. Then, the preliminary screening test and the verification test were performed by quantitative real time PCR (qRT-PCR). Finally, the level of miRNAs in serum exosomes was measured.

Results

MiR-10a, miR-21, miR-135b, miR-221, and miR-214 were upregulated in the BTCs group compared to the control group. The change in the miR-221 level was statistically significant when the malignant group was compared with the benign group (P<0.01). Meanwhile, miR-135b and miR-214 were enriched in serum exosomes.

Conclusion

Five miRNAs in the serum were found to be significantly upregulated in patients with BTCs. Among them, miR-221 can serve as an early diagnostic marker for BTCs patients. MiR-10a, miR-21, miR-135b and miR-214 can be used as biomarkers for the diagnosis of biliary diseases.

Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

BACKGROUND

A previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.

AIM

To determine whether saline irrigation can improve CBD clearance after lithotripsy.

METHODS

This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.

RESULTS

Between October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).

CONCLUSION

Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis.

AIM

To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events.

METHODS

We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar.

RESULTS

A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: -0.11 [-0.31, 0.08], P=0.27, I²=86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [-0.03, 0.04], P=0.62, I²=48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: -0.19 [-0.27, -0.12], P<0.00001, I²=0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [-0.01, 0.11], P=0.12, I²=57%), perforation (0.4% vs 0%; RD: 0.00 [-0.01, 0.02], P=0.7, I²=0%) or cholangitis (1.8% vs 3.2%; RD: -0.01 [-0.09, 0.06], P=0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P<0.00001, I²=0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: -0.10 [-0.24, 0.04], P=0.18, I²=61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [-0.02, 0.13], P=0.12, I²=0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD -0.01 [-0.11, 0.09], P=0.82, I²=0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P=0.01).

CONCLUSION

Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.

Recognizing Post-Endoscopy Complications: A Database Filter Reduces Quality Assurance Workload for Inpatients

BACKGROUND AND AIMS

Documentation of complications of gastrointestinal endoscopy within the commonly used endoscopy documentation systems are mostly limited to acute complications during endoscopy included in the post-procedural endoscopy report. We tested a documentation system-based filter to reduce the workload by maintaining a high sensitivity to recognize post-endoscopy complications.

METHODS

Of all inpatient endoscopic resections during 1 year and all endoscopic retrograde cholangiopancreatography (ERCP) procedures during 4 months in 1 tertiary referral centre, post-procedural complications during hospital stay were individually analyzed retrospectively from the hospital databases (gold standard). In comparison, information technology-based filters were assessed searching for specific tests and data within 2 days after endoscopy and/or until discharge. These were second endoscopy, surgery, or an abdominal computed tomography (CT) or haemoglobin drop ≥2 g/dL for endoscopic resection. For ERCP cases, any case with lipase determination and post-ERCP CT scan was selected. Main outcomes were the sensitivity of these filters to recognize post-endoscopy complications and the percentage of workload reduction.

RESULTS

Three hundred twenty-two inpatients who underwent endoscopic resections and 302 ERCP cases (all inpatients) were included. Post-endoscopy complications occurred in 7.14% (endoscopic resection) and 3.7% (ERCP). The above-mentioned filters identified 100% of all resection and post-ERCP complications compared to detailed case file analysis, at the same time reducing the quality management workload to 14 and 31%, respectively.

CONCLUSIONS

Post-procedural monitoring of advanced endoscopic procedures performed on inpatient procedures has a high sensitivity (100%) and reduces case-by-case screening workload for complications by 70-85%. Outpatient interventions, however, require a different system for monitoring of post-endoscopy complications after discharge.

Risk factors of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones

To explore the risk factors related to the recurrence of common bile duct stones (CBDS) after endoscopic retrograde cholangiopancreatography (ERCP), so as to provide reference for reducing the recurrence of CBDS after ERCP.The clinical data of 385 patients with CBDS treated by ERCP from March 2012 to May 2016 were collected. According to the diagnostic criteria of recurrence of CBDS, the patients were divided into recurrence group and control group. The general information of the patients, personal history, past history, and surgical-related information were collected. Univariate analysis and multivariate logistic regression analysis were performed on the collected data to identify risk factors for recurrence of CBDS after ERCP.A total of 262 patients were included in the study, of which 51 had recurrence of CBDS, with a recurrence rate of 19.46%. Multivariate Logistic analysis () showed greasy diet (P = .436), history of cholecystectomy (P = .639) and gallstone size (P = .809) were not independent risk factor for recurrence of stones after ERCP in CBDS. But age ≥65 (P = .013), history of common bile duct incision (P = .001), periampullary diverticulum (P = .001), common bile duct diameter ≥1.5 cm (P = .024), ERCP ≥2 (P = .003), the number of stones ≥2 (P = .015), the common bile duct angle ≤120° (P = .002) and the placement of bile duct stent (P = .004) are important independent risk factor for recurrence of stones after ERCP in CBDS.This study confirmed that ag ≥65, history of choledochotomy, periampullary diverticulum, diameter of common bile duct (≥15 mm), multiple ERCP, the number of stones ≥2, stent placement and angle of common bile duct < 120° were independent risk factors for recurrence of CBDS after ERCP.

Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study

Background

Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. To date, there is lack of consensus regarding who should administer sedation in these patients. Several studies have investigated the safety and efficacy of non-anesthesiologist-administered sedation for ERCP; however, data regarding anesthesiologist-administered sedation remain limited. This prospective single-center study investigated the safety and efficacy of anesthesiologist-administered sedation and the rate of successful performed ERCP procedures.

Methods

The study included 200 patients who underwent ERCP following anesthesiologist-administered sedation with propofol and remifentanil. Procedural data, oxygen saturation, systolic blood pressure (SBP), heart rate, recovery score, patient and endoscopist satisfaction, as well as 30-day mortality and morbidity data were analyzed.

Results

Sedation-related complications occurred in 36 of 200 patients (18%) and included hypotension (SBP < 90 mmHg) and hypoxemia (O₂ saturation < 90%) in 18 patients (9%) each. Most events were minor and did not necessitate discontinuation of the procedure. However, ERCP was terminated in 2 patients (1%) secondary to sedation-related complications. Successful cannulation was performed in all patients. The mean duration of the examination was 25 ± 16 min. Mean recovery time was 14 ± 10 min, and high post-procedural satisfaction was observed in both, patients (mean visual analogue scale [VAS] 9.6 ± 0.8) and endoscopists (mean VAS 9.3 ± 1.3).

Conclusion

This study suggests that anesthesiologist-administered sedation is safe in patients undergoing ERCP and is associated with a high rate of successful ERCP, shorter procedure time, and more rapid post-anesthesia recovery, with high patient and endoscopist satisfaction.

Endoscopic retrograde cholangiography via a permanent access loop

BACKGROUND/AIMS

The aim of this study was to investigate the indications, technical and clinical success, and complications of the endoscopic retrograde cholangiography (ERC) via a permanent access loop (PAL).

MATERIALS AND METHODS

Twenty patients who underwent ERC through PAL between 2009 and 2017 were included in this study. The technical success was described as achieving access to the bile ducts through PAL and the clinical success was described as the clinical and laboratory improvement of the patients after the procedure.

RESULTS

The study was performed with 20 patients. The median follow-up duration was 24 months (3-96) and the median number of ERC sessions was 3.9 (1-10). The most common ERC indications through PAL were stones (40%) and cholangitis (30%). In 16 patients (75%), anastomotic or branched strictures were observed. The improvement of strictures via intermittent stenting and dilatation was observed in 6 patients, but no improvement was observed in 5 patients. The treatment of those 5 patients continues. In this study, the technical success was 100% and clinical success was 85%. While no mortality due to PAL-mediated ERC was observed, free wall perforation was seen in one patient who was referred to surgery.

CONCLUSION

PAL-mediated ERC procedure is a technique with high technical and clinical success and low complication rate in patients who require frequent percutaneous procedures and those with difficult access to the biliary tract.

Nonsteroidal anti-inflammatory drugs alleviate severity of post-endoscopic retrograde cholangiopancreatography pancreatitis by inhibiting inflammation and reducing apoptosis

BACKGROUND AND AIM

The prophylactic effect of nonselective nonsteroidal anti-inflammatory drugs on post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis has been observed for a long time. However, whether the selective nonsteroidal anti-inflammatory drugs possess similar abilities and the mechanisms by which nonsteroidal anti-inflammatory drugs work remain unclear. The present study aimed to determine the protective effects of nonsteroidal anti-inflammatory drugs on post-ERCP pancreatitis in a rat model and examine underlying mechanisms.

METHODS

Thirty-two female rats were equally and randomly divided into four groups: the sham group, post-ERCP pancreatitis model group, indomethacin-pretreated group, and parecoxib-pretreated group. Indomethacin or parecoxib was delivered 30 min prior to surgery; 24 h after post-ERCP pancreatitis establishment, the rats were sacrificed. Serum amylase and lipase activities, inflammatory cytokine release, pancreatic histopathological scores, neutrophil infiltration, and the expression pattern cyclooxygenase at the protein level and pancreatic apoptosis were quantified and analyzed.

RESULTS

Both indomethacin and parecoxib inhibited the activities of serum amylase and lipase and reduced the severity of pancreatic histopathology. Mechanistically, both drugs decreased the expression level of cyclooxygenase 2; however, they had no influence on the cyclooxygenase 1 protein level. Moreover, they reduced inflammatory cytokine release, neutrophil infiltration into the pancreas, and NF-κB p65 activation. Notably, we found that apoptotic cells in the pancreas were remarkably diminished after the administration of both nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

Both selective and nonselective nonsteroidal anti-inflammatory drugs exert protective effects against post-ERCP pancreatitis by restraining inflammation and reducing acinar cell apoptosis through the inhibition of cyclooxygenase 2.

EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video)

BACKGROUND AND AIMS

Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper GI anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in the de novo creation of an enteroenteric anastomosis for the performance of ERCP in non-Roux-en Y gastric bypass (RYGB) patients.

METHODS

This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions), and secondary outcomes were technical success and rate/severity of adverse events.

RESULTS

Eighteen patients (mean age, 63 years; 13 women) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100% and of ERCP was 94.44% (17/18). Fourteen patients underwent separate-session EDEE with a median of 21 days (interquartile range [IQR], 11.5-36) between the 2 procedures. Median total procedure time was 111 minutes (IQR, 81-192). Clinical success and adverse events occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 days (IQR, 54-142).

CONCLUSIONS

This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

Endoscopic Retrograde Cholangiopancreatography Leading to Pharyngeal Perforation

Endoscopic retrograde cholangiopancreatography (ERCP) had become the favored method to access the pancreaticobiliary system because it is a safer and less invasive method compared to surgery. However, as with any procedure, ERCP comes with its own risks and potential complications. We present a unique case of a patient who underwent ERCP and developed necrotizing infection of the neck and a submandibular abscess. The patient is a 66-year-old female who presented to an outside hospital with complaint of right upper quadrant abdominal pain, workup of which revealed choledocholithiasis. ERCP was attempted; however, cannulation was unsuccessful. The patient was discharged home after the procedure, but within 48 h she presented to our institution complaining of left-sided neck pain, dysphagia, and drooling. CT of the neck revealed extensive gas and fluid collections at the left submandibular space. The patient was taken to the operating room for drainage of the left neck abscess. Drainage and irrigation of the abscess yielded Streptococcus mitis and Hemophilus parainfluenza. The rest of patient's hospital course was uncomplicated, and she was discharged with appropriate follow-up. In the case of our patient, ERCP was complicated by a perforation of the hypopharynx. Pharyngeal perforation can be subclassified into supraglottic and infraglottic. The most frequent cause of perforations is due to increased pressure in an intrinsically weak anatomical region of the pharynx. Such perforations are commonly due to the advancement of the endotracheal tube or transthoracic echo probe, but can also be due to advancement of an endoscope.

Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

OBJECTIVES

The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice.

METHODS

Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups.

RESULTS

A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group.

CONCLUSIONS

In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: Outcomes and potential factors affecting technical failure

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II gastrectomy patients is technically demanding and factors affecting its technical difficulty have not yet been clarified. This study aimed to investigate the outcomes of ERCP in Billroth II gastrectomy patients and identify potential factors affecting its technical failure.

PATIENTS AND METHODS

A large retrospective study of 308 consecutive patients (391 procedures) with Billroth II gastrectomy-who underwent ERCP from January 2002 to December 2016-was conducted. The outcomes of ERCP and potential factors affecting its technical failure were analyzed.

RESULTS

The success rate of duodenal ampullary access, selective duct cannulation and the accomplishment of expected procedures was 81.3% (318/391), 86.5% (275/318) and 97.3% (256/263), respectively, and the technical success rate was 70.3% (275/391). The overall ERCP-related complication rate was 15.3% (60/391). The multivariate analysis indicated that first-time ERCP attempt [odds ratio (OR) 4.29, 95% confidence interval (CI) 2.34-7.85, P < 0.001], Braun anastomosis (OR 3.65, 95% CI 1.38-9.64, P < 0.009), and no cap-assisted gastroscope (OR 3.05, 95% CI 1.69-5.51, P < 0.001) were significantly associated with technical failure.

CONCLUSIONS

ERCP is safe, effective and feasible for Billroth II gastrectomy patients. Previous ERCP history, absence of Braun anastomosis and the use of a cap-assisted gastroscope are the predictive factors for its technical success.