Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

BACKGROUND AND AIMS

Although quality improvement is crucial for ERCP, a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation.

METHODS

Our hospital performs approximately 200 ERCPs annually, with 1 expert endoscopist performing approximately half of them and 3 nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases 3 years before and after the introduction of TPS. The primary endpoints of the study were the differences in 2 ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP).

RESULTS

A total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before, 87.4%; after, 92.3%, P = .032), whereas the incidence of PEP decreased, but not significantly (before, 4.0%; after, 2.8%; P = .402). All endoscopists benefited from using TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before, 85.5%; after, 93.1%; P = .019).

CONCLUSIONS

TPS can effectively enhance the quality of ERCP irrespective of practice volume.

A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging

BACKGROUND

Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis.

METHODS

Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation.

RESULTS

The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation.

CONCLUSIONS

The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.

Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation

BACKGROUND

Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods.

METHODS

Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed.

RESULTS

A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8-2.9) and type 4 (OR 2.1, 95% CI 1.1-3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51-10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0-6.6).

CONCLUSIONS

MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3.

Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto

BACKGROUND

Most of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.

AIM

To compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.

METHODS

Patients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.

RESULTS

A total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.

CONCLUSION

Many clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

Influence of periampullary diverticula on endoscopic retrograde cholangiopancreatography

The present study aimed to explore the influence of the presence of periampullary diverticula (PAD) on the implementation of endoscopic retrograde cholangiopancreatography (ERCP). A total of 388 patients with pancreaticobiliary disease who underwent ERCP for the first time between January 2017 and December 2018 were included and they were divided into a PAD group (n=179) and non-PAD (N-PAD) group (n=209) according to the presence or absence of PAD. A logistic regression model was used to analyze the risk factors for PAD. The prevalence of PAD in males was higher than that in females [odds ratio (OR)=2.250, 95% CI: 1.670-3.801]. The prevalence of PAD in patients with bile duct stone was 57.92% and higher than that in patients without stone (OR=4.475, 95% CI: 2.932-7.679). The morbidity of PAD in elderly patients with bile duct stone was higher than in those without stone (OR=6.728, 95% CI: 3.790-11.943). Among the elderly patients, the constituent ratio of males in the PAD group was higher than that in the N-PAD group (χ²=13.543, P<0.001). The constituent ratio of patients who underwent endoscopic sphincterotomy (EST) was lower than that in the N-PAD group (χ²=10.800, P<0.001). In conclusion, the occurrence of PAD was high in elderly males and closely related to the occurrence of bile duct stones.

Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study

OBJECTIVE

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists.

MATERIALS AND METHODS

Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests.

RESULTS

The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications.

CONCLUSIONS

Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study

BACKGROUND AND AIM

Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation.

METHODS

Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP.

RESULTS

Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio ≥ 1.5, and absence of PAD were independent risk factors for PEP.

CONCLUSION

Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).

Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience

BACKGROUND

Periampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty.

AIM

This study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events.

METHODS

Prospectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models.

RESULTS

Significant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation.

CONCLUSION

The presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1. Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.

AIM

To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.

METHODS

A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events.

RESULTS

There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis.

CONCLUSION

Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.

The influence of periampullary diverticula on ERCP for treatment of common bile duct stones

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

BACKGROUND

Different types of periampullary diverticulum (PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography (ERCP) cannulation, but the clinical significance of the two current PAD classifications for cannulation is limited.

AIM

To verify the clinical value of our newly proposed PAD classification.

METHODS

A new PAD classification (Li-Tanaka classification) was proposed at our center. All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.

RESULTS

A total of 3564 patients with native papillae were enrolled, including 967 (27.13%) PAD patients and 2597 (72.87%) non-PAD patients. In the Li-Tanaka classification, type I PAD patients exhibited the highest difficult cannulation rate (23.1%, P = 0.01), and type II and IV patients had the highest cannulation success rates (99.4% in type II and 99.3% in type IV, P < 0.001). In a multivariable-adjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio (OR) = 1.87, 95% confidence interval (CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group, the difficulty of cannulation in the type I PAD group according to the Li-Tanaka classification was greater (OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower (OR = 0.27, 95%CI: 0.11-0.66, P < 0.001), while it was higher in the type II PAD group (OR = 4.44, 95%CI: 1.61-12.29, P < 0.01).

CONCLUSION

Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.

Does periampullary diverticulum affect ERCP cannulation and post-procedure complications? an up-to-date meta-analysis

Research conclusions differ on the impact of periampullary diverticulum (PAD) on endoscopic retrograde cholangiopancreatography (ERCP). An up-to-date meta-analysis evaluated the role of PAD in ERCP, especially in terms of cannulation failure and early complications. A comprehensive literature search was performed. All statistical analyses were carried out with the Review Manager 5.3 software. Horizontal lines represented a 95% confidence interval (CI) and the area of each square in forest plots. Twenty-six studies including 23 826 patients with or without PAD who underwent ERCP were evaluated. PAD was associated with an increase in the overall cannulation failure rate (RR=1.46, 95% CI: 1.27-1.67; p<.00001), but in the subgroup of studies performed post-2000, PAD was irrelevant to cannulation failure (RR=1.16, 95% CI: 0.96-1.41; p=0.12). In overall analyses, PAD was also associated with a high risk of ERCP-related pancreatitis (RR=1.32, 95% CI: 1.10-1.59; p=0.003), perforation (RR=1.73, 95% CI: 1.06-2.82; p=0.030), and bleeding (RR=1.48, 95% CI: 1.13-1.93; p=0.005). The presence of PAD increased the overall cannulation failure rate, but not the rate post-2000. PAD also affected the occurrence of early pancreatitis, perforation, and bleeding.

Endoscopic papillary large balloon dilation with minor sphincterotomy for periampullary diverticular papilla

Background To observe the outcome of endoscopic papillary large balloon dilation (EPLBD) with minor sphincterotomy (mEST) for periampullary diverticular papilla related to stone removal. Methods Patients with confirmed periampullary diverticulum (PAD) during stone removal from May 2016 to April 2018 were reviewed retrospectively. The Chi-square test with Yates correction or Fisher's exact test was used for the analysis of categorical data and a normality test was applied for continuous data. Results A total of 154 consecutive patients (89 males and 65 females, aged 51-87 years) with confirmed PAD during stone removal were included in the study. Cases were divided into the conventional EST group (n = 79) and the mEST plus EPLBD group (n = 75). The number of patients with an initial treatment success was greater in the EPLBD+mEST group compared with the EST group (96% vs 86.1%, p=0.03) and the procedure time for EPLBD+mEST was shorter than that for EST alone (46.1±13.7 min vs 53.3±11.6 min, p=0.01). The rate of complications in the EPLBD+mEST group was lower than in the EST group (17.3% vs 32.9%, p=0.04). When PAD was >15 mm, the initial success rate was higher (92.6% vs 73.9%, p=0.04) and the rate of overall complications was lower (14.8% vs 41.7%, p=0.03) in the EPLBD+mEST group than those in the EST group. Although, this was similar when PAD was <15 mm. Conclusion EPLBD+mEST might be safer and more effective than conventional EST alone for stone removal in the presence of PAD.

Patient-related factors associated with successful cannulation by trainees during hands-on endoscopic retrograde cholangiopancreatography training

BACKGROUND AND AIM

Hands-on endoscopic retrograde cholangiopancreatography (ERCP) training is essential for trainees to grasp the technique. Cannulation success rate (CSR) is considered one of the main indicators of competency of trainees. We aimed to investigate whether patient-related factors had an impact on the CSR of trainees.

METHODS

A post hoc analysis of data from two multicenter studies (NCT02002650 and NCT03057769) was conducted. Patients aged 18-90 years with native papilla undergoing ERCP were eligible for this study. Only procedures involving trainees in centers strictly following "10-min criteria" for initial cannulation were enrolled. Primary outcome was CSR by trainees.

RESULTS

From December 2013 to October 2017, 20 trainees in four centers were involved in initial cannulation in 1044 patients with native papilla. Primary CSR by trainees was 61.0% (436/715), 31.5% (70/222) and 44.9% (48/107) in patients with common bile duct stone (CBDS), biliary stricture (BS) and other indications, respectively (P < 0.001). In multivariate analysis, indication of BS (OR, 0.31; 95% CI, 0.22-0.44; P < 0.001) and presence of type A diverticulum (OR, 1.69; 95% CI, 1.23-2.33; P = 0.001) were both independently associated with cannulation success of trainees. Biliary infection was significantly higher in the BS than in the CBDS group (3.6% vs 0.7%, P = 0.004), whereas other post-ERCP complications were comparable between the two groups.

CONCLUSIONS

Indication of BS and the presence of type A diverticulum were independently associated with the success of cannulation by trainees. These findings indicate that greater effort is needed for trainees to improve the ability of cannulation in BS.

Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION

Periampullary diverticulum (PAD) is most often asymptomatically found in elderly population. ERCP in the presence of PAD is technically challenging since the location and orientation of the ampulla could be altered. Various studies have reported differing results on the technical success and safety outcomes of ERCP in the presence of PAD. We aimed at a meta-analysis of such studies to assess the technical success and the occurrence of complications during ERCP in patients with PAD.

METHODS

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2017). The search was done in accordance with PRISMA guidelines to identify studies. Studies that reported on the ERCP outcomes based on the presence of PAD were included. Both prospective and retrospective studies, manuscripts and abstracts were included. Only articles in English literature were included. The primary analysis focused on the overall technical success of ERCP in the presence of PAD, and the secondary analysis was to estimate the risk of occurrence of complications.

RESULTS

Our search resulted in 16 studies that were included for final analysis. These 16 studies reported on 2794 patients, who had PAD, and the control group included 13,032 patients, who did not have a PAD during ERCP. Our meta-analysis of this data showed an Odd's ratio estimate of having a successful ERCP procedure in patients with PAD to be 0.51 [95% C.I. (0.35-0.72)] when compared to patients without it. This was statistically significant, with a p value 0.00. Considerable heterogeneity was noted among the studies. The heterogeneity proportion was quantified at 74.6% based on I² statistic. The secondary outcomes measured were complications. We analyzed the pooled Post-ERCP Pancreatitis (PEP), cholangitis, perforation, and bleeding. Only those studies that had the data for these complications in both the study and the control groups were selected. PEP: The pooled Odd's estimate of having PEP was 1.28, [95% C.I (0.88-1.87)] from 12 studies reporting on 1863 patients with PAD in comparison with 7803 patients without it. The risk of PEP occurrence tended to be more in the group without PAD, though it was not statistically significant, with a p value 0.20. There was some heterogeneity observed between the studies, with the quantification I² statistic being 28.6%. Our analysis shows that having PAD does not put a patient at increased risk for PEP. Bleeding: The pooled Odds estimate was 1.69, 95% C.I. 0.88-3.25 from nine studies reporting on 1816 patients with PAD in comparison with 5327 patients without it. This was not statistically significant, p value 0.11. Considerable heterogeneity was noted, with I² being 55.7%. The risk of having a bleed was noted to be more in control group, and having PAD did not put patients at increased risk for bleeding during an ERCP procedure. Perforation: Patients with PAD undergoing ERCP were not at increased risk for perforation. Seven studies reported on this complication. This was noted in seven patients out of 1245 in study group, and 19 patients out of 4912 in control group. The pooled Odd's estimate was 1.24, 95% C.I. 0.54-2.87. There was no statistical significance, p value 0.61. No heterogeneity was noted among the studies included in this analysis. Cholangitis: Only four studies reported on this complication. In a total of 778 patients in study group, four had cholangitis and eight had this complication out of 3886 patients in the control group. The pooled Odd's was 2.12, 95% C.I. 0.61-7.33. There was no statistical significance, p value 0.24. No heterogeneity was noted.

CONCLUSION

ERCP is technically feasible and increasingly successful when performed by experts in the presence of PAD. The risk of complications such as PEP, bleeding, perforation and cholangitis does not differ between ERCP done in patients with and without PAD.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.

The presence of periampullary diverticulum increased the complications of endoscopic retrograde cholangiopancreatography

BACKGROUND

The use of needle-knife fistulotomy technique in patient with periampullary diverticula (PAD) for biliary duct cannulation may lead to risk of complications. The present study aimed to investigate the association between PAD and the complications of endoscopic retrograde cholangiopancreatography (ERCP), unsuccessful cannulation rates and to determine the rates of cannulation complications using sphincterotomy and needle-knife fistulotomy.

MATERIALS AND METHODS

The ERCP procedures were held in Gastroenterology Endoscopy Unit between September 2015 and October 2016 and were retrospectively evaluated. The patients were divided into two groups, a PAD group and a non-PAD group. These groups were compared regarding demographic characteristics, ERCP complications and mortality.

RESULTS

A total of 827 patients fulfilling the criteria for ERCP were enrolled in the study. Of 827 patients, 164 had PAD and 663 did not have PAD (non-PAD). The success rate of cannulation was 98.8% in patients with PAD and 98.6% in patients without PAD. There was no statistical difference of cannulation types with sphincterotomy and with needle-knife fistulotomy between the two groups. Mean baseline number of guide wire cannulation attempts was 1.96±0.20 in PAD group. No complications were observed in PAD patients treated with needle-knife fistulotomy. ERCP-related complications rates (bleeding, pancreatitis, and perforation) were higher in the PAD group (P=0.007).

CONCLUSION

In conclusion, there is a strong association between PAD and higher rates of cannulation complications, independent of cannulation technique. In certain situations, and in the hands of experienced endoscopists, needle-knife fistulotomy might be a feasible option for successful biliary cannulation in certain patients with PAD.

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study

Background/Aims

Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls.

Methods

We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease.

Results

The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls.

Conclusions

PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

Two Biliary Cannulation Techniques for ERCP in Patients With Intradiverticular Papilla: A Retrospective Review

PURPOSE

To compare the effectiveness and complications of the different cannulation techniques for bile duct stones removal in patients with intradiverticular papilla.

MATERIALS AND METHODS

The records of 472 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures for bile duct stones removal from January 2014 to December 2016 were retrospectively reviewed. A total of 42 patients with CBD stones were included in the study and data of included patients were collected retrospectively. The outcomes and complications of ERCP procedures were compared.

RESULTS

Of 42 ERCP procedures included in the study, patients were divided into Two-devices-in-one-channel group (n=20) and Endoclip group (n=22). The success rate of CBD cannulation at first attempt in Two-devices-in-one-channel and Endoclip groups was 85.0% (17/20) and 54.5% (12/22), respectively (P<0.05). The average time it took to cannulation in Endoclip group was much longer than that in Two-devices-in-one-channel Group (17.55±2.06 vs. 10.6±2.75 min, P<0.05). Overall complications occurred in 3 cases of Two-devices-in-one-channel group and in 4 cases of Endoclip group, respectively (15.0% vs. 18.2%, P>0.05). There was no statistically significant difference between groups regarding the complications.

CONCLUSIONS

Two-devices-in-one-channel and Endoclip techniques are both safe and effective for bile duct cannulation in patients with intradiverticular papilla.

Retroperitoneal Perforation Caused by Migration of a Pancreatic Spontaneous Dislodgement Stent into Periampullary Diverticula

An 85-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) for obstructive jaundice. Selective bile duct cannulation was unsuccessful because of periampullary diverticula (PAD). A pancreatic spontaneous dislodgement stent (PSDS) (5F diameter, 3 cm, straight type) was inserted to prevent post-ERCP pancreatitis. Three days after ERCP, she complained of abdominal pain, and computed tomography revealed retroperitoneal perforation because of PSDS migration to the PAD. If the papillary orifice is observed at the diverticular rim or in the diverticula, a pigtailed PSDS on the duodenal side or flanged stent on the pancreatic ductal side should be inserted in order to prevent this rare adverse event.

浅谈影响ERCP操作的制约因素

内镜下逆行性胆胰管造影术(endoscopic retrograde cholangiopancreatography, ERCP)由于具有创伤小、时间短的优点, 已在胆胰疾病的诊治方面具有举足轻重的作用, 尤其在胆总管结石、胆囊切除术后的胆管复发结石的治疗方面已经成为了首选. 但随着ERCP的广泛开展和认识的不断提高, 大量研究显示局部解剖因素, 尤其是十二指肠周围憩室、乳头嵌顿结石和乳头狭窄是影响ERCP操作成功的主要解剖因素. 同时医护患三者间的配合也是影响ERCP操作成功的重要原因. 本文系统复习相关文献资料, 对ERCP操作失败的原因作一综述.

Impact of periampullary diverticula on technical success and complications of endoscopic retrograde cholangiopancreatography

AIM

To investigate the association of periampullary diverticula (PAD) with pancreaticobiliary diseases as well as the impact of PAD on the technical success and complications of endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 1455 consecutive patients who underwent ERCP from January 2016 to December 2016 at The First Affiliated Hospital of Nanchang University were analyzed retrospectively. The patients were divided into a PAD group (n = 293) and a non-PAD group (n = 1162) according to the presence or absence of PAD. The rate of pancreaticobiliary diseases was analyzed and compared between the PAD group and non-PAD group, and the technical success rate of ERCP and the incidence of postoperative complications were also compared.

RESULTS

The rate of PAD increased with age (P < 0.05). The incidence rates of suppurative cholangitis and acute pancreatitis (AP) and carcinoma of the pancreatic head in patients with PAD were significantly higher than those in patients without (P < 0.05). The rates of postoperative complications, such as hemorrhage, perforation, post-ERCP pancreatitis (PEP) and hyperamylasemia, were significantly higher in patients with PAD (P < 0.05). No significant differences was observed in the success rate of ERCP (P > 0.05).

CONCLUSION

PAD is associated with an increased rate of pancreaticobiliary diseases as well as the occurrence of postoperative complications of ERCP. However, the presence of PAD dose not affect the technical success rate of ERCP.

Number of Endoscopic Retrograde Cholangiopancreatography Procedures Required for Short Biliary Cannulation Time

Background. Several previous studies assessed the competence in endoscopic retrograde cholangiopancreatography (ERCP) using the bile duct cannulation success rate. However, the cannulation time is also important, because a long cannulation time was reported to be a risk factor for post-ERCP pancreatitis. Aim. To determine the number of ERCP procedures required for short cannulation time of the bile duct. Methods. We retrospectively analyzed 605 ERCP procedures performed for bile duct cannulation in patients with native papilla at our institution between March 2012 and December 2015. The successful procedures were divided into 2 groups: group L and group S (cannulation time > 15 minutes and ≤15 minutes, resp.). An analysis of the relationship among the biliary cannulation time, ERCP experience, and other factors was then conducted. Results. Multivariate analysis showed that the ERCP experience of ≤300 procedures (odds ratio, 2.080; 95% confidence interval, 1.337–3.142; P = 0.001) and malignant biliary stricture due to pancreatic cancer (odds ratio, 1.912; 95% confidence interval, 1.072–3.412; P = 0.028) were found to be significantly associated with a cannulation time of >15 minutes. Conclusions. Our findings suggested that an ERCP experience of ≤300 procedures and malignant biliary stricture due to pancreatic cancer were associated with prolonged biliary cannulation time.

Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography

BACKGROUND AND AIM

Periampullary diverticulum (PAD) is frequently encountered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to investigate the association of PAD with pancreaticobiliary diseases as well as the impact of PAD on the technical success of ERCP and different methods of bile duct stone extraction.

PATIENTS AND METHODS

A total of 1489 cases of patients with PAD were identified from 6390 patients who underwent ERCP. These patients were compared with 1500 controls without PAD in terms of biliary stone formation, technical success, and complications of ERCP.

RESULTS

Patients with PAD had increased prevalence of bile duct stones, gallstones, and cholangitis (P<0.01). Successful cannulation rates were similar in the PAD and the control group (98.59 vs. 99.07%, P=0.225). The incidence of complications did not differ between the PAD and the control group. Successful stone removal rate of endoscopic sphincterotomy (EST) was lower in the PAD group than in the control group (83.53 vs. 94.31%, P=0.005). In patients with PAD, the rate of successful stone removal was lower in the EST group than in the endoscopic papillary balloon dilation (EPBD) and EPBD combined with limited EST (ESBD) group. The rates of complications were similar among different treatments (EST, EPBD, or ESBD) in patients with PAD.

CONCLUSION

PAD is associated with bile duct stones, gallstones, and cholangitis. In addition, PAD should not be considered a barrier to a successful cannulation. Moreover, EST is less effective than EPBD and ESBD in patients with PAD, whereas EST, EPBD, and ESBD are equally safe in patients with PAD.

The Impact of Duodenal Diverticuli and the Execution of Endoscopic Retrograde Cholangiopancreaticography

Introduction. Duodenal diverticuli alter the anatomy of the papillary region and can make an ERCP difficult. Aim. To study the outcome of ERCP in cases of duodenal diverticuli. Patients and Methods. Consecutive ERCPs in a period of 24 years were included. Endoscopy reports were studied for presence of diverticuli. Success of the procedure and findings were noted. Clinical records were searched for clinical presentation of the patient. Patients without duodenal diverticuli were used as comparison. Results. 2795 procedures were done in 2092 patients. Of these, 211 (10%) had diverticuli. Diverticuli occurred significantly more often in women (p < 0.001). ERCP was significantly more often inconclusive in cases of a diverticulum, 12.8% versus 6.3%, p < 0.001. In cases of a successful ERCP, patients with diverticuli showed more often no abnormalities in the bile duct, 26% versus 17%, p < 0.001. In 64% of cases, the reason for ERCP was cholestasis. There was no significant difference in presence of stones or cholangitis. Biliary pancreatitis was seen more often in patients without diverticuli, 4.4% versus 1.4%, p = 0.04. This was also the case for malignancies, 18.5% versus 6.6%, p < 0.001. Conclusion. It is concluded that duodenal diverticuli can be responsible for cholestasis. Presence of a diverticulum in the duodenum makes the ERCP procedure more complex.

Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center

Aims. We here investigated the association of different types of periampullary diverticula (PAD) with pancreaticobiliary disease and with technical success of endoscopic retrograde cholangiopancreatography (ERCP). Methods. A total of 850 consecutive patients who underwent their first ERCP were entered into a database. Of these patients, 161 patients (18.9%) had PAD and the age- and sex-matched control group comprised 483 patients. Results. PAD was correlated with common bile duct (CBD) stones (59.6% versus 35.0% in controls; P = 0.008) and negatively correlated with periampullary malignancy (6.8% versus 21.5% in controls; P = 0.004). The acute pancreatitis was more frequent (62.5%) in patients with PAD type 1 followed by PAD type 2 (28.9%, P = 0.017) and type 3 (28.0%, P = 0.006). No significant differences were observed in successful cannulation rate and post-ERCP complications among the 3 types of PAD. Type 1 PAD patients had less recurrence of CBD stones than did the patients who had type 2 or type 3 PAD (53.8% versus 85.7%; P = 0.043). Conclusions. PAD, especially type 1 PAD, is associated with an increased acute pancreatitis as well as occurrence and recurrence of CBD stones. PAD during an ERCP should not be considered as an obstacle to a successful cannulation.

Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation

Periampullary diverticulum (PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD is usually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography (ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD, suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.

Old age is associated with increased severity of complications in endoscopic biliary stone removal

BACKGROUND AND AIM

Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal.

METHODS

This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications.

RESULTS

Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115).

CONCLUSIONS

Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

The effect of biliary stenting on difficult common bile duct stones

Introduction

If common bile duct (CBD) stones (choledocholithiasis) are left untreated, they may cause increases in morbidity and mortality due to several conditions.

Aim

In this study, using transient biliary stenting following the failure of an initial endoscopic retrograde cholangiopancreatography (ERCP) session, we aimed to show the effects of making the CBD stones smaller and easier to remove in the following session.

Material and methods

In 156 of 1300 (12%) patients with CBD stones, who underwent balloon screening and/or basket lithotripsy following ERCP and CBD cannulation, it was not possible to remove the stones in the first session. Of these 156 patients, 64 (4.9%) were further followed and tested following transient biliary stenting.

Results

In the last ERCP following biliary stenting, the maximum stone sizes and stone indices were decreased in 54 (83%) patients and stone fragmentation was observed in 46 (72%) patients. Complete and incomplete removal was obtained in 40 (62.5%) and 24 (37.5%) patients, respectively.

Conclusions

Biliary stenting, fragmentation and the reduction in the size of difficult common bile duct stones caused by the first session of ERCP may increase the chance of success in the next session of ERCP.

Endoscopic papillary large balloon dilation in patients with periampullary diverticula

AIM: To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) for bile duct stone extraction in patients with periampullary diverticula.

METHODS: The records of 223 patients with large common bile duct stones (≥ 10 mm) who underwent EPLBD (12-20 mm balloon diameter) with or without limited endoscopic sphincterotomy (ES) from July 2006 to April 2011 were retrospectively reviewed. Of these patients, 93 (41.7%) had periampullary diverticula (PAD), which was categorized into three types. The clinical variables of EPLBD with limited ES (EPLBD + ES) and EPLBD alone were analyzed according to the presence of PAD.

RESULTS: Patients with PAD were significantly older than those without (75.2 ± 8.8 years vs 69.7 ± 10.9 years, P = 0.000). The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and non-PAD groups, however, there was significantly less need for mechanical lithotripsy in the PAD group (3.2% vs 11.5%, P = 0.026). Overall stone removal rates, complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD + ES and EPLBD alone in patients with PAD (96.6% vs 97.1%; 72.9% vs 88.2%; and 5.1% vs 0%, respectively). No significant differences with respect to the rates of pancreatitis, perforation, and bleeding were observed between EPLBD + ES and EPLBD alone in the PAD group (3.4% vs 14.7%, P = 0.095; 0% vs 0%; and 3.4% vs 8.8%, P = 0.351, respectively).

CONCLUSION: EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD, regardless of PAD subtypes.

Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis

OBJECTIVES

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.

METHODS

A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.

RESULTS

A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).

CONCLUSIONS

ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Impact of periampullary diverticula on the outcome and fluoroscopy time in endoscopic retrograde cholangiopancreatography

BACKGROUND

It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangiopancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD.

METHODS

Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla's location with respect to the diverticulum on procedure was also investigated.

RESULTS

A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A than group B (P<0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P<0.001; 76.51 vs 47.42 seconds, P<0.001). There was no significant difference between the two groups in the complication rate. The type of papilla's location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications.

CONCLUSION

The presence of a PAD does not affect the success rate and complications of therapeutic ERCP in expert hands; however, the fluoroscopy time is significantly longer in patients with PAD.

ERCP features and outcome in patients with periampullary duodenal diverticulum

Background. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography (ERCP), it may lead to post-ERCP morbidity. We compared baseline characteristics and clinical data as well as ERCP results in patients with and without periampullary diverticulum. Methods. Clinical, laboratory, and ERCP data of 780 patients referred to the Taleghani Hospital, as a great referral endoscopy center, in Iran were prospectively analyzed. Results. The periampullary diverticulum was identified in 44 patients (5.6%). Cannulation of common bile duct was more failed in patients with diverticulum compared to others (35.5% versus 11.5, P < 0.001). Patients with diverticulum had eight times more often common bile duct stone compared to patients without diverticulum (54.5% versus 12.2%, P < 0.001). Post-ERCP complications were observed in 2.3% and 4.2% of patients with and without diverticulum, respectively, which did not significantly differ in both groups. Conclusion. Because of more failure cannulation in the presence of periampullary diverticulum, ERCP requires more skills in these patients. Prevalence of common bile duct stone was notably higher in patients with diverticulum; therefore, more assessment of bile stone and its complications in these patients is persistently recommended.

Intradiverticular ampulla of vater: personal experience at ERCP

Introduction. Conflicting results have been reported about the true impact of intradiverticula ampulla (IA) on the technical success and complication rate of endoscopic retrograde cholangiopancreatography (ERCP). Patients. A total of 500 patients who underwent ERCP were divided into two groups according to the presence (group A, 81 patients) or absence (group B, 419 patients) of IA. Success rate, difficulty at cannulation, findings at ERCP, and procedure-related complications were retrospectively reviewed. Results. Successful cannulation was achieved in 100% of group A patients compared to 98% of group B patients (P = ns). There was a significant difference in the type of cannulation that was routinary in group B (P < 0.05), while requiring guidewire in group A (P < 0.05). Cholangitis (P < 0.05), microstones (P < 0.01), dilated common bile duct without stones (P < 0.01), stone recurrence (P < 0.01), and transient postprocedure hyperamylasemia (P < 0.01) were more frequently observed in group A. There was no significant difference in complication rate between both groups. Conclusions. The finding of an IA at ERCP should not be considered a predictor for failed cannulation. IA is associated with post-ERCP transient hyperamylasemia and is a risk factor for biliary stone disease and its recurrence.

Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones

BACKGROUND AND AIM

Periampullary diverticula (PAD) are not uncommon findings during endoscopic retrograde cholangiopancreatography, but its clinical significance had not been established. To investigate the clinical characteristics associated with PAD and their relationships with the type and size of PAD in patients with common bile duct (CBD) stones was aimed.

METHODS

Three hundred seventy patients undergoing endoscopic retrograde cholangiopancreatography between March 2010 and July 2012 were consecutively enrolled, and their demographics, laboratory data, and CBD stone-related characteristics according to PAD type and PAD size were analyzed.

RESULTS

Mean age, mean size of CBD stones, prevalence of systemic inflammatory response syndrome, and serum C-reactive protein level differed in patients with CBD stones according to the presence or absence of PAD. The presence of PAD and positive blood culture were correlated with systemic inflammatory response syndrome (P = 0.033 and P < 0.001, respectively). The recurrence of CBD stones was more frequent, and the diameter of CBD was larger in patients with PAD type I than in those with PAD type III. Mean age and CBD diameter were lower in patients with PAD size < 15 mm than those with PAD size ≥ 15 mm. Multivariate analyses indicated that CBD diameter was related to PAD size (P = 0.002) and the recurrence of CBD stones was related to PAD type (P = 0.001).

CONCLUSIONS

PAD are associated with larger CBD stones and severe cholangitis with CBD stones. CBD diameter is related to PAD size, and the recurrence of CBD stones is related to PAD type.

Entering the duodenal diverticulum: A method for cannulation of the intradiverticular papilla

Successful cannulation of the common bile duct may be difficult in patients in whom the papilla is located entirely within a diverticulum. In this study, we report successful biliary cannulation in three patients following intubation of the distal tip of the duodenoscope into the duodenal diverticulum and locating the major papilla. No complications occurred during the operation or during the postoperative period. This method didn’t need second incubation an endoscope and might lower the burden of patients. So this skill is useful to deal with the papilla hidden inside the large diverticulum because of its safety and convenience.

Results of repeat endoscopic retrograde cholangiopancreatography after initial biliary cannulation failure following needle-knife sphincterotomy

BACKGROUND AND AIM

After failed biliary cannulation with needle knife sphincterotomy (NKS), endoscopic retrograde cholangiopancreatography (ERCP) is sometimes repeatedly performed in clinically stable patients; however, there are few reports about the results. This study assessed the results of repeated ERCPs after failure with NKS.

METHODS

After failed NKS, patients who underwent repeated ERCP for the same purpose within 3 days were retrospectively identified. Success was defined as deep placement of a catheter into the common bile duct.

RESULTS

Sixty-nine patients underwent a second ERCP procedure and, of those, six underwent a third ERCP. Of the 69 patients, cannulation was successful in 76.8% (53/69): 46 of 58 patients without additional NKS and 7 of 11 with additional NKS. Success increased to 79.7% (55/69) after the results of the third ERCP were included. Common causes of failed NKS were biliary deep cannulation failure (78.3%) and blocking of the endoscopic view due to bleeding (13.0%). There was a significant difference in success rates between the one day (65.7%) and the combined 2-3 day (88.2%) cases (P = 0.027). Except for the interval between ERCPs, there were no other factors associated with success rates. Complications occurred in 8, 11, and one patient after initial, second, and third ERCP and there was no difference of complication rates between each ERCPs.

CONCLUSIONS

In cases with biliary cannulation failure with NKS, it is more worthwhile repeating ERCP 2 or 3 days after such failure than one day after, if the patient's condition permits delay of procedure.

[The effect of periampullary diverticulum on the outcome of bile duct stone treatment with endoscopic papillary large balloon dilation]

BACKGROUND/AIMS

Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment.

METHODS

We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed.

RESULTS

PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9±11.1 years. Mean diameter of the stones was 14.8±6.0 mm and mean diameter of CBD was 21.6±7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (≥15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups.

CONCLUSIONS

PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.

Pneumothorax following ERCP: report of four cases and review of the literature

We report four patients with pneumothorax as a complication of ERCP with sphincterotomy. With conservative treatment all patients recovered. Previously, 16 comparable cases have been reported in the literature. The main risk factor for this rare complication seems (pre-cut) sphincterotomy. Pneumothorax is usually right-sided or bilateral and accompanied by pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema. The prognosis seems favourable with a non-surgical approach including intravenous antibiotics, fasting and when indicated chest tube drainage.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center.

METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP.

RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017).

CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy

BACKGROUND

The management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations remains controversial. Τhe aim of the study was to determine the incidence of perforations following ERCP, their characteristics, operative and non-operative management options and clinical outcome.

METHODS

A retrospective review of ERCP-related perforations, during a 21-year period, was performed. Each perforation was categorized into types I to IV according to the location, mechanism and radiographic evaluation of the injury. Comparisons were made between patients treated operatively and non-operatively.

RESULTS

Forty-four perforations (0.4%) occurred in 9,880 procedures. They were mainly caused by the passage of the endoscope (type I) in 7 (16%) and sphincterotomy (type II) in 30 (68%) patients. The management was non-operative in 32 (72%) and operative in 12 patients. In multivariate analysis, only the type of perforation (type I: endoscope-related) was found significant for predicting operative treatment. The hospital stay was longer for patients requiring an operation (median, 24 vs 9 days). The overall mortality was 2/44 (4.5%). There was no death in the non-operative group.

CONCLUSIONS

The need for immediate operative intervention should be based on the type of injury and clinical findings. Patients with type I perforations should be treated surgically and primary repair should be tried. Patients with type II injuries may be treated initially non-operatively. Delayed operative intervention will be required in a minority of these patients.

Difficult biliary cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD).

METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated.

RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047).

CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.