Minimizing complications in endoscopic retrograde cholangiopancreatography and sphincterotomy

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography

BACKGROUND AND OBJECTIVES

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure.

STUDY DESIGN

A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis.

RESULTS

The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group.

CONCLUSION

ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later?

Training in endoscopic retrograde cholangiopancreatography (ERCP) requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. So far, there are limited data regarding what constitutes competency in ERCP, including achievement and maintenance. Recent studies have highlighted overall procedural numbers are not enough to warrant competency, although more is better. We performed a comprehensive literature search until June 2017 using predetermined search terms to identify relevant articles and summarized their results as a narrative review. Selective native papilla deep cannulation should be used as a benchmark for assessing successful cannulation. Accurate and validated ERCP performance measures are needed to develop a curriculum that allows transition from numbers-based competency. However, available guidelines fail to state what degree of hands-on involvement is required by the trainee for the case to be counted in their overall procedural numbers. Qualitative assessment of competency should be done by trained raters using specially designed assessment tools. Competence continues to increase with practice following formal training in a fairly steady manner. The learning curve for overall common bile duct cannulation success may be a readily available surrogate for individual trainee progression and may correspond to learning curves for therapeutic interventions.

Comparative Relaxant Effects of Ataciguat and Zaprinast on Sheep Sphincter of Oddi

BACKGROUND

Relaxing the sphincter of Oddi (SO) is an important process during endoscopic retrograde cholangiopancreatography (ERCP) procedures. This issue suggests that the easier the sphincterotomy and cannulation, the more post-ERCP complications decrease.

AIMS

To compare the relaxant effects of ataciguat (a novel soluble guanylyl cyclase activator) and zaprinast (an inhibitor of phosphodiesterase 5) on sheep SO in vitro, thus testing whether they can be used during ERCP.

STUDY DESIGN

Animal experimentation.

METHODS

Sheep SO rings were placed in tissue baths and their isometric tension to ataciguat and zaprinast were tested. We also tested their isometric tension against ataciguat in the presence of 1H-(1,2,4) oxadiazole (4,3-a) quinoxalin-1-one (ODQ) which is a soluble guanylyl cyclase inhibitor.

RESULTS

Ataciguat and zaprinast both triggered concentration addicted relaxation on sheep SO rings (p=0.0018, p=0.0025 respectively) but the relaxation of the ataciguat was significantly greater than that of zaprinast at all concentrations (p=0.0024). It was observed that decreased relaxation responses were initiated by ataciguat in the presence of ODQ (p=0.0012).

CONCLUSION

Ataciguat and zaprinast both have relaxing effects on sphincter of Oddi, although that of zaprinast is lower. We believe that ataciguat and zaprinast can be used in ERCP procedures in order to relax the sphincter of Oddi and thus can be used locally in order to decrease complications.

Parameters That May Be Used for Predicting Failure during Endoscopic Retrograde Cholangiopancreatography

Aim. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for the diagnosis and treatment of hepatic, biliary tract, and pancreatic disorders. However, failure during cannulation necessitates other interventions. The aim of this study was to establish parameters that can be used to predict failure during ERCP. Methods. A total of 5884 ERCP procedures performed on 5079 patients, between 1991 and 2006, were retrospectively evaluated. Results. Cannulation was possible in 4482 (88.2%) patients. For each one-year increase in age, the cannulation failure rate increased by 1.01-fold (P = 0.002). A history of previous hepatic biliary tract surgery caused the cannulation failure rate to decrease by 0.487-fold (P < 0.001). A tumor infiltrating the ampulla, the presence of pathology obstructing the gastrointestinal passage, and peptic ulcer increased the failure rate by 78-, 28-, and 3.47-fold, respectively (P < 0.001). Conclusions.Patient gender and duodenal diverticula do not influence the success of cannulation during ERCP. Billroth II and Roux-en-Y gastrojejunostomy surgeries, a benign or malignant obstruction of the gastrointestinal system, and duodenal ulcers decrease the cannulation success rate, whereas a history of previous hepatic biliary tract surgery increases it. Although all endoscopists had equal levels of experience, statistically significant differences were detected among them.

Complications of endoscopic and radiologic investigation of biliary tract disorders

The investigation and treatment of disorders of the human biliary tree depend considerably on invasive endoscopic and radiologic procedures. These are associated with a significant risk of complications, some of which can be fatal. This review looks at these complications through the lens of 40 years of publications in the medical literature, and identifies the strengths and weaknesses of their current classification, diagnosis, and treatment.

An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital

OBJECTIVE

The use of early precut during endoscopic retrograde cholangiopancreatography (ERCP) is controversial because of its association with a higher risk of complications. This study examined the efficacy and safety of a strategy of early precut for biliary access during difficult ERCP in a general hospital.

METHODS

Data from January 2007 to June 2009 were reviewed. Criteria for performing early precut were: (i) inadvertent guidewire cannulation of pancreatic duct on three occasions; (ii) biliary stone impacted at papilla; (iii) inability to achieve deep cannulation within 10 min. Study exclusion criteria were: (i) the inability to visualize the papilla because of anatomical distortions; (ii) complete tumour occlusion of distal bile duct; (iii) failure to adhere to inclusion criteria. The efficacy and safety of this strategy of early precut for biliary access was analyzed.

RESULTS

A total of 765 ERCP cases were analyzed. A precut was performed in 55 out of 765 cases (7.2%). There were no significant differences in terms of age, gender and diagnoses between the precut and no precut groups. After precut immediate biliary cannulation was achieved in 89% of patients and this increased to 98.2% with a repeat ERCP. The overall complication rate after ERCP was 2.1% (bleeding: 0.7%; pancreatitis: 1.3%; perforation: 0.3%). The only complication after the precut was pancreatitis, and this was not significantly different from the group without a precut (1.8 vs 1.3%).

CONCLUSION

The strategy of early precut for biliary access was safe and effective.