Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Updates in Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Although endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be a safe and effective approach in treating these diseases while carrying lower morbidity than traditional surgical treatments, ERCP has associated risks, with post-ERCP pancreatitis (PEP) being the most common serious adverse event and carries significant morbidity and health care cost. PEP results from multifactorial factors involving trauma to the pancreatic duct and papilla, leading to subsequent obstruction and impairment of pancreatic drainage. Important risk factors for PEP include history of prior PEP, suspected sphincter of Oddi dysfunction, difficult cannulation, pancreatic duct contrast injections, and pancreatic sphincterotomy.

Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis

OBJECTIVE

Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA.

DESIGN

Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ2 test, Mann-Whitney-U-test and log-rank test for survival.

RESULTS

Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable.

CONCLUSIONS

The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

Why is the rectal route for NSAIDS favorable for preventing post-ERCP pancreatitis?

OBJECTIVE

Acute pancreatitis is a frequent, burdensome adverse event of endoscopic retrograde cholangiography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have reduced post-ERCP pancreatitis (PEP) risk by about 50 % and show greater efficacy over parenteral or oral administration, although the mechanism for its superiority remains unclear. To probe this question, we investigated in a preclinical model, the pharmacokinetics in the blood, pancreas and other tissues of the NSAID diclofenac given via the rectal, intravenous, or intragastric routes.

METHODS

The data on diclofenac was extracted from a larger study that examined a combination of diclofenac and tacrolimus. 20.8 mg diclofenac/kg body weight, which is the mouse equivalent dosing used in clinical practice for PEP prophylaxis, was administered to C57BL/6J mice via the rectal, intravenous and intragastric (oral) routes. Cross-collection of blood and tissues was done at various timepoints after administration for the evaluation of drug levels and pharmacokinetic parameters.

RESULTS

Rectal diclofenac demonstrated favorable blood pharmacokinetics and systemic bioavailability as well as sustained pancreas penetration. The total pancreas exposure to diclofenac over 24 h following rectal dosing was not significantly different as compared to intravenous and oral dosing.

CONCLUSION

Our findings suggest that the efficacy of rectal diclofenac in PEP prevention relates more to its higher and consistent systemic exposure than its absolute pancreas levels. The implications are that the rectal route provides both systemic and pancreas exposure for the full duration of PEP vulnerability.

Prospective validation and revision of predictive models for post-ERCP pancreatitis: focus on procedure-related factors and a novel risk stratification approach

INTRODUCTION

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event after endoscopic retrograde cholangiopancreatography (ERCP). Although retrospective models to predict PEP have shown promise, their real-world applicability remains uncertain. Thus, we used prospectively derived cohort data to validate current prediction models.

METHODS

We conducted a prospective cohort study involving patients who underwent ERCP between August 2020 and December 2023. We validated the original PEP-risk prediction models using prospective cohort data and, if necessary, refined them using logistic regression analysis.

RESULTS

Among the 1112 study participants, the original PEP-risk prediction models had limited performance. Although PEP incidence tended to increase across risk groups, the differences were mostly insignificant. Logistic regression highlighted procedural factors-total procedure time [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.01-1.26 per 5 min], unintended pancreatic duct cannulation (OR 2.56, 95% CI 1.11-5.93), and pancreatic opacification (OR 2.57, 95% CI 1.19-5.58)-as independent PEP risk factors. This led to a revised model that assigned 1, 8, and 8 points to these factors. Patients stratified into low- (0-2 points), intermediate- (3-10 points), and high-risk groups (≥ 11 points) exhibited PEP incidences of 2.6% (95% CI 1.5-4.1%), 7.1% (95% CI 4.8-10.3%), and 12.6% (95% CI 8.6-17.8%), respectively.

CONCLUSIONS

We highlighted limitations of existing PEP-prediction models that necessitate refinement based on procedural variables. Our revised model accounted for the prolonged total procedure time, unintended pancreatic duct cannulation, and pancreatic opacification, offering enhanced accuracy in predicting PEP risk.

Outcomes of bile duct cannulation using a novel contrast-enhanced catheter: A single-center, retrospective cohort study

BACKGROUND

Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation. Despite the development of several cannulation devices, none have effectively facilitated the procedure.

AIM

To evaluate the efficacy of a recently developed catheter for bile duct cannulation.

METHODS

We retrospectively examined 342 patients who underwent initial cholangiopancreatography. We compared the success rate of bile duct cannulation and the incidence of complications between the groups using existing and novel catheters.

RESULTS

The overall success rates of bile duct cannulation were 98.3% and 99.1% in the existing and novel catheter groups, respectively (P = 0.47). The bile duct cannulation rate using the standard technique was 73.0% and 82.1% in the existing and novel catheter groups, respectively (P = 0.042). Furthermore, when catheterization was performed by expert physicians, the bile duct cannulation rate was significantly higher in the novel catheter group (81.3%) than in the existing catheter group (65.2%) (P = 0.017). The incidence of difficult cannulation was also significantly lower in the novel catheter group (17.4%) than in the existing catheter group (33.0%) (P = 0.019).

CONCLUSION

The novel catheter improved the bile duct cannulation rate using the standard technique and reduced the frequency of difficult cannulation cases, valuable tool in endoscopic retrograde cholangiopancreatography procedures performed by experts.

Assessment of safety and patency of 7-mm covered metal stents for preoperative biliary drainage in pancreatic cancer: Prospective multicenter study

Background and study aims

For preoperative biliary drainage of pancreatic cancer (PC), a 10-mm diameter metal stent (MS) is commonly used; however, the rate of pancreatitis is high. It is hypothesized that smaller-diameter MS may reduce the rate of pancreatitis. Therefore, we conducted a multicenter prospective study to evaluate the efficacy and safety of 7-mm MS.

Patients and methods

Patients requiring initial biliary drainage for obstructive jaundice caused by PC and scheduled for surgery from six facilities were included. After endoscopic retrograde cholangiography, a 7-mm MS was placed at the site of biliary obstruction. The primary endpoint was the rate of pancreatitis, and the secondary endpoints included early and late adverse events (AEs). The pancreatitis rate was assumed to be 18% and 5% with 10- and 7-mm MS, respectively; with a power of 80% and one-sided significance level of 10%, the planned enrollment was 38 patients. If pancreatitis occurred in no more than three patients, this indicates that the 7-mm MS effectively reduced incidence of pancreatitis.

Results

Overall, 38 patients were enrolled, and 35 patients in whom a 7-mm MS was successfully placed were analyzed. All MS were placed after sphincterotomy. Pancreatitis occurred in four patients (11.4%) and no early AEs were observed. Surgery was performed in 24 patients and late AEs included stent occlusion in eight patients (23%) and cholecystitis in four patients (11%).

Conclusions

The 7-mm MS did not reduce incidence of pancreatitis among surgical candidates for PC.

Identification of risk factors associated with post-ERCP pancreatitis in patients with easy cannulation: a prospective multicenter observational study (with videos)

BACKGROUND AND AIMS

Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation.

METHODS

We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

RESULTS

Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

CONCLUSIONS

Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).

Early prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis via dynamic changes of leukocyte: A retrospective study

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains a major concern for clinicians. Hence early identification of PEP is meaningful to minimize medical risks.

AIMS

This study aims to explore the value of dynamic leukocyte changes for early prediction of PEP.

METHODS

Patients from January 2017 to December 2018 (training set) and January 2019 to December 2022 (test set) were retrospectively reviewed. The dynamic changes of leukocyte, neutrophil, and lymphocyte were examined to evaluate the diagnostic value of PEP.

RESULTS

A total of 498 patients (36 PEP cases) in training set and 948 patients (71 PEP cases) in test set were analyzed. Four predictors were finally identified in training set containing margin and ratio of 3h-post ERCP leukocyte count (Po Leu) to pre-ERCP leukocyte count (Pr Leu), 3h post-ERCP neutrophil-to-lymphocyte ratio (NLR) and pre-ERCP fibrinogen levels. ROC analysis revealed the optimal thresholds were 2.3 (x109/L), 1.6, 4.8 and 3.1 (g/L), respectively. The sensitivity and specificity of Po Leu - Pr Leu and Po Leu/Pr Leu were 71.0%, 82.7%, 66.1% and 86.3% to diagnosis PEP in patients with hyperamylasemia.

CONCLUSIONS

For early identification of PEP, the elevation of amylase and lipase still exhibits the highest sensitivity, while the dynamic changes of leukocyte would be helpful for the different diagnosis of hyperamylasemia.

Multistep validation of a post-ERCP pancreatitis prediction system integrating multimodal data: a multicenter study

BACKGROUND AND AIMS

The impact of various categories of information on the prediction of post-ERCP pancreatitis (PEP) remains uncertain. We comprehensively investigated the risk factors associated with PEP by constructing and validating a model incorporating multimodal data through multiple steps.

METHODS

Cases (n = 1916) of ERCP were retrospectively collected from multiple centers for model construction. Through literature research, 49 electronic health record (EHR) features and 1 image feature related to PEP were identified. The EHR features were categorized into baseline, diagnosis, technique, and prevention strategies, covering pre-ERCP, intra-ERCP, and peri-ERCP phases. We first incrementally constructed models 1 to 4 incorporating these 4 feature categories and then added the image feature into models 1 to 4 and developed models 5 to 8. All models underwent testing and comparison using both internal and external test sets. Once the optimal model was selected, we conducted comparisons among multiple machine learning algorithms.

RESULTS

Compared with model 2 that incorporated baseline and diagnosis features, adding technique and prevention strategies (model 4) greatly improved the sensitivity (63.89% vs 83.33%, P < .05) and specificity (75.00% vs 85.92%, P < .001). A similar tendency was observed in the internal and external tests. In model 4, the top 3 features ranked by weight were previous pancreatitis, nonsteroidal anti-inflammatory drug use, and difficult cannulation. The image-based feature has the highest weight in models 5 to 8. Finally, model 8 used a random forest algorithm and showed the best performance.

CONCLUSIONS

We first developed a multimodal prediction model for identifying PEP with a clinical-acceptable performance. The image and technique features are crucial for PEP prediction.

Indomethacin Does Not Reduce Post-ERCP Pancreatitis in High-Risk Patients Receiving Pancreatic Stenting

BACKGROUND

Rectal indomethacin reduces pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, there is insufficient evidence regarding its added benefits in patients already receiving prophylactic pancreatic stenting. Our goal was to evaluate the impact of indomethacin in high-risk patients undergoing pancreatic stenting.

METHODS

A cohort study was conducted on all patients who underwent the rescue cannulation technique for challenging bile duct cannulation (selected high-risk patients). Patients were split into two groups based on the prophylaxis method for post-ERCP pancreatitis (PEP): one receiving a combination of indomethacin and pancreatic stenting, while the other received pancreatic stenting alone. Comparative analyses were carried out on PEP, hyperamylasemia, gastrointestinal bleeding, and postoperative hospital stay among post-ERCP pancreatitis patients.

RESULTS

Between November 2017 and May 2023, a total of 607 patients with native papillae were enrolled, with 140 grouped into the indomethacin plus stent group and 467 into the stent alone group. The overall PEP rate was 4.4% in the entire cohort, with no statistical differences observed between the groups in terms of PEP rates (P = 0.407), mild PEP (P = 0.340), moderate to severe PEP (P = 1.000), hyperamylasemia (P = 0.543), gastrointestinal bleeding (P = 0.392), and postoperative hospital stay (P = 0.521). Furthermore, sensitivity analysis using multivariable analysis also validated these findings.

CONCLUSIONS

Indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement. Therefore, the additional administration of rectal indomethacin to further mitigate PEP appears to be not necessary.

Rise in First-Time ERCP for Benign Indications >1 Year After Cholecystectomy Is Associated With Worse Outcomes

BACKGROUND & AIMS

Greater availability of less invasive biliary imaging to rule out choledocholithiasis should reduce the need for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients who have a remote history of cholecystectomy. The primary aims were to determine the incidence, characteristics, and outcomes of individuals who undergo first-time ERCP >1 year after cholecystectomy (late-ERCP).

METHODS

Data from a commercial insurance claim database (Optum Clinformatics) identified 583,712 adults who underwent cholecystectomy, 4274 of whom underwent late-ERCP, defined as first-time ERCP for nonmalignant indications >1 year after cholecystectomy. Outcomes were exposure and temporal trends in late-ERCP, biliary imaging utilization, and post-ERCP outcomes. Multivariable logistic regression was used to examine patient characteristics associated with undergoing late-ERCP.

RESULTS

Despite a temporal increase in the use of noninvasive biliary imaging (35.9% in 2004 to 65.6% in 2021; P < .001), the rate of late-ERCP increased 8-fold (0.5-4.2/1000 person-years from 2005 to 2021; P < .001). Although only 44% of patients who underwent late-ERCP had gallstone removal, there were high rates of post-ERCP pancreatitis (7.1%), hospitalization (13.1%), and new chronic opioid use (9.7%). Factors associated with late-ERCP included concomitant disorder of gut-brain interaction (odds ratio [OR], 6.48; 95% confidence interval [CI], 5.88-6.91) and metabolic dysfunction steatotic liver disease (OR, 3.27; 95% CI, 2.79-3.55) along with use of anxiolytic (OR, 3.45; 95% CI, 3.19-3.58), antispasmodic (OR, 1.60; 95% CI, 1.53-1.72), and chronic opioids (OR, 6.24; 95% CI, 5.79-6.52).

CONCLUSIONS

The rate of late-ERCP postcholecystectomy is increasing significantly, particularly in patients with comorbidities associated with disorder of gut-brain interaction and mimickers of choledocholithiasis. Late-ERCPs are associated with disproportionately higher rates of adverse events, including initiation of chronic opioid use.

Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs.

METHODS

Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models.

RESULTS

The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events.

CONCLUSIONS

EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.

Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial

BACKGROUND

The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention.

METHODS

In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete.

FINDINGS

Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups.

INTERPRETATION

For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines.

FUNDING

US National Institutes of Health.

Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor?

BACKGROUND

Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis.

METHODS

Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses.

RESULTS

Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05).

DISCUSSION

This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.

Clinical impact of pancreatic steatosis measured by CT on the risk of post-ERCP pancreatitis: a multicenter prospective trial

BACKGROUND AND AIMS

Pancreatic steatosis (PS) may be a risk factor for acute pancreatitis. Whether it is also a risk factor for post-ERCP pancreatitis (PEP) has not been evaluated. This study aimed to determine the impact of PS on PEP development.

METHODS

This multicenter prospective trial enrolled 786 consecutive patients who underwent contrast-enhanced abdominal CT and subsequent first-time ERCP. PS was evaluated based on pancreatic attenuation on unenhanced CT images. The risk of PS for the development of PEP was evaluated using a logistic regression model.

RESULTS

Of 527 patients included in the study, 157 (29.8%) had PS and 370 (70.2%) did not. At 24 hours after ERCP, there was a significant difference in the PEP identified in 22 patients (14.0%) in the PS group and 23 patients (6.2%) in the "no PS" (NPS) group (P = .017). Diabetes and hypertension were more common in the PS group than in the NPS group; no differences in dyslipidemia were found. Patients with PS had a higher risk for the development of PEP than those with NPS (odds ratio, 2.09; 95% confidence interval, 1.08-4.03). No other variables were identified as risk factors for PEP.

CONCLUSIONS

PS is a significant risk factor for PEP for which preventive measures should be considered. Standardized measurement protocols to assess PS by CT are needed. (Clinical trial registration number: KCT0006068.).

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.

Endoscopic retrograde cholangiopancreatography utilisation and outcomes in the first advanced endoscopy centre in Palestine at Al-Ahli Hospital: a retrospective cohort study

OBJECTIVE

To evaluate the utilisation and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures, success rates, incidence and risk factors for procedural-related complications in a single centre-based study.

STUDY DESIGN

Retrospective cohort study.

SETTING

First advanced tertiary endoscopy centre in Palestine.

PARTICIPANTS

A total of 1909 procedures on 1303 patients were included in the analysis: females were 57.9% of the cases (n=755), 1225 patients (94%) were from West Bank and Jerusalem and 78 (6%) were from Gaza Strip. All patients who underwent ERCP throughout the period from December 2017 to September 2022 were selected to participate in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes of interest in our analysis were success rates, procedural outcomes and post- procedural complications including pancreatitis, bleeding and others. Two multivariate logistic regression models were performed to calculate the risk of post-ERCP complications and post-ERCP pancreatitis (PEP) in patients with certain risk factors like demographic factors, procedural techniques' variation, pancreatic duct manipulations and others. We also discussed the management of the failed procedures.

RESULTS

The overall complication rate was 5%, including PEP (n=43, 2.3%), infection/cholangitis (n=20, 1%), bleeding (n=9, 0.5%) and perforation (n=7, 0.4%). The mortality rate was 0.6% (n=11). Risk factors for adverse events included pancreatic duct cannulation and PEP (p<0.001, OR=3.64). Additionally, younger patients (≤45) were found to carry a higher risk for PEP when compared with older patients (≥65) (p=0.023, OR=2.84). In comparison with sphincterotomy, the double-wire technique was associated with a higher risk of complications (p=0.033, OR=2.29).

CONCLUSIONS

We summarised the utilisation and outcomes of ERCP among the Palestinian population in the first advanced centre in Palestine. Cannulation success rates are similar to the established standards and are acceptable compared with other centres worldwide. Perioperative complication rates of ERCP remain infrequent, and death is quite unusual and thus considered a safe procedure.

Impact of center and endoscopist ERCP volume on ERCP outcomes: a systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes.

METHODS

We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I2 = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I2 = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I2 = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I2 = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I2 = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I2 = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates.

CONCLUSIONS

HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.

Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials

BACKGROUND AND AIMS

The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs).

METHODS

The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality.

RESULTS

One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48).

CONCLUSIONS

The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.

ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs.

AREAS COVERED

This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023.

EXPERT OPINION

Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.

Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study

Background and study aims Endoscopist techniques affect biliary cannulation success and the risk of adverse events during endoscopic retrograde cholangiopancreatography (ERCP). This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods Practicing endoscopists were sent an anonymous 28-question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD, respectively, before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut NKTs and likelihood of prophylactic PD stent ( P <0.001 for both). Conclusions A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques; however, almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic PD stent placement, factors known to be associated with cannulation success and adverse outcomes.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP.

Methods

A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression.

Results

A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05).

Conclusion

Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study

BACKGROUND AND AIMS

Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures.

METHODS

A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis.

RESULTS

Of survey respondents (N = 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P ≤ .001), practice at a teaching program (P ≤ .001), <10 years in practice (P = .005), higher procedure volume (P ≤ .001), and higher proportion of pancreatic cases (P ≤ .001).

CONCLUSIONS

Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.

Endoscopic retrograde cholangiopancreatography outcomes in inflammatory bowel disease patients: a 12-year analysis of a national database

BACKGROUND

Despite inflammatory bowel disease's (IBD) association with hepatobiliary disorders and the use of endoscopic retrograde cholangiopancreatography (ERCP) for both diagnostic and therapeutic evaluation of these diseases, it remains a poorly studied area within the literature. The purpose of this study is to examine the effect of IBD on the occurrence of adverse events (AE) pertaining to ERCP.

METHODS

This project utilized the National Inpatient Sample (NIS) database, the largest inpatient database in the USA. All patients 18 years or older with and without IBD undergoing ERCP were identified from 2008 to 2019. Post-ERCP AEs were analyzed using multivariate logistic or linear regression controlling for age, race, and existing comorbidities using the Charlson comorbidity index (CCI).

RESULTS

There was no difference in post-ERCP pancreatitis (PEP) or mortality. IBD patients were also found to have a lower risk of bleeding and decreased length of stay (LOS) despite adjustment for comorbidities. They also underwent less sphincterotomies when compared to the non-IBD cohort. Subgroup analysis between ulcerative colitis (UC) and Crohn's disease (CD) did not find any significant differences in outcomes.

CONCLUSION

To our knowledge, this is the largest study to date evaluating ERCP outcomes in IBD patients. After adjustment of co-variates, there was no difference in the occurrence of PEP, infections, and perforation. IBD patients were less likely to experience post-ERCP bleeding and mortality and had shorter LOS which may be due to the decreased frequency of sphincterotomy in this population.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Temporal trend and factors associated with post-endoscopic retrograde cholangiopancreatography pancreatitis in children in the USA: a nationwide, retrospective cohort study

Pancreatitis is the most common adverse event following endoscopic retrograde cholangiopancreatography (ERCP). Meanwhile, the national temporal trend of post-ERCP pancreatitis (PEP) in children remains to be reported. The purpose of this study is to investigate the temporal trend and factors associated with PEP in children. We conducted a nationwide study using data from the National Inpatient Sample database during 2008-2017 and included all patients aged ≤ 18 years who underwent ERCP. The primary outcomes were temporal trends and factors associated with PEP. The secondary outcomes were in-hospital mortality, total charges (TC), and total length of stay (LOS). A total of 45,268 hospitalized pediatric patients who underwent ERCP were analyzed; of whom, 2043 (4.5%) were diagnosed with PEP. The prevalence of PEP decreased from 5.0% in 2008 to 4.6% in 2017 (P = 0.0002). In multivariable logistic analysis, adjusted risk factors of PEP were hospitals located in the West (aOR 2.09, 95% CI 1.36-3.20; P < .0001), bile duct stent insertion (aOR 1.49, 95% CI, 1.08-2.05; P = 0.0040), and end-stage renal disease (aOR 8.05, 95% CI 1.66-39.16; P = 0.0098). Adjusted protective factors of PEP were increasing age (aOR 0.95, 95% CI 0.92-0.98; P = 0.0014) and hospitals located in the South (aOR 0.53, 95% CI 0.30-0.94; P < .0001). In-hospital mortality, TC, and LOS were higher in patients with PEP than those without PEP.

CONCLUSION

This study shows a decreasing national trend over time and identifies multiple protective and risk factors for pediatric PEP. Endoscopists can use the insights from this study to evaluate relevant factors before performing ERCP in children to prevent PEP and reduce the medical-care burden.

WHAT IS KNOWN

• Although ERCP has become indispensable procedure in children as they are in adults, education and training programs for ERCP in children are underdeveloped in many countries. • PEP is the most common and most serious adverse event following ERCP. Research on PEP in adults showed rising hospital admission and mortality rates associated with PEP in the USA.

WHAT IS NEW

• The national temporal trend of PEP among pediatric patients in the USA was decreasing from 2008 to 2017. • Older age was a protective factor for PEP in children, while end-stage renal disease and stent insertion into the bile duct were risk factors.

The Incidence and Severity of Post-ERCP Pancreatitis in Patients Receiving Standard Administration of NSAIDs: a Systematic Review and Meta-analysis

BACKGROUND

Routine rectal administration of 100 mg of diclofenac or indomethacin was demonstrated to be an effective prevention method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The systematic review and meta-analysis aimed to estimate the incidence and severity of post-ERCP pancreatitis (PEP) and explore the discrepancies of PEP incidences among different subgroups.

METHODS

The PubMed, Web of Science, and Ovid EMBASE databases were searched for studies published until December 2020. Only randomized controlled trials (RCTs) reported rectal administration of 100 mg or higher doses of diclofenac or indomethacin, with PEP as the primary outcomes were eligible for inclusion. The overall and severity of PEP were estimated. Subgroup analysis was performed based on geographic regions, risk level, study beginning time, type of NSAIDs, administration time, and sample size.

RESULTS

There were 26 randomized controlled trials (RCTs) with 7954 patients in 31 NSAIDs arms. The pooled incidences were 7.2% for overall PEP (95% confidence interval (CI) 5.9-8.5%), 5.0% for mild PEP (95% CI, 4.0-6.0%), and 1.5% for moderate and severe PEP (0.8-2.3%). PEP rate were higher in patients receiving rectal indomethacin than that of patients receiving rectal diclofenac (7.8% (95% CI, 6.4-9.3%) vs 3.8% (95% CI, 2.2-5.3%), p = 0.009). The PEP rates of high-risk patients and average-risk patients were 8.9% (95% CI, 5.6-12.2%) and 6.4% (95% CI, 5.1-7.6%), respectively (p = 0.160).

CONCLUSIONS

The incidence of PEP was higher in patients receiving 100 mg rectal indomethacin than patients receiving 100 mg diclofenac. The effect of 100 mg diclofenac versus indomethacin on preventing PEP requires further study.

The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE.

METHODS

We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes.

RESULTS

After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05).

CONCLUSION

Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage.

Post-ERCP Pancreatitis: Prevention, Diagnosis and Management

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

Prognostic scores in post-endoscopic retrograde cholangiopancreatography acute pancreatitis: should we use all, some, or none?

BACKGROUND/AIMS

Acute pancreatitis is the most commonly observed adverse event following endoscopic retrograde cholangiopancreatography (ERCP). Early risk stratification is crucial in the management of these patients, to reduce unfavorable outcomes. Multiple prognostic scores are already used in acute pancreatitis, regardless of its etiology. Scarce data is available for their use specifically on post-ERCP acute pancreatitis (PEP). We aimed to compare the accuracy of different prognostic scores at PEP diagnosis for the prediction of a moderate-to-severe course.

METHODS

Cross-sectional study of consecutive ERCPs performed between 2010 and 2020. The final sample included patients with PEP, with the severity graded according to the Atlanta classification. For each patient, different prognostic scores were calculated. Each score's accuracy for the prediction of a moderate-to-severe course was assessed by analysis of receiving-operating-characteristics (ROC) curves.

RESULTS

From 2012 ERCPs, 102 (5.1%) were complicated by PEP. From these, 34 (1.7% of all ERCPs) were classified as moderate-to-severe. The scores with the best accuracy in predicting a moderate-to-severe course were the BISAP [ area under curve (AUC) = 0.92], Balthazar (AUC = 0.89) and Glasgow-Imrie (AUC = 0.88) scores, with very good to excellent acuities. APACHE II (AUC = 0.81), Marshall score (AUC = 0.81) and PANC3 score (AUC = 0.76) revealed good accuracies. Ranson's criteria on admission (AUC = 0.70) and HAPS classification (AUC = 0.67) presented less accurate results. Optimal cutoffs for the top scoring classifications were BISAP ≥3 (sensitivity 88.3% and specificity 83.8%), Balthazar ≥2 (sensitivity 84.8% and specificity 85.3%) and Glasgow-Imrie ≥4 (sensitivity 81.0% and specificity 82.6%).

CONCLUSION

BISAP, Balthazar and Glasgow-Imrie classifications presented the best results for predicting moderate-to-severe PEP, and represent the most useful prognostic scores for risk stratification in this population.

Prevention and Management of Complications of Biliary Endoscopy

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.

The Landscape of Acute Pancreatitis Trials Registered in ClinicalTrials.gov: A Cross-sectional Study

OBJECTIVES

Clinical studies are important in informing evidence-based practice for patients with acute pancreatitis (AP). To determine whether registered studies adequately meet this need, we leveraged the ClinicalTrials.gov database to provide an overview of studies pertaining to AP.

METHODS

ClinicalTrials.gov was searched and the search term used was AP. Analysis was restricted to studies registered before January 12, 2021.

RESULTS

Of 363,632 trials overall, 234 (0.06%) were eventually included for analysis. Interventional studies and observational studies comprised 67.5% and 32.5% of these studies respectively. Most studies were initiated 2007 or later. Endoscopic retrograde cholangiopancreatography was the single most frequent cause of AP specified in these studies (16.7%). Nearly 72% of these studies had a sample size greater than 50. With respect to study design, 87.3% of interventional studies were randomized, 53.5% were blinded. The top 3 countries with the largest number of registered studies were China (n = 59), followed by the United States (n = 53) and India (n = 12).

CONCLUSIONS

Our results indicate that the research activity falls short of what is needed in terms of the burden of AP. The distribution of these AP-related studies by global regions indicates that there exists regional disparities.

Application of non-steroidal anti-inflammatory drugs in prevention of pancreatitis after endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most important methods for the clinical diagnosis and treatment of biliary and pancreatic diseases. Post-ERCP pancreatitis (PEP) is the most common complication. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in clinical prevention of PEP, but the application standards are not unified. This article reviews the progress in the research of the preventive effect of different types of NSAIDs on PEP, their administration routes, timing, and dosage, and combination with other drugs, as well as the preventive effect of NSAIDs in different risk stratification populations, and points out that indomethacin and diclofenac are the most commonly used types of NSAIDs, which should be given at 100 mg via rectal administration before ERCP in all non-selected patients with no contraindications.

Endoscopic Ultrasound-Guided Biliary Interventions in Liver Disease

If endoscopic retrograde cholangiopancreatography (ERCP) fails in cases of biliary obstruction and jaundice, percutaneous drains have been traditionally the current second-line option. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) with choledocoduodenostomy or hepaticogastrostomy is alternative modality that have shown equivalent or better technical and clinical success compared with percutaneous drainage. Similarly, EUS-guided gallbladder drainage has emerged as a therapeutic option in acute cholecystitis as well. Furthermore, EUS-BD avoids some of the pitfalls of percutaneous drainage. Current research in EUS-BD involves optimizing devices to improve technical and clinical success. In centers with advanced endoscopists trained in these procedures, EUS-BD is an excellent second-line modality.

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis

BACKGROUND AND AIMS

EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied.

METHODS

We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis.

RESULTS

LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

INTRODUCTION

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

AREAS COVERED

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

EXPERT OPINION

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

Endoscopic retrograde cholangiopancreatography-related adverse events in Korea: A nationwide assessment

Background

Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure‐related adverse events (AEs) is significant.

Objective

We conducted this nationwide cohort study since there have been few reports on the real‐world data regarding ERCP‐related AEs.

Methods

Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed.

Results

A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP‐related AEs was 4.7% consisting of post‐ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP‐related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP.

Conclusions

ERCP‐related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.

The Neutrophil-Lymphocyte Ratio as an Early Predictive Marker of the Severity of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background and objectives: Factors predictive of severe non-iatrogenic acute pancreatitis have been investigated, but few studies have evaluated prognostic markers of severe post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The neutrophil–lymphocyte ratio (NLR) has been studied for predicting severe acute pancreatitis. We examined the predictive value of NLR in patients with PEP. Materials and Methods: From January 2012 to August 2021, 125 patients who developed PEP were retrospectively evaluated. The NLR was measured before, and on days 1 and 2 after, ERCP. PEP was categorized as mild, moderate, or severe according to consensus guidelines, based on the prolongation of planned hospitalization. Patients were divided into two groups, mild-to-moderate vs. severe PEP. Results: We analyzed 125 patients with PEP, 18 (14.4%) of whom developed severe PEP. The baseline NLR was similar between the two groups (2.26 vs. 3.34, p = 0.499). The severe PEP group had a higher NLR than the mild/moderate PEP group on days 1 (11.19 vs. 6.58, p = 0.001) and 2 (15.68 vs. 5.32, p < 0.001) post-ERCP. The area under the curve of the NLR on days 1 and 2 post-ERCP for severe PEP was 0.75 (95% confidence interval (CI), 0.64–0.86)) and 0.89 (95% CI, 0.81–0.97), respectively; NLR on day 2 had greater power to predict severe PEP. The optimal cutoff value of the NLR on days 1 and 2 after ERCP for prediction of severe PEP was 7.38 (sensitivity, 72%; specificity, 69%) and 8.17 (sensitivity, 83%; specificity, 83%), respectively. In a multivariate analysis, a Bedside Index of Severity in Acute Pancreatitis score ≥3 (odds ratio (OR) 9.07, p = 0.012) and NLR on day 2 > 8.17 (OR 18.29, p < 0.001) were significantly associated with severe PEP. Conclusions: The NLR on day 2 post-ERCP is a reliable prognostic marker of severe PEP.

Adverse events associated with endoscopic retrograde cholangiopancreatography: protocol for a systematic review and meta-analysis

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is performed to diagnose and manage conditions of the biliary and pancreatic ducts. Though effective, it is associated with common adverse events (AEs). The purpose of this study is to systematically review ERCP AE rates and report up-to-date pooled estimates.

METHODS AND ANALYSIS

A comprehensive electronic search will be conducted of relevant medical databases through 10 November 2020. A study team of eight data abstracters will independently determine study eligibility, assess quality and abstract data in parallel, with any two concordant entries constituting agreement and with discrepancies resolved by consensus. The primary outcome will be the pooled incidence of post-ERCP pancreatitis, with secondary outcomes including post-ERCP bleeding, cholangitis, perforation, cholecystitis, death and unplanned healthcare encounters. Secondary outcomes will also include rates of specific and overall AEs within clinically relevant subgroups determined a priori. DerSimonian and Laird random effects models will be used to perform meta-analyses of these outcomes. Sources of heterogeneity will be explored via meta-regression. Subgroup analyses based on median dates of data collection across studies will be performed to determine whether AE rates have changed over time.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study as it is a planned meta-analysis of previously published data. Participant consent is similarly not required. Dissemination is planned via presentation at relevant conferences in addition to publication in peer-reviewed journals.PROSPERO registration numberCRD42020220221.

Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography in the diagnosis of autoimmune pancreatitis and IgG4-related sclerosing cholangitis

Endoscopic retrograde cholangiopancreatography is used to evaluate the narrowing of the main pancreatic duct in autoimmune pancreatitis (AIP) and biliary stricture in IgG4-related sclerosing cholangitis (IgG4-SC). Intraductal ultrasonography enables detailed visualization of the thickening of the bile duct wall in IgG4-SC. Pancreatic cancer, cholangiocarcinoma, and primary sclerosing cholangitis are important mimicking conditions of AIP and IgG4-SC. Diffuse or segmental stricture without marked upstream dilatation is a typical pancreatographic finding in AIP. By contrast, a single, short stricture with marked upstream dilatation is a typical finding in pancreatic cancer. The cholangiogram of IgG4-SC is classified into four types based on biliary stricture location, and this cholangiogram classification is useful for the differential diagnosis of IgG4-SC. Endoscopic retrograde cholangiography can be used to distinguish between IgG4-SC and primary sclerosing cholangitis. A segmental/long and intrapancreatic stricture is a characteristic finding of IgG4-SC, whereas band-like strictures, a beaded or pruned-tree appearance, and diverticulum-like outpouching are characteristic of primary sclerosing cholangitis. The characteristic intraductal ultrasonographic findings of circular-symmetrical wall thickening, smooth outer and inner margins, and homogeneous internal echo at the biliary stricture site are useful for diagnosis of IgG4-SC. Thickening of the bile duct wall at non-stricture sites is also a typical intraductal ultrasonographic finding of IgG4-SC and can be used for differential diagnosis from cholangiocarcinoma. Transpapillary bile duct and duodenal papilla biopsy during endoscopic retrograde cholangiopancreatography are also useful in the diagnosis of IgG4-SC.

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Updated Review of Current Preventive Strategies

Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography, with incidence rates as high as 16% in some centers. Recent studies have also shown an upward trend in hospitalization due to endoscopic retrograde cholangiopancreatography-related pancreatitis. Early interventions taken before, during, and after the procedure can significantly reduce the risk of pancreatitis and decrease morbidity and mortality of the patients. To select appropriate patients for endoscopic retrograde cholangiopancreatography, in-depth knowledge of the patient-related and procedure-related risk factors is required. This updated clinical review outlines various pharmacological agents and surgical methods used for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Current evidence supports the use of rectal non-steroidal anti-inflammatory drugs and pancreatic stent placement as an effective preventive strategy. Further research is needed to compare these preventive modalities to improve patient outcomes after endoscopic retrograde cholangiopancreatography.