ERCP in the Very Elderly: Outcomes Among Patients Older than Eighty

Life expectancy is rising, which is increasing the demand for endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Little data, particularly on complex procedures, has been reported. In this study, we compare the differences in the success and complications in ERCP between patients older and younger than 80 years old. We used a large endoscopic database reviewing the ERCPs performed and 30-day complications addressing age, degree of difficulty of procedures, and complications. A total of 2,606 patients underwent 3,924 ERCPs. Six hundred and twenty-eight were octogenarians undergoing 728 procedures. Mean age was 83.5 years in the octogenarian group and 59.0 years in the younger group. The endoscopic success rate was lower in octogenarians (96.9 vs. 98.3%, P = 0.004). Overall, complication rates between both groups was significantly less in older compared to younger patients (1.64 vs. 3.50%, P = 0.006). Complication and failure rates were higher as procedure complexity increased in all patients. ERCP in the elderly carries a high degree of success with low complication rates. Elderly patients carry similar risks of bleeding and perforation and a lower risk of pancreatitis.     

Endoscopic retrograde cholangiopancreatography in infants and children.

BACKGROUND: Although many reports describe the use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in children, few mention therapeutic application of this technique in pediatric patients with pancreatic or biliary disease. METHODS: We report our 4-year experience of 80 ERCPs performed in 59 children for obstructive jaundice or cholestasis with dilatation of the biliary tree (32 children), biliary atresia (11), recurrent pancreatitis (8), and blunt trauma to the abdomen (8). RESULTS: The patients' ages ranged from 5 weeks to 18 years. The appropriate duct was cannulated in 94% of cases. Common bile duct sphincterotomy was performed in 35 patients and pancreatic duct sphincterotomy in one. Multiple procedures were done in 16 patients where biliary stents were inserted; in one patient with chronic pancreatitis and pancreaticolithiasis, pancreatic stent was inserted. Four patients developed mild pancreatitis, one had moderate pancreatitis and one had leak of contrast, which was treated by administration of clear fluids orally for one day. One patient with benign stenosis of the hepatic duct developed cholangitis after migration of the stent into the bowel lumen. CONCLUSION: Diagnostic and therapeutic ERCP can be done as safely and effectively in pediatric patients as in adults.     

Preoperative ERCP has no impact on islet yield following total pancreatectomy and islet autotransplantation (TPIAT): Results from the Prospective Observational Study of TPIAT (POST) cohort

Background and aimsMany patients undergoing total pancreatectomy with islet autotransplant (TPIAT) for severe, refractory chronic pancreatitis or recurrent acute pancreatitis have a history of endoscopic retrograde cholangiopancreatography (ERCP). Using data from the multicenter POST (Prospective Observational Study of TPIAT) cohort, we aimed to determine clinical characteristics associated with ERCP and the effect of ERCP on islet yield.MethodsUsing data from 230 participants (11 centers), demographics, pancreatitis history, and imaging features were tested for association with ERCP procedures. Logistic and linear regression were used to assess association of islet yield measures with having any pre-operative ERCPs and with the number of ERCPs, adjusting for confounders.Results175 (76%) underwent ERCPs [median number of ERCPs (IQR) 2 (1-4). ERCP was more common in those with obstructed pancreatic duct (p = 0.0009), pancreas divisum (p = 0.0009), prior pancreatic surgery (p = 0.005), and longer disease duration (p = 0.004). A greater number of ERCPs was associated with disease duration (p < 0.0001), obstructed pancreatic duct (p = 0.006), and prior pancreatic surgery (p = 0.006) and increased risk for positive islet culture (p < 0.0001). Mean total IEQ/kg with vs. without prior ERCP were 4145 (95% CI 3621-4669) vs. 3476 (95% CI 2521-4431) respectively (p = 0.23). Adjusting for confounders, islet yield was not significantly associated with prior ERCP, number of ERCPs, biliary or pancreatic sphincterotomy or stent placement.ConclusionsERCP did not appear to adversely impact islet yield. When indicated, ERCP need not be withheld to optimize islet yield but the risk-benefit ratio of ERCP should be considered given its potential harms, including risk for excessive delay in TPIAT.     

ERCP in orthotopic liver transplanted patients

BACKGROUND/AIMS: Biliary complications after orthotopic liver transplantation (OLT) are still common. The aim of the study was to assess the effectiveness of ERCP as a diagnostic and treatment tool in the management of biliary tract OLT complications. METHODOLOGY: The diagnostic and treatment effectiveness of ERCP in the management of biliary tract OLT complication from 1/1995 to 12/2001 was reviewed. RESULTS: 24/251 (9.6%) OLT patients presented biliary complications. These patients underwent a total of 31 ERCP (seven patients received two ERCP). The ERCP indication was cholestasis in 25 (80.6%). The success rate of these 31 ERCPs was 87%. In the 25 ERCPs indicated in patients with cholestasis, the procedure revealed strictures of the biliary anastomosis in 3, hepatic hilum strictures in 5, SOD in 4, lithiasis in 7 and sclerosing cholangitis in one. The final diagnosis of three patients with normal biliary tract was intrahepatic cholestasis. In three of the four patients with biliary leaks the ERCP's confirmed the diagnosis. The final treatment efficacy was 100% (7/7 patients), 50% (2/4 p.), 0% (0/3 p.), 75% (3/4 p.) and 100% (4/4 p.) for patients with biliary stones, strictures of the hilum, anastomotic strictures, biliary leaks and SOD, respectively. In the acute pancreatitis and in the PSC endoscopic treatment was not indicated. There were two mild cases of pancreatitis. CONCLUSIONS: Because of its availability, diagnostic accuracy, treatment efficacy and safety, ERCP should be used as the first-line procedure for treatment of biliary tract complications after OLT.     

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.RESULTS: From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%).CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.     

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP) has been widely used in pediatric patients with cholangiopancreatic diseases.AIM To evaluate the efficacy, safety, and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction(PBM).METHODS A multicenter, retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019. They were divided into four PBM groups based on the fluoroscopy in ERCP. Their clinical characteristics, specific ERCP procedures, adverse events, and long-term follow-up results were retrospectively reviewed.RESULTS Totally, 112 ERCPs were performed on the 75 children with symptomatic PBM.Clinical manifestations included abdominal pain(62/75, 82.7%), vomiting(35/75,46.7%), acholic stool(4/75, 5.3%), fever(3/75, 4.0%), acute pancreatitis(47/75,62.7%), hyperbilirubinemia(13/75, 17.3%), and elevated liver enzymes(22/75,29.3%). ERCP interventions included endoscopic sphincterotomy, endoscopic retrograde biliary or pancreatic drainage, stone extraction, etc. Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis(9/75, 12.0%), gastrointestinal bleeding(1/75, 1.3%), and infection(2/75, 2.7%).During a mean follow-up period of 46 mo(range: 2 to 134 mo), ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis. The overall effective rate of ERCP therapy was 82.4%; seven patients(9.3%) were lost to follow-up, eight(11.8%) re-experienced pancreatitis, and eleven(16.2%)underwent radical surgery, known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy.CONCLUSION ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM, with the characteristics of minor trauma, fewer complications, and repeatability.     

Endoscopic retrograde cholangiopancreatography in the elderly: a prospective and comparative study

OBJECTIVE: In this study we aimed to compare the utility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly and younger groups of people. METHODS: The study involved 299 patients who underwent ERCP for the first time between March 2002 and January 2003. Group A consisted of 202 patients who were 69 years of age or younger and group B involved 97 patients who were 70 years of age or older. The patients were prospectively identified and data were gathered on them prospectively. Clinical and biochemical features, ERCP procedures, ERCP diagnosis, complications and length of hospital stay were compared between the two groups. RESULTS: Group B patients presented with more specific symptoms compared with group A. Laboratory findings were similar in both groups other than mean bilirubin levels, which were higher in the elderly group. Selective biliary cannulation was technically successful in 99% of both groups. Pre-cut papillotomy was performed in 49.5% of group A patients and 56.7% of group B patients. Choledocholithiasis was the most frequent diagnosis in both groups. Benign biliary stenosis was more frequent in group A and malignant biliary stenosis in group B. Among the malignant aetiologies, pancreatic carcinoma was the most common cancer in both groups. Post-procedural complications developed in 27 (9%) patients. There were 16 (7.9%) complications (six bleeding, five pancreatitis, three perforation and two cholangitis) in the 202 patients aged under 70 years. In comparison, 11 (11.3%) of the 97 patients aged over 70 years developed a complication (bleeding in six, pancreatitis in one, perforation in one, cholangitis in two and ileus in one). Twelve (nine group A and three group B) patients died within 5-30 days of the procedure. Length of hospital stay was comparable for both groups (15.53+/-12.43 days in group A and 14.84+/-11.56 days in group B). CONCLUSIONS: Diagnostic and therapeutic ERCP has similar outcomes in both elderly and younger patients. ERCP is effective and safe in elderly patients with naive papilla. The more invasive procedures like pre-cut papillotomy may be performed safely in the elderly.     

Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older

GOALS: To review our experience of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years and older. BACKGROUND: ERCP is effective in the investigation and treatment of biliary disease; however, in the very elderly, a perception of high procedural risk and lack of efficacy may limit its use. STUDY: Retrospective analysis of ERCPs performed on patients 90 years of age and older from one institution. RESULTS: Between 1987-2000, 23 ERCPs were performed on patients 90 years of age and more (16 women; age range, 90-96 years). The primary indications were obstructive jaundice (16 patients), pancreatitis (2), cholangitis (1), unexplained abdominal pain (1), and planned follow-up (3). The main endoscopic findings were common bile duct (CBD) stone (15 patients), pancreatic carcinoma (2), cholangiocarcinoma (2), and dilated duct (only 1). Sixteen sphincterotomies were performed, with successful common duct clearance in 10 patients. Seven biliary stents were inserted for benign disease and three, for malignancy. In two patients, CBD cannulation was unsuccessful. Three minor hemorrhages were controlled endoscopically. Three patients died of nonprocedural causes. CONCLUSIONS: ERCP is safe and effective in the very elderly. The decision to undergo ERCP should be determined by clinical need.     

Complications of endoscopic retrograde cholangiopancreatography. A study in a small ERCP unit.

BACKGROUNDS AND AIM: endoscopic retrograde cholangiopancreatography (ERCP) is an established procedure to drain the biliary and pancreatic ducts. Nevertheless, there are complications which seem to be more common in centers performing less than 200 ERCPs per year. Sometimes, however, due to the distribution of health resources, it is necessary to perform this technique in centers with a smaller number of procedures. We present the experience of ERCP-related complications in a small unit. MATERIAL AND METHODS: this is a retrospective study on prospective data recorded during six years (1997-2002). In this period, two endoscopists working together performed 507 ERCPs, which yields an approximately average of 84 procedures per year. RESULTS: in 507 ERCPs performed during this period of time, 55 complications arose (10.85%), and four patients died (0.79%) as a consequence of the procedure. There were 28 pancreatitis (5.5%), eight post-sphincterotomy bleeding events (1.6%), seven bilioduodenal perforations (1.4%), eight sepsis episodes of biliary origin (1.6%), and other 4 different complications. There were 418 (82.4%) successful ERCPs--either diagnostic or therapeutic--,which gave rise to 46 (11%) complications. There were 89 (17.6%) failed diagnostic or therapeutic ERCPs, which gave rise to 9 (10.11%) complications (p = 0.8 between both groups). Thirty five (7%) ERCPs were exclusively diagnostic and caused 6 (17%) complications. The 187 procedures performed for choledocholithiasis originated 14 (7.4%) complications, and represented the group with the lowest morbidity rate (p = 0.04). CONCLUSIONS: the complications rate in our center is within the range of reported figures. ERCPs performed for choledocholithiasis was associated with the lowest complications rate. The risk-benefit ratio in the anticipated, purely diagnostic ERCP must be carefully weighed due to its morbidity.     

Risk factors for complications after performance of ERCP

BACKGROUND: ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS: Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS: Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS: The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.     

Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy

BACKGROUND: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. METHODS: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. RESULTS: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. CONCLUSION: When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.     

Improved stent characteristics for prophylaxis of post-ERCP pancreatitis.

BACKGROUND & AIMS: Pancreatic stenting is an effective method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. METHODS: A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3-4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10-14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. RESULTS: The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3-4F stents compared with 80% with 5-6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). CONCLUSIONS: Small diameter (3-4F), unflanged pancreatic stents are more effective than the traditionally used stents (5-6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3-4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.     

Relapses of biliary acute pancreatitis in patients with previous attack of biliary pancreatitis and gallbladder in situ

AIM: To evaluate relapse of acute pancreatitis in patients with biliary pancreatitis in whom coexisting diseases or patient refusal have excluded cholecystectomy. PATIENTS AND METHODS: Forty-seven patients presenting a first episode of biliary acute pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). RESULTS: ERCP with ES was successful in all but one patient (97.8%) who was then cholecystectomised. Complications related to the endoscopic procedure were reported in five patients (10.6%). During the follow-up period (median time 12 months; range 1-84 months), 10 patients (21%) suffered from biliary complications. Three patients (6.4%), all with lithiasis of the gallbladder, had relapses of acute pancreatitis, two of them within 2 months of the previous episode, and one about a year later after ingestion of a rich meal and alcoholic beverages. The first two were cholecystectomised. Two patients died during the follow-up period from unrelated diseases. CONCLUSIONS: In subjects who are at high risk for anaesthesia, endoscopic procedures may be utilised.     

Comparison of Performance and Safety of Endoscopic Retrograde Cholangiopancreatography Across Pediatric Age Groups

Background and Study Aim

Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be overall effective and safe in children, but its performance characteristics and safety profile have not been specifically evaluated according to age. We aim to compare the indications, findings, interventions, and safety outcomes of ERCP across pediatric age groups.

Methods

A retrospective cross-sectional study of pediatric patients (ages 17 or below) who underwent ERCP between October 1998 and April 2011 at a tertiary-care academic center. Data on indications, findings, technical success, and adverse events of ERCP were collected and compared according to age groups (0–6, 7–12, or 13–17 years).

Results

There were 289 procedures performed in 154 children (mean age, 11.5 years). The number of patients undergoing ERCP increased with age; teenagers constituted the largest group (52.6 %) and had the most procedures (49.8 %). Children aged 0–6 years had an equal distribution of biliary and pancreatic cases; children aged 7–12 years had predominantly pancreatic indications. Most procedures in teenagers were for biliary indications. Overall, the technical success rates of ERCPs were similar across age groups (P = 0.661). Seventeen adverse events (5.9 % of procedures) were identified: post-procedure pancreatitis (12 cases; 4.2 %), hypoxia (3; 1.0 %), and hemorrhage (2; 0.7 %). The youngest group had more adverse events (12.0 %, compared to 6.3 and 2.1 % in other groups; P = 0.049), mostly due to mild pancreatitis.

Conclusion

ERCP is generally safe in the pediatric population, although the risk of mild post-procedure pancreatitis may be higher among the youngest children.     

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

BACKGROUND: EUS may be used to reduce the need of diagnostic ERCP. OBJECTIVE: Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. DESIGN: A randomized study. SETTING: A university medical unit. PATIENTS: Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. INTERVENTIONS: In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. MAIN OUTCOME MEASUREMENTS: The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. RESULTS: Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. CONCLUSIONS: In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.     

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study

BACKGROUND: Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers. METHODS: Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria. RESULTS: Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic. CONCLUSIONS: Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.     

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.     

Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

OBJECTIVES: Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study. METHODS: One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists. RESULTS: Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (< or = 60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater. CONCLUSIONS: The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.     

Endoscopic retrograde cholangio-pancreatography in pancreatitis with persistent or recurrent pain

We have reviewed the endoscopic retrograde cholangiopancreatograms (ERCPs) of 115 patients already known to have pancreatitis, who were referred because of persistent or recurrent pain, in order to determine the prevalence of those lesions that have been regarded as amenable to conservative surgery. Such lesions were seen on the pancreatograms of 35 patients and on the cholangiograms of 29 patients. In all, 53 patients (46.1%) had 'treatable' lesions demonstrated at ERCP. Preoperative ERCP is helpful in demonstrating operable features in both pancreatic and biliary systems, and should be part of any prospective long-term study of pain relief in pancreatitis.     

诊断与治疗性逆行胰胆管造影并发胰腺炎危险因素分析

目的：探讨诊断性胰、胆管显影与胆道支架、乳头括约肌切开取石术等治疗抗逆行胰、胆管造影（ERCP）,对术后并发胰腺炎的影响。方法：412例ERCP操作分为7组,诊断性ERCP为胆胰双管显影（ERCP）组、单纯胆管显影（ERC）组组与单纯管显影（ERP）组,治疗组ERCP分为双管显影加支架术（ERCP＋支架）组、ERC＋支架组、ERCP＋乳头肌切开（EST）取石组及ERC＋EST取石组,比较各组术后4h、24h血清淀粉酶及临床症状改变。结果：术后4h、24h高淀粉酶血症发生率为17．7％及4．4％,并发急性胰腺炎的发生率为3．95,各组中以ERP组发病率为最高。结论：在ERCP操作中,反复胰管造影是并发术后胰腺炎主要危险因素,EST、支架治疗并不增加胰腺炎的发病率。