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Introduction: Diagnosis of choledocholithiasis, a common manifestation of gallstone disease, is mainly based on advanced endoscopic techniques such as ERCP and EUS. Since the 1970s, ERCP has been a key method in the diagnosis and treatment of choledocholithiasis, allowing direct visualization and therapeutic interventions. However, technological developments have brought the emergence of EUS as a complementary tool, providing high-resolution imaging of the bile ducts. Understanding the diagnostic accuracy, therapeutic options and complications of both modalities is key to optimizing the care of patients with bile duct stones. Aim of the study: The aim of our study is to review and compare various diagnostic methods of bile duct stones, as well as to assess their effectiveness, accuracy, and potential complications. Materials and methods: Electronic sources, particularly PubMed and Google Scholar databases, were searched using keywords such as "endoscopic ultrasonography", "endoscopic retrograde cholangiopancreatography" and "choledocholithiasis". Conclusions: With the use of modern technologies, such as endoscopic ultrasonography (EUS) and retrograde choleangiopancreatography (ERCP), it has become possible to diagnose bile duct stones more accurately and introduce more effective and less invasive therapies. The development of the availability of diagnostic tests, especially those that do not require invasive procedures, has helped reduce the risk of complications. EUS may be the preferred tool of choice for patients with gallstones, as it is associated with a lower risk of complications compared to ERCP alone. Decisions regarding the use of specific diagnostic and therapeutic modalities should be made on a case-by-case basis, taking into account medical and economic considerations. [ABSTRACT FROM AUTHOR]

Selective cannulation during endoscopic retrograde cholangiopancreatography can be particularly challenging when the papilla is invisible, either due to an intradiverticular papilla (IDP) or because it is covered by a mucosal fold. Endoclipassisted cannulation is an effective and safe technique for everting and fixing the papilla and it can be used alone or in combination with other devices. In this report, we achieved successful papillary cannulation in two cases of IDP and one case where the papilla was covered by a mucosal fold. In two cases, cannulation was accomplished by repositioning the invisible papilla using an endoclip alone, while in one case, we used an endoclip-assisted technique to push a redundant fold with a catheter. Endoclipassisted papillary cannulation can be applied in different situations, either alone or in combination with other devices. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires abundant clinical experience and endoscopic skills, and can lead to various complications, some of which may progress to life-threatening conditions. With expanding indications and technological advancements, ERCP is widely utilized, enhancing procedural accessibility. However, without proper quality management, the procedure can pose significant risks. Quality management in ERCP is essential to ensure safe and successful procedures and meet societal demands for improved healthcare competitiveness. To address these concerns, the Korean Pancreatobiliary Association has developed a Korean-specific ERCP quality indicator reflecting domestic medical environments and realities. Initially, based on a review of foreign ERCP quality indicators and related literatures, key questions were formulated for five preprocedural items, three intra-procedural items, and four post-procedural items. Descriptions and recommendations for each item were selected through peer evaluation. The developed Korean-specific ERCP quality indicator was reviewed by external experts based on the latest evidence and consensus in this fields. This Korean-specific indicator is expected to significantly contribute to improving ERCP quality in Korea, as it is tailored to local needs. [ABSTRACT FROM AUTHOR]

Objective: The primary aim of this study was to investigate the guidance effect of the bispectral index (BIS) on the target plasma concentration (TPC) of propofol required for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP). Second, to identify propofol consumption, recovery time, and adverse events. Methods: A total of 42 consecutive patients with liver cirrhosis and 43 consecutive patients with healthy livers were enrolled. Propofol was administered via a target control infusion (TCI) syringe pump (Marsh Model) at BIS 60-70. Patients were not intubated, were placed in the prone position, and underwent spontaneous breathing. Propofol TPCs (µg mL-1) and BIS values were recorded at T0 (baseline), T1 (5 min after induction), T2 (5 min into ERCP), T3 (15 min), T4 (30 min), and T5 (recovery). Results: TPCs and propofol consumption were lower in patients with cirrhosis than in those without cirrhosis (T4: 2.7±0.5 vs. 3.3±0.4 µg mL-1), P=0.001, and 270.4±6.9 mg vs. 390.8±13.4 mg, P=0.001), respectively. Patients with cirrhosis required more time to recover (8.5±2 vs. 6.2±0.9 min, P=0.001), despite comparable ERCP durations (31.1±11.1 vs. 34±12.5 min, P=0.28). A significant decline in TPC values among patients with cirrhosis with time (T1: 3.3±0.3, T2: 3.1±0.3, T3: 2.9±0.4, T4: 2.7±0.5 µg mL-1, P=0.001), indicating a cumulative effect. One patient with cirrhosis required bag-mask ventilation, while three patients without cirrhosis were converted to general anaesthesia. Conclusion: Combining the TCI Marsh pharmacokinetic model with BIS monitoring lowered the TPC levels required for deep sedation in patients with cirrhosis compared with healthy patients and allowed for individual variations. The prone position in deeply sedated and non-intubated spontaneous breathing patients is not without the risk of hypoxia. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The primary aim of this study was to investigate the guidance effect of the bispectral index (BIS) on the target plasma concentration (TPC) of propofol required for deep sedation during endoscopic retrograde cholangiopancreatography (ERCP). Second, to identify propofol consumption, recovery time, and adverse events. Methods: A total of 42 consecutive patients with liver cirrhosis and 43 consecutive patients with healthy livers were enrolled. Propofol was administered via a target control infusion (TCI) syringe pump (Marsh Model) at BIS 60-70. Patients were not intubated, were placed in the prone position, and underwent spontaneous breathing. Propofol TPCs (µg mL-1) and BIS values were recorded at T0 (baseline), T1 (5 min after induction), T2 (5 min into ERCP), T3 (15 min), T4 (30 min), and T5 (recovery). Results: TPCs and propofol consumption were lower in patients with cirrhosis than in those without cirrhosis (T4: 2.7±0.5 vs. 3.3±0.4 µg mL-1), P=0.001, and 270.4±6.9 mg vs. 390.8±13.4 mg, P=0.001), respectively. Patients with cirrhosis required more time to recover (8.5±2 vs. 6.2±0.9 min, P=0.001), despite comparable ERCP durations (31.1±11.1 vs. 34±12.5 min, P=0.28). A significant decline in TPC values among patients with cirrhosis with time (T1: 3.3±0.3, T2: 3.1±0.3, T3: 2.9±0.4, T4: 2.7±0.5 µg mL-1, P=0.001), indicating a cumulative effect. One patient with cirrhosis required bag-mask ventilation, while three patients without cirrhosis were converted to general anaesthesia. Conclusion: Combining the TCI Marsh pharmacokinetic model with BIS monitoring lowered the TPC levels required for deep sedation in patients with cirrhosis compared with healthy patients and allowed for individual variations. The prone position in deeply sedated and non-intubated spontaneous breathing patients is not without the risk of hypoxia.

Congenital anomalies of the biliary tree are rare and present challenges for endoscopists performing interventions such as endoscopic retrograde cholangiopancreatography (ERCP). The reported incidence of ectopic biliary drainage ranges from 2% to 20%, and the condition is often associated with pancreatobiliary complications, including choledocholithiasis (56%), cholangitis (39%), and acute pancreatitis (18.2%). These developmental abnormalities originate during embryogenesis. Uncommon sites for the ampullary opening include the third or fourth part of the duodenum, the stomach, and the pancreatic duct. We report a rare case of ectopic ampulla opening into the pylorus, which presented with cholangitis and was successfully managed with a modified ERCP technique.

Background : : Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic method that is used for the diagnosis and treatment of pancreaticobiliary diseases. ERCP may have to be performed two or more times, which carries a risk of complications and even death. Various risk factors influence the likelihood of ERCP recurrence.Methods : : A retrospective study was conducted at Pauls Stradins Clinical University Hospital. Fifty patients with a history of repeat ERCP were enrolled. The total ERCP count was 122. The total death rate, 30-day postprocedural mortality, laboratory markers, and primary diagnosis were analyzed, and the therapeutic interventions used during ERCP, common bile duct’s diameter, and causes of repeat ERCP were evaluated.Results : : The postprocedural 30-day mortality of repeat ERCP was 3.3%, and the overall death rate was 8%. We found a significant difference between the number of repeat ERCPs and exitus letalis (mean = 2.25 vs. mean = 1.37). The most common primary diagnosis for repeat ERCP was choledocholithiasis (64%; n = 32). We found a significant relationship between choledocholithiasis and history of cholecystectomy (P < 0.001) and obesity (P < 0.001). The rate of successful cannulation for ERCP reached 88.5%, with a significant difference between the success of cannulation and bilirubin level (205.64 ± 234.42 μmol/L vs. 58.71 ± 97.65 μmol/L, P = 0.037). The results showed a significant relationship between the success of cannulation and the presence of jaundice (P = 0.014) and periampullary diverticulum (P = 0.017).Conclusion : : A greater number of repeated ERCPs carries a higher risk of overall death outcome. The disturbances in laboratory markers (decreased hemoglobin; elevated leucocytes, bilirubin, creatinine, alkaline phosphatase, C-reactive protein) could be a risk factor for negative 30-day postprocedural outcome. The risk factors for repeating ERCP include adiposity, history of cholecystectomy, bilirubin level, jaundice, and periampullary diverticulum.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea.

Background/Objectives: Endoscopic papillectomy (EP) is the preferred treatment for ampullary tumors because it has fewer side effects than surgical removal. This study retrospectively compared a new anchoring EP method (A-EP) with the conventional (C-EP) approach. Methods: Ninety-nine patients who underwent EP at a single medical institution between 2009 and 2021 were retrospectively reviewed. In all patients, the indications for EP were pathological adenoma with <10 mm of biliary invasion and a tumor diameter <30 mm on endoscopic ultrasonography. The exclusion criteria were antiplatelet/anticoagulant use, previous upper GI surgery, or prior biliary/pancreatic endoscopic therapy. One expert endoscopist performed the two types of EPs, A-EP and C-EP. Results: Sixty-two patients underwent A-EP, and 37 underwent C-EP. There were no significant differences in baseline characteristics, such as sex, age, tumor size, and ductal invasion on endoscopic ultrasound. The A-EP group had higher en bloc resection rates (95.2% vs. 78.4%, p = 0.010). Although the difference was not statistically significant, it tended towards fewer incidences of pancreatitis (p = 0.081) and duct stricture (p = 0.081). The recurrence rate was lower in the A-EP group (8.1% vs. 37.8%, p = 0.000). There were no significant differences between the two groups regarding the follow-up period (A-EP vs. C-EP, 725 vs. 1045 days, p = 0.109) or the days of recurrence (A-EP vs. C-EP, 341 vs. 562 days, p = 0.551). Conclusions: A-EP showed better outcomes than C-EP in terms of en bloc resection and recurrence rates, providing evidence for the efficacy of this novel EP method. [ABSTRACT FROM AUTHOR]

Background and aims: Endoscopic multiple plastic stents are an established first-line treatment for anastomotic biliary stricture (ABS) management after liver transplantation (LT). Fully covered self-expandable metallic stents (FCSEMSs) have recently been used with favorable outcomes, but long-term treatment outcomes remain an issue for ABS. We evaluated the long-term outcomes of FCSEMS for the management of refractory ABS after LT. Methods: We reviewed the prospectively collected and maintained endoscopic retrograde cholangiography database at Asan Medical Center to retrieve consecutive post-LT ABS cases that underwent an endoscopic FCSEMS placement between August 2009 and August 2019 after MPS placement failure. Results: A total of 34 patients were enrolled in this study. Technical success had been achieved in all subjects (100%). The median stent placement duration was 3.1 months (IQR 2.7–6.1). Stricture resolution was achieved in 26 patients (clinical success 76.5%, 95% confidence interval 62–91). Early adverse events developed in 3 patients (8.8%), including distal stent migration. Late adverse events occurred in 9 patients (26.5%), including cholangitis (n = 7, 20.6%) and asymptomatic distal stent migration (n = 2, 5.9%). The median follow-up period was 57.9 months (IQR 51.9–64.3). Stricture recurrence occurred in 3 of 26 patients who achieved clinical success (11.5%). Conclusions: FCSEMS placement appears to be an effective and advisable intervention for refractory ABS as it can provide persistent stricture improvement over the long-term. [ABSTRACT FROM AUTHOR]

A 65-year-old woman was diagnosed with an 8 cm large common bile duct stone and multiple stones in both intrahepatic ducts because of abnormal liver function tests. After a multidisciplinary approach, surgical removal was considered, and primary closure after laparoscopic removal of the common bile duct stone was performed. The patient recovered without complications and was discharged on the fourth postoperative day. Endoscopic removal of common bile duct stones is the standard treatment, but surgical removal through laparoscopic common bile duct exploration is also a safe and effective treatment method for such huge gallstones.

Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved multidrug-resistant micro-organisms (MDROs), outbreaks involving non-MDROs are also likely to occur. Detection challenges arise as these infections often resolve before culture or because causative strains are not retained for comparison with duodenoscope strains. To identify and analyse DAIs spanning a seven-year period in a tertiary care medical centre. This was a retrospective observational study. Duodenoscope cultures positive for gastrointestinal flora between March 2015 and September 2022 were paired with duodenoscope usage data to identify patients exposed to contaminated duodenoscopes. Analysis encompassed patients treated after a positive duodenoscope culture and those treated within the interval from a negative to a positive culture. Patient identification numbers were cross-referenced with a clinical culture database to identify patients developing infections with matching micro-organisms within one year of their procedure. A 'pair' was established upon a species-level match between duodenoscope and patient cultures. Pairs were further analysed via antibiogram comparison, and by whole-genome sequencing (WGS) to determine genetic relatedness. Sixty-eight pairs were identified; of these, 21 exhibited matching antibiograms which underwent WGS, uncovering two genetically closely related pairs categorized as DAIs. Infection onset occurred up to two months post procedure. Both causative agents were non-MDROs. This study provides crucial insights into DAIs caused by non-MDROs and it highlights the challenge of DAI recognition in daily practice. Importantly, the delayed manifestation of the described DAIs suggests a current underestimation of DAI risk. [ABSTRACT FROM AUTHOR]

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To determine the effectiveness of the different pharmacological agents in preventing post-ERCP acute pancreatitis We included clinical trials of pharmacological interventions for prophylaxis of acute post-ERCP pancreatitis. The event evaluated was acute pancreatitis. We conducted a search strategy in MEDLINE (OVID), EMBASE, and Cochrane Central Register of Controlled Trials from inception to nowadays. We reported the information in terms of relative risks (RR) with a 95% confidence interval. We assessed the heterogeneity using the I2 test. We included 84 studies for analysis (30,463 patients). The mean age was 59.3 years (SD ± 7.01). Heterogeneity between studies was low (I2 = 34.4%) with no inconsistencies (p = 0.2567). Post ERCP pancreatitis was less in prophylaxis with NSAIDs (RR 0.65 95% CI [0.52 to 0.80]), aggressive hydration with Lactate Ringer (RR 0.32 95% CI [0.12–0.86]), NSAIDs + isosorbide dinitrate (RR 0.28 95% CI [0.11–0.71]) and somatostatin and analogues (RR 0.54 [0.43 to 0.68]) compared with placebo. NSAIDs, the Combination of NSAIDs + isosorbide dinitrate, somatostatin and analogues, and aggressive hydration with lactate ringer are pharmacological strategies that can prevent post-ERCP pancreatitis when compared to placebo. More clinical trials are required to determine the effectiveness of these drugs. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course. Background: Endoscopic biliary stent implantation is a recognized and effective method for the treatment of benign and malignant diseases of the bile duct and pancreas, ensuring smooth bile drainage. Currently, stent migration is considered a long-term and complex process, and in most cases, stents are removed through endoscopy or expelled from the body through the intestinal cavity. In rare cases, stents lead to formation of duodenocolic fistulas. Case Report: We report a case of duodenal colon fistula caused by a biliary stent penetrating the duodenum and entering the ascending colon. We removed the stent through endoscopy and clamped the fistulas of the colon and duodenum separately with titanium clips. Due to the presence of large common bile duct stones, nasobiliary drainage was performed again. Later, laparoscopic choledocholithotomy was performed, and the patient was discharged after rehabilitation. Conclusions: ERCP endoscopy must consider the possibility of stent displacement in patients with biliary stents. In the case of CBD biliary stent dislocation in the patient, continuous abdominal plain films and physical examinations are required until spontaneous discharge is confirmed. In addition, for patients with benign bile duct stenosis undergoing biliary drainage, doctors should urge them to return to the hospital on time to remove the stent. For patients with postoperative abdominal pain or peritonitis symptoms, abdominal CT scan confirmation is required and early intervention should be considered. [ABSTRACT FROM AUTHOR]

A prediction system for common bile duct (CBD) stones was originally published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and was last revised in 2019. We wanted to investigate its application in an Asian population, who have different etiologies of bile duct stone formation and accessibility to medical service compared to the West. This is a single center retrospective study. Patients who received endoscopic ultrasound (EUS) for suspected CBD stones were collected from our endoscopic record system over a 10-year period. The accuracy of the revised ASGE criteria was estimated according to the results of EUS. A minimum follow-up of 6 months was required to detect false negative results. 142 patients were enrolled, 87 (61%) patients had CBD stones. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the revised ASGE criteria for high-risk patients were 69%, 38%, 64%, 44%, and 57%. 36% of the ASGE-defined high-risk patients negative for CBD stones on EUS. The two significant predictors for CBD stone were CBD dilatation (adjusted OR 3.06, 95% C.I. 1.31–7.17, p = 0.010) and ascending cholangitis (adjusted OR 2.28, 95% C.I. 1.01–5.15, p = 0.047). ASGE recommends that patients defined as high-risk for choledocholithiasis be considered for direct ERCP without prior need for confirmation imaging. However, our findings indicate a high rate (36%) of patients in that group negative for CBD stones on EUS. Hence, EUS is still be suggested first in selective high-risk patients so that diagnostic ERCP can be avoided in our Asian society. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS: Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS: This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS: Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p

BackgroundCurrent guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy.MethodsThe Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions.ResultsA total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death.ConclusionIndex admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21–43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83–34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45–33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11–0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01–0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP. [ABSTRACT FROM AUTHOR]

Objective To investigate the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) combined with electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system in the treatment of difficult choledocholithiasis. Methods A retrospective analysis was performed for the clinical data of 12 patients with difficult choledocholithiasis who underwent ERCP and electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system in Department of Gastroenterology, Jilin People’s Hospital, from May to November 2022. The clinical effect of lithotripsy and lithotomy was observed, and postoperative complications and time of surgical operation were assessed. Results Among the 12 patients, 11 (91.67%) were successfully treated by electrohydraulic lithotripsy under direct view, 9 (75.00%) achieved firstattempt success in lithotripsy, and 11 (91.67%) had complete removal of calculi；1 patient was found to have stenosis of the bile ducts caused by multiple biliary tract surgeries, and grade Ⅱ intrahepatic bile duct stones above the sites of stenosis were removed under direct view, but there were still residues of grade Ⅲ intrahepatic bile duct stones, which led to the fact that complete calculus removal was not achieved. The mean time of ERCP operation was 91.3±26.2 minutes, including a time of 41.8±22.2 minutes for energy lithotripsy. There were 2 cases of postoperative biliary tract infection which were improved after anti-infective therapy, 2 cases of hyperamylasemia which were not given special treatment, and 3 cases of mild pancreatitis which were improved after symptomatic medication, and there were no complications such as bleeding and perforation. Conclusion ERCP combined with electrohydraulic lithotripsy under the direct view of eyeMax biliary-pancreatic imaging system is safe, effective, and feasible in the treatment of difficult choledocholithiasis. [ABSTRACT FROM AUTHOR]

Objective To investigate the efficacy and safety of endoscopic retrograde cholangiopancreatography （ERCP） during pregnancy and puerperium through a comparative analysis. Methods A retrospective analysis was performed for the clinical data of 22 patients in pregnancy and 39 patients in puerperium who received ERCP in Digestive Endoscopy Center of The First Affiliated Hospital of Nanchang University from January 2007 to August 2022. The two groups of patients were compared in terms of baseline data, diagnosis during ERCP, interventions, laboratory results before and after ERCP, post- ERCP complications, and delivery and fetal outcomes. The independent-samples t test was used for comparison of continuous data between two groups, and the chi-square test or the Fisher’s exact test was used for comparison of categorical data between two groups. Results There were no significant differences between the patients in pregnancy and those in puerperium in all baseline data （all P>0.05） except the rate of CT examination （22.73% vs 58.97%，χ² =7.44，P=0.006）. During the ERCP procedure， compared with the patients in puerperium， the patients in pregnancy had a significantly lower proportion of the patients who underwent biliary stone extraction or endoscopic papillary balloon dilation （χ² =4.007 and 4.315， both P<0.05） and a significantly higher proportion of the patients who did not receive X-ray fluoroscopy （χ² =12.103， P=0.001）. After ERCP, both groups had significant improvements in white blood cell count， total bilirubin， direct bilirubin， alanine aminotransferase, and aspartate aminotransferase （all P<0.05）. The overall incidence rate of post-ERCP complications was 7.04% （5/71） for all patients, with post-ERCP biliary infection as the most common complication （3/71，4.23%）and there was no significant difference in the incidence rate of post-ERCP complications between the two groups （P>0.05）. As for delivery and fetal outcomes, compared with the patients in puerperium, the patients in pregnancy had a significantly higher proportion of patients with early termination of pregnancy （50.00% vs 0，χ² =20.528，P<0.001） and a significantly lower proportion of patients with cesarean section （36.36% vs 76.92%，χ² =4.756，P=0.029）. There were no significant differences in the incidence rates of adverse events such as abnormal fetal development and stillbirth between the two groups （P>0.05）. Conclusion With strict control of ERCP indications and timing， ERCP is effective and relatively safe in both pregnancy and puerperium and has a comparable incidence rate of post-ERCP complications to that in the general population, with relatively good delivery and fetal outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) is widely used for the pathological diagnosis of solid pancreatic lesions but in cases with obstructive jaundice, transpapillary sampling can be performed during endoscopic retrograde cholangiopancreatography with transpapillary biliary stent placement. Thus, it is still controversial whether EUS‐FNA should be performed prior to endoscopic retrograde cholangiopancreatography with biliary stent placement or only after negative transpapillary sampling. Methods The accuracy, sensitivity, and specificity of EUS‐FNA for solid pancreatic lesions with or without indwelling biliary stents were retrospectively studied in patients undergoing EUS‐FNA between January 2017 and December 2021. We also conducted a meta‐analysis including our data to compare the accuracy and sensitivity of EUS‐FNA with or without biliary stents. Results A total of 509 patients (40 with biliary stents and 469 without biliary stents) were included. The accuracy (77.5% vs. 94.5%, p < 0.001) and sensitivity (71.0% vs. 91.7%, p < 0.001) were lower in EUS‐FNA with biliary stents. A meta‐analysis confirmed that accuracy (odds ratio [OR] of 0.43, 95% confidence interval [CI] 0.29–0.62, p < 0.001) and sensitivity (OR of 0.46, 95% CI 0.33–0.64, p < 0.001) were lower in EUS‐FNA with biliary stents. There were no statistically significant differences between plastic stents and self‐expandable metallic stents for accuracy or sensitivity. Conclusions The presence of biliary stents had a negative impact on the diagnostic performance of EUS‐FNA, and EUS‐FNA prior to endoscopic retrograde cholangiopancreatography with biliary stent placement should be considered in cases with obstructive jaundice.

Treatment of malignant pancreatic and/or biliary strictures requires tissue diagnosis. Since cytologic brushings at endoscopic retrograde cholangiopancreatography (ERCP) of these strictures has a poor sensitivity for malignancy (30-83%) (see ME Ryan. Gastrointestinal Endoscopy 1991;37(2):139-143; and MB Cohen, Wittchow RJ, Johlin FC, et al. Mod Pathol 1995;8:498-502), tissue diagnosis must be obtained by another route. We report our experience of percutaneous biopsy of malignant pancreatic and/or biliary strictures even when no radiographic mass is present.At ERCP, five patients demonstrated pancreatic and/or biliary duct strictures, had atypical cytological brushings, and had their strictures stented. No mass to account for the strictures could be identified on CT. These five patients underwent percutaneous biopsy of the persistent material by CT within 10 days of the ERCP.Two patients had adenocarcinoma of the pancreas. One patient had malignant lymphoma and another had cholangiocarcinoma. One patient had inflammatory cells and was followed.If the diagnosis of malignancy cannot be made at the time of the ERCP sampling, then our experience suggests that a percutaneous biopsy should be performed even if a mass is not present using the stent as a target.

In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline "very strong" predictors, ultrasound with stone had the strongest performance. Of the "strong" predictors, CBD > 6 mm demonstrated the strongest performance. "Moderate" predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors.

Abstract Background and objective For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal. Methods The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared. Results A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P

Background and aimsNoninvasive predictors of choledocholithiasis have generally exhibited marginal performance characteristics. We aimed to identify noninvasive independent predictors of endoscopic retrograde cholangiopancreatography (ERCP)-confirmed choledocholithiasis and accordingly developed predictive machine learning models (MLMs).MethodsClinical data of consecutive patients undergoing first-ever ERCP for suspected choledocholithiasis from 2015-2019 were abstracted from a prospectively-maintained database. Multiple logistic regression was used to identify predictors of ERCP-confirmed choledocholithiasis. MLMs were then trained to predict ERCP-confirmed choledocholithiasis using pre-ERCP ultrasound (US) imaging only and separately using all available noninvasive imaging (US/CT/magnetic resonance cholangiopancreatography). The diagnostic performance of American Society for Gastrointestinal Endoscopy (ASGE) "high-likelihood" criteria was compared to MLMs.ResultsWe identified 270 patients (mean age 46 years, 62.2% female, 73.7% Hispanic/Latino, 59% with noninvasive imaging positive for choledocholithiasis) with native papilla who underwent ERCP for suspected choledocholithiasis, of whom 230 (85.2%) were found to have ERCP-confirmed choledocholithiasis. Logistic regression identified choledocholithiasis on noninvasive imaging (odds ratio (OR) = 3.045, P = 0.004) and common bile duct (CBD) diameter on noninvasive imaging (OR=1.157, P = 0.011) as predictors of ERCP-confirmed choledocholithiasis. Among the various MLMs trained, the random forest-based MLM performed best; sensitivity was 61.4% and 77.3% and specificity was 100% and 75.0%, using US-only and using all available imaging, respectively. ASGE high-likelihood criteria demonstrated sensitivity of 90.9% and specificity of 25.0%; using cut-points achieving this specificity, MLMs achieved sensitivity up to 97.7%.ConclusionsMLMs using age, sex, race, presence of diabetes, fever, body mass index (BMI), total bilirubin, maximum CBD diameter, and choledocholithiasis on pre-ERCP noninvasive imaging predict ERCP-confirmed choledocholithiasis with good sensitivity and specificity and outperform the ASGE criteria for patients with suspected choledocholithiasis.

Background/Aims: There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Methods: Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. Results: A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of ID-RFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Conclusions: Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Background : : Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP). While ERCP maintains a success rate of 90% to 95% in patients with native anatomy, the data are less robust for patients with post-pancreaticoduodenectomy (PD) anatomy. We conducted a retrospective analysis of the technical success (TS) and clinical success (CS) rates of ERCP in post-PD patients. In addition, we describe our experience using novel rigidizing overtubes to facilitate post-PD ERCP. Methods : : Patients with PD referred to our institution between 2006 and 2021 for ERCP were included. Major outcomes included the TS rate (successful biliary intervention) and the CS rate (improvement in patient symptomatology with or without normalization of bilirubin levels). Results : : In total, 47 patients underwent 102 ERCPs for biliary (n = 98) and pancreatic (n = 4) indications. The overall TS and CS rates were 82.4% and 75.5%, respectively. Rigidizing overtubes were utilized in 5 patients who underwent 11 ERCPs, with TS and CS rates of 90.9% and 90.9%, respectively. The overall adverse event rate was 4.9%, with no adverse events noted in cases with rigidizing overtubes. Conclusion : : Despite the challenges in ERCP in patients with surgically altered anatomy, this retrospective analysis demonstrates a moderately high TS rate with minimal adverse events. A rigidizing overtube may be utilized to improve TS and CS in patients with post-surgical anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for management of pancreatobiliary diseases; however, post-ERCP pancreatitis (PEP) remains as an unsolved problem. Although various risk factors for PEP have been reported, the prediction of PEP remains controversial. This study aimed to develop a predictive model for PEP. Consecutive patients undergoing ERCP for biliary indications at two centers were retrospectively studied. Using data from a training cohort, we utilized a multivariable model to select five variables to construct a nomogram. The predictive model was internally and externally validated. Based on the nomogram, the patients were categorized into low-, moderate-, and high-risk groups. Using the data of 2224 patients in the training cohort, five variables were selected to generate a nomogram: 1) sex, 2) indication for ERCP, 3) difficult cannulation, 4) guidewire insertion into the pancreatic duct, and 5) endoscopic sphincterotomy or sphincteroplasty. The most significant risk factor was endoscopic papillary balloon dilation such as endoscopic sphincterotomy or sphincteroplasty. The bias-corrected concordance index was 0.72 in the training cohort and 0.72 in the validation cohort. Calibration curves for both cohorts demonstrated good agreement between the predicted and observed frequencies of the actual outcome. In the validation cohort, PEP developed in 5.0% and 14% of patients in the moderate- and high-risk groups, respectively. We successfully developed a good predictive model for PEP. The prevention of PEP in high risk patients should be investigated further. [ABSTRACT FROM AUTHOR]

Objective: Rare disease Background: Profound transaminitis (>1000 international units per liter [IU/L]) is typically associated with ischemic and viral or toxic hepatitis. Pancreaticobiliary causes are less likely to be included in the workup, especially in patients who have undergone cholecystectomy. We present a case of recurrent choledocholithiasis in a 52-year-old woman 7 years after cholecystectomy, presenting with severe transaminitis, illustrating the diagnostic challenges of this presentation. Case Report: A 52-year-old woman presented to the Emergency Department (ED) with acute upper abdominal pain. Computed tomography (CT) of the abdomen without contrast showed no abnormalities and mild common bile duct (CBD) dilation was noted on ultrasound (US) abdomen. Laboratory studies were significant for elevated transaminases greater than 1000 units/L and alkaline phosphatase (ALP) greater than 200 units/L. She was diagnosed with acute hepatitis of unknown etiology without undergoing further investigation of the biliary tract and was discharged after improvement with supportive therapy. She returned 4 months later with similar symptoms and laboratory findings, but with more CBD dilation and intrahepatic biliary dilation on CT and US. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and multiple stones and sludge were removed from the CBD. Conclusions: This report has shown that pancreaticobiliary causes should be included in the workup of severe transaminitis, even in patients with a remote history of cholecystectomy. Failure to do so may subject patients to extensive, unnecessary workup and delay correct management. [ABSTRACT FROM AUTHOR]

Background and objective: For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal. Methods: The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared. Results: A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214). Conclusion: For high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal. [ABSTRACT FROM AUTHOR]

Although hemorrhage after endoscopic retrograde cholangiopancreatography (ERCP) is mostly mild and self- limited, sometimes blood transfusion and endoscopic hemostasis are still needed. However, rebleeding may occur after conventional endoscopic hemostasis and thus requires interventional vascular embolization or surgical intervention, which might significantly increase the risk of death associated with post-ERCP bleeding. This article discusses the risk factors for post-ERCP bleeding, including disease-specific factors, patient-related factors, and operation-related factors, and elaborates on different measures for the prevention and treatment of post-ERCP bleeding, so as to provide a reference for identifying the high-risk population for bleeding and developing precise surgical strategies in clinical practice. [ABSTRACT FROM AUTHOR]

Objective To investigate the predictive value of dynamic changes in serum prealbumin (PAB) in the treatment of malignant obstructive jaundice (MOJ) with the first endoscopic retrograde cholangiopancreatography (ERCP) biliary stenting. Methods The clinical data of 119 patients with MOJ who were relieved by ERCP stenting for the first time were retrospectively analyzed. Patients were divided into the survival group and the death group according to whether their survival period was greater than 1 year. The liver function indexes of patients before and 7 days after surgery were collected, and the dynamic change rate of PAB (7 d after surgery/preoperative) was calculated. The receiver operating characteristic (ROC) curve was used to determine the best cut-off value of the dynamic change rate of PAB. Patients were divided into two groups according to the cut-off value. The survival curves of the two groups were plotted by K-M method, and risk factors affecting the long-term survival prognosis of patients were analyzed by the Cox proportional hazard model. Results The 1- year survival rate of 119 patients was 45.4% (54/119) and the case fatality rate was 54.6% (65/119). The dynamic rate of PAB was 1.1 (0.9, 1.4) in the survival group, and 0.9 (0.7, 1.0) in the death group, which was significantly higher in the survival group than that in the death group (P＜0.05). ROC analysis showed that the area under the ROC curve was 0.799 （95% CI：0.704-0.895）and the optimal cut-off value of PAB dynamic rate was 1.008, and the survival analysis showed that the one-year survival rate of the group with high PAB dynamic rate was significantly higher than that in the group with low PAB dynamic rate (P＜0.01). Multivariate analysis showed that low dynamic rate of PAB was an independent risk factor for long-term survival of patients with MOJ after ERCP. Conclusion The dynamic rate of PAB can be used as a potential prognostic indicator for MOJ patients. [ABSTRACT FROM AUTHOR]

In conventional endoscopic retrograde cholangiopancreatography (ERCP), the patient lies prone or in a semi-prone position under deep sedation and maintains spontaneous ventilation. Sedative-induced respiratory depression and unprotected airway compromise patients' safety. The gastro-laryngeal tube (G-LT) is a novel reusable supraglottic airway device with two separate ports for endoscopy and ventilation. This study attempts to evaluate the performance characteristic of G-LT. One hundred and forty patients undergoing ERCP were enrolled and randomized. In Group G, patients underwent ERCP with G-LT, whereas Group S patients underwent ERCP conventionally. G-LT insertion attempts, esophageal visualization times, vital parameters, propofol consumption, endoscopists' and anesthesiologists' satisfaction scores, time to achieve Modified Aldrete Score of ≥ 9, and complications were recorded. Both groups showed similar demographic parameters and 100% procedure completion rates. G-LT group showed shortened esophageal visualization times (4.71 ± 1.687 s vs 7.37 ± 1.515 s) and increased propofol consumption (423.14 ± 106.982 mg vs 178.00 ± 100.125 mg). Group G showed better endoscopic maneuvrability and lesser hemodynamic variability. Sore throat, dysphagia, and mucosal trauma were higher in the G-LT group. G-LT provides less intra-procedural hemodynamic changes, quicker esophageal visualization, and better scope maneuvrability at the cost of higher propofol consumption, sore throat, dysphagia, and mucosal trauma. Clinical Trial Registry of India CTRI/2021/06/034212 (Registered on: 14/06/2021) [ABSTRACT FROM AUTHOR]

Background: The presentation of the patient with acute cholangitis (AC) ranges from mild illness to life‐threatening shock. Therefore, prompt diagnosis and treatment are critical. Abdominal ultrasound (US) is the imaging of choice to locate bile duct dilatation. Other modalities include abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP). Objectives: To determine whether sonographic common bile duct dilatation in emergency department (ED) patients with AC predicts outcomes including sepsis, hospital length of stay (LOS), admission to the intensive care unit (ICU), time to ERCP, and mortality. Methods: Electronic medical records of all patients hospitalized in a tertiary care medical center between July 2012–February 2021 with a discharge diagnosis of cholangitis were assessed. Patients were dichotomously classified as CBD dilated or CBD non‐dilated based on ultrasound. Dilation was defined as CBD larger than 6 mm in patients younger than 60 or larger than 6 mm + 1 mm per decade in patients over 60. Results: The study included 271 patients‐ 172 with CBD dilation versus 99 without. Mean LOS was 9.92 days for those with a dilated CBD versus 13.4 days without. The mean time to ERCP was 4.26 days for those with a dilated CBD versus 6.56 days without. Sepsis, mortality, and ICU admission were scarce and there was no statistically significant difference between the cohorts. Conclusion: Patients with a dilated CBD per the abdominal US performed during the patient's ED stay, underwent ERCP earlier, and were hospitalized fewer days than patients without CBD dilation. [ABSTRACT FROM AUTHOR]

Background : : Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of therapeutic endoscopy. The aim of this trial was to determine whether a combination of rectal diclofenac and vigorous hydration with Ringer's lactate is superior to the corresponding individual treatments for preventing PEP in high-risk patients. Methods : : This randomized, open-label, controlled trial was conducted from August 2020 to January 2022. We included patients who were at high risk of developing PEP. Three intervention groups were made: group A, diclofenac sodium suppository (100 mg); group B, aggressive hydration with Ringer's lactate; group C, a combination of diclofenac and aggressive hydration. PEP was defined as a serum amylase level > 3 times the upper limit of normal with epigastric pain within 24 hours after endoscopic retrograde cholangiopancreatography. Results : : A total of 144 patients were included and 48 cases were randomized to each intervention group. The incidence of PEP was 8.3%, 10.4%, and 8.3% in groups A, B, and C, respectively. A personal history of alcohol consumption and more than one pancreatic duct guidewire cannulation were significantly associated with the development of PEP. Conclusion : : No difference in the incidence of PEP was observed with or without the use of aggressive hydration. Combining aggressive hydration with a rectal nonsteroidal anti-inflammatory drug for preventing PEP cannot be recommended.

Chronic pancreatitis (CP) is a chronic, progressive, inflammatory disease of the pancreas. Pancreatolithiasis is a complication of CP. In this case report, we present a patient with a giant solitary pancreatic stone that necessitated surgery. A 34-year-old patient with CP presented to our outpatient clinic with abdominal pain. Computed tomography revealed near-total atrophy of the pancreatic parenchyma and an 85-mm-long stone within the main pancreatic duct. Due to abdominal pain refractory to medical treatment and the long-term malignancy risk in the near-totally atrophic pancreas, the decision was made to perform surgery based on a multidisciplinary team meeting. Total pancreatectomy was carried out and a 30 × 85 mm pancreatic stone filling the main pancreatic duct was found in the specimen. Intractable pain, local complications of adjacent organs, and suspicion of a malignant lesion are indications for surgery in patients with CP. A case-based clinical approach is necessary for the management of pancreatic stones.

Objective To investigate the clinical application value of modified 7Fr pancreatic duct plastic stent in biliary drainage. Methods Clinical data were collected from 121 patients with choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) lithotomy and biliary drainage in Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, from April 2021 to June 2022, and according to the method for postoperative biliary drainage, they were divided into modified stent group with 59 patients and nasobiliary drainage group with 60 patients. The patients in the modified stent group received drainage with the modified 7Fr pancreatic duct plastic stent, and those in the nasobiliary drainage group received nasobiliary drainage. A retrospective analysis was performed for their clinical data, and stent dislodgement was observed for the modified stent group. The two groups were compared in terms of clinical outcome, postoperative comfort, and postoperative complications. The independent-samples t test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the chi-square test was used for comparison of categorical data between groups. Results Both groups achieved a stone clearance rate of 100%. There were significant differences between the two groups in the length of postoperative hospital stay and the total length of hospital stay (t = -3.997 and 2.317, both P ＜0.05). After treatment, both groups had significant reductions in total bilirubin (TBil), direct bilirubin (DBil), indirect bilirubin (IBil), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (all P ＜0.05), and there were no significant differences between the two groups in the changes in TBil, DBil, IBil, ALP, alanine aminotransferase, and AST after treatment (all P ＞0.05). Also, no significant differences were observed between the two groups in the changes in biochemical parameters after treatment (all P ＞0.05). There were significant differences between the two groups in comfort score within 24 hours after surgery and the time to first eating and drinking after surgery (t = 2.001, 3.579, and 4.604, all P ＜0.05). There were no significant differences in complications between the two groups (all P ＞0.05). In the modified stent group, the rate of spontaneous stent dislodgement was 83.05%, and there were no complications such as stent occlusion, displacement, rupture, perforation, and infection. Conclusion After complete bile duct stone removal by ERCP, biliary drainage using the modified 7Fr pancreatic duct plastic stent has a similar effect to nasobiliary drainage and can shorten the length of postoperative hospital stay, improve postoperative comfort, and accelerate postoperative recovery, with a relatively high spontaneous dislodgement rate. Therefore, it is safe and effective in clinical practice. [ABSTRACT FROM AUTHOR]

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established. To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients. Swedish nationwide multi-registry study. The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020. Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P =.005) by on average 31 minutes, 95% confidence interval (CI) [10.3–52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P =.010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P =.006) and for larger stones >8 mm in size (25% versus 8%, P <.001). LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones. • Laparoscopic transcystic common bile duct exploration (LTCBDE) and transgastric endoscopic retrograde cholangiogram (ERC) are both safe procedures with low adverse event rates. • Transgastric ERC was more often used in the acute setting and for larger stones. • The LTCBDE procedure was on average half an hour faster. [ABSTRACT FROM AUTHOR]

Hemobilia is an uncommon diagnosis and is often not suspected in the absence of recent hepatobiliary intervention or trauma. Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome is a rare occurrence. We report the case of a 61-year-old male who presented with epigastric pain and vomiting. Blood tests demonstrated hyperbilirubinemia with elevated inflammatory markers. Magnetic resonance cholangiopancreatography revealed type I Mirizzi syndrome in the presence of a 21 mm cystic duct stone. During endoscopic retrograde cholangiopancreatography, hemobilia was identified. Subsequent triple phase computed tomography imaging identified a 12 mm cystic artery pseudoaneurysm. Angiography with successful coiling of the cystic artery was accomplished. Cholecystectomy was performed, confirming type I Mirizzi syndrome. This case demonstrates the importance of considering ruptured pseudoaneurysm in patients presenting with evidence of upper gastrointestinal bleeding in the setting of biliary stone disease. Transarterial embolization, followed by surgical management, is effective in both the diagnosis and management of ruptured cystic artery pseudoaneurysm with associated hemobilia. [ABSTRACT FROM AUTHOR]

Biliary intraductal papillary mucinous neoplasm (IPMN) is a rare biliary neoplasia preferably treated with oncologic resection. Endoscopic radio frequency (RF) ablation may be used as a palliative measure. We present a rare case, where heavy co-morbidities prevented surgery. Continuous mucus production caused recurrent episodes of severe cholangitis. Several ERCPs (endoscopic retrograde cholangio pancretography) were necessary due to recurrent biliary obstruction. RF ablation was not effective in the dilated common bile duct without a stricture. Standard biliary stents failed due to either migration or occlusion. When other options failed, an exceptional decision was made: a covered large diameter oesophageal stent was inserted in ERCP into the bile duct to secure bile flow and stop mucus production. Digital cholangioscopy was crucial adjunct to standard ERCP in endoscopic management. The palliative treatment method was successful: there were no stent-related adverse events or readmissions for cholangitis. The follow-up in the palliative care lasted until patient's last 10 months of lifetime. [ABSTRACT FROM AUTHOR]

Pediatric trauma patients are increasing, and trauma is the leading cause of death in children. Pancreatic injury is known as the fourth most common solid organ injury, but the diagnosis of pancreatic injury is often delayed due to the retroperitoneal location of the pancreas and the low sensitivity and specificity of diagnostic tests. Endoscopic retrograde cholangiopancreatography (ERCP) is an important test for the diagnosis and treatment of various biliary tract and pancreatic diseases. However, cases of performing ERCP in traumatic pancreatic injury in children have been rarely reported. Thus, we aimed to evaluate the usefulness of ERCP in traumatic pancreatic injury in children. Between January 1983 and December 2022, pediatric patients under the age of 18 who were treated for traumatic pancreatic injury at a single institution were recruited and retrospectively analyzed. Patient characteristics and clinical outcomes were assessed. Thirty-one patients were enrolled in this study. Among them, 15 (48.4%) patients underwent ERCP. The time to diet was significantly longer in the ERCP group. There were no statistically significant differences in other characteristics between the ERCP and the non-ERCP group. In nine (60%) patients of the ERCP group, ERCP was used for therapeutic intervention or as a decision-making tool for surgery, and was used to resolve pancreas-related complications. ERCP may be useful for the diagnosis and treatment of traumatic pancreatic injury in children. In addition, ERCP can be safely applied in children, and complications related to ERCP also may not increase. When obscure pancreatic injury is suspected, it is necessary to consider performing ERCP. [ABSTRACT FROM AUTHOR]

ObjectiveThe aim of the study was to determine whether clinical characteristics and management of pediatric acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) differ across INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In Search for a cuRE) sites.Study designData were collected from INSPPIRE and analyzed per US regions and "non-US" sites. Between-group differences were compared by Pearson chi-square test. Differences in disease burden were compared by Kruskal-Wallis test.ResultsOut of the 479 subjects, 121 (25%) were enrolled in West, 151 (32%) Midwest, 45 Northeast (9%), 78 (16%) South, and 84 (18%) at non-US sites. Hispanic ethnicity was more common in South (P

The guidewire is an essential accessory in ERCP. Although rare, guidewires can cause complications, such as subcapsular hepatic hematoma, perforation, knotting, fracture, and impaction, during ERCP. This report describes a guidewire impaction during the endoscopic treatment of a patient with symptomatic chronic pancreatitis. The methods used to treat guidewire impaction are not well known. In the present case, the impacted guidewire was retrieved by inserting another guidewire and dilating the space adjacent to it. Endoscopists should check for the free movement of the guidewire before stent deployment. Additionally, it is important to ask for help from experienced senior staff to overcome any challenges during the procedure. In conclusion, endoscopists should be aware of the possibility of a guidewire impaction during ERCP.

Fluoroscopy is used frequently during endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP). However, exposure to radiation is an important health concern, primarily because of the potential increase in the lifetime risk of malignancy. This consideration is important for patients and staff exposed to radiation during ERCP. Thus, an understanding of how radiation doses are measured during ERCP and the potential risks of this radiation is important. Additionally, staff must be educated about methods used to minimize the radiation dose, such as the use of different imaging techniques, the general principles of fluoroscopy, and advances in hardware and software. The use of personal protective equipment is also essential to minimize occupational exposure. However, no comprehensive ERCP guideline on the use of X-ray systems in clinical settings or on radiation protection for operators has been established. This review focuses on the properties of fluoroscopy systems and methods of radiation protection for physicians and assistants participating in ERCP.

ERCP is the standard treatment for common bile duct stones (CBD stones). On the other hand, in approximately 10% of patients with CBD stones, the complete removal of the stones cannot be achieved by conventional ERCP, which performs endoscopic sphincterotomy followed by stone extraction. Additional advanced and complex procedures are often necessary to remove these “difficult bile duct stones”, including endoscopic papillary large balloon dilatation or mechanical lithotripsy. Advances in cholangioscopy have made electrohydraulic or laser lithotripsy under direct endoscopic visualization possible during ERCP. Cholangioscopy-guided lithotripsy using the SpyGlass DS system could be a better treatment tool for removing difficult stones. The focus of this review was to describe single-operator cholangioscopy in the management of difficult CBD stones.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive endoscopic technique that has many diagnostic and therapeutic implications. It is a procedure with small but significant life-threatening complications. To ensure the best possible care, minimize complications, and improve the quality of health care, a constant review of the performance of the operator using ideal benchmark standards is needed. Hence, quality indicators are necessary. The American and European Societies of Gastrointestinal Endoscopy have provided guidelines on quality measures for ERCP, which describe the skills to be developed and training to be implemented in performing quality ERCP. These guidelines have divided the indicators into pre-procedure, intraprocedural, and post-procedure measures. The focus of this article was to review the quality indicators of ERCP. [ABSTRACT FROM AUTHOR]