ERCP topics

Abstract

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) has evolved significantly during the last two decades. While endoscopic management of biliary obstruction was initially hailed as a breakthrough, ERCP has developed tremendously and now offers a number of therapeutic applications. Although many endoscopists have expanded their armamentarium to include complex and controversial areas such as the management of pancreatitis, fluid collections, and sphincter of Oddi dysfunction (SOD), serious complications continue to occur. Numerous abstracts presented at this year's Digestive Disease Week (DDW) meeting addressed new techniques, while others focused on improving procedure safety. Selected abstracts are reviewed here. Post-ERCP pancreatitis and other complicationsPrevention of postprocedural complications was the focus of several abstracts this year. ERCP-induced pancreatitis continues to be a relevant clinical problem, despite technical advances and better understanding of predisposing factors. Identifying preprocedural risk factors may allow better case selection, excluding the highest-risk patients. The Indiana group examined the relationship between the extent of pancreatic duct filling and frequency of pancreatitis in 14 487 ERCPs [1]. Patients were divided into four groups according to the extent of pancreatic duct opacification: Group 1 (n = 6890) had no attempted opacification of the pancreatic duct; group 2, opacification of the head only; group 3, opacification of the head and body; group 4, opacification to the tail. The post-ERCP pancreatitis rates in each group were 1.0 %, 3.5 %, 4.6 %, and 8.5 %, respectively. There was a significantly higher incidence of pancreatitis with increased opacification of the pancreatic ductal system (P < 0.001), suggesting that less filling of the pancreatic duct was associated with less post-ERCP pancreatitis. It follows, therefore, that preprocedure magnetic resonance pancreatography may allow less pancreatic duct filling at ERCP, improving the safety of the procedure. Cost-benefit analyses, however, will be necessary to determine whether this strategy is a real option.Precut sphincterotomy to gain access to the common bile duct has been associated with a high risk of pancreatitis. In contrast, needle-knife sphincterotomy over a pancreatic stent has been shown to be safer than conventional pull-type sphincterotomy without a stent in patients with SOD. There have been no prospective studies comparing outcomes between the two techniques. A report from Alabama [2] prospectively compared the post-ERCP pancreatitis rate among high-risk patients undergoing two different endoscopic pancreatic sphincterotomy (EPS) techniques. Forty-eight patients diagnosed with pancreatic sphincter hypertension were randomly assigned to undergo EPS using a needle-knife over a pancreatic stent (n = 24) or with a pull-type sphincterotome followed by pancreatic stent (n = 24). The post-ERCP pancreatitis rate was significantly higher among patients undergoing EPS using the pull-type sph...

Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

“…They reported an 83% success rate in the first session with a 7% rate of mechanical lithotripsy in 58 patients in whom endoscopic removal of bile duct stones using standard EST and balloon/ basket extraction had failed. Recently, multiple published series have shown that the overall first session success rates of stone removal with EBD following EST ranged from 80% to 100% [24,25,27,38] , and these success rates were similar to those of EST. Although some recent studies have reported that the stone clearance rate for the initial session of EBD following EST is high, the outcome for large stone removal by ELBD following EST remains controversial.…”

The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum

“…2,13 As previously reported, the risk of post-ERCP pancreatitis after difficult cannulation is increased compared with that after standard cannulation. 14,15 Possible explanations for this include excessive manipulation that result in mechanical trauma, edema of the pancreatic sphincter, and repeated contrast injections into the pancreatic duct.…”

Cholangioscopy-assisted extraction of choledocholithiasis and partial sediment-like gallstones through papillary support: A pilot exploration for super minimally invasive surgery

“…Endoscopic retrograde cholangiopancreatography (ERCP) has become a well-established technique for common bile duct (CBD) stones 1 2 . However, it has always been necessary to perform endoscopic sphincterotomy (EST) during ERCP, resulting in the loss of sphincter function and probable regurgitation.…”