Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) has become the main treatment modality for many pancreatobiliary disorders. There are limited prospective studies regarding safety of ERCP in cirrhotic patients. We evaluated the outcome of ERCP in a group of cirrhotic patients in comparison to non cirrhotic group.

Aims & Methods

the aim of the study was to investigate complications and success of ERCP in cirrhotic patients. In this prospective (cohort) comparative study, 54 cirrhotic patients undergoing therapeutic ERCP were compared to 65 non cirrhotics as control group. Basic patient pre endoscopic, interventional data and 30 days follow up data were collected and analysed.

Results

One hundred and nineteen consecutive patients were prospectively enrolled in this study. The most common indication for ERCP in both groups was choledocholithiasis. (70.4% in cirrhotics vs 53.8% in non cirrhotics). There was no significant difference in the frequency of overall complications between cirrhotics and noncirrhotics (11.1% vs 12.3 respectively, P=0.84). Incidence of individual complications in cirrhotics versus non cirrhotics were as follows :Post-ERCP pancreatitis (PEP) (0% vs 4.6%, P=0.250), bleeding (3.7 vs 3.1%, p=0.375), cholangitis (7.4% vs 3.1%, p=0.4) , perforation (0% vs 1.5%). All were non significant. Regarding 30 days mortality among our patients, it was higher in the cirrhotic group but did not reach the level of statistical significance (11.5% in cirrhotics versus 4.6% in non cirrhotics; P=0.18). Clinical success was insignificantly higher in the non cirrhotic group ( 87.7% vs 79.6%, p=0. 478). On multivariable analysis, the independent predictors of mortality among our patients were previous history of variceal bleeding, presence of splenomegaly and ascites and occurrence of post ERCP cholangitis. There was significant delay in improvement of serum bilirubin level in the cirrhotic group.

Conclusion

ERCP is considered safe and effective (as regard clinical success) in cirrhotic patients with results comparable to non cirrhotics, however advanced status of liver disease leads to delay in improvement of serum bilirubin in cirrhotic patients and this delay should not be considered as failure of ERCP procedure.

Introduction

Managing biliopancreatic disease in elderly patients is a growing challenge, where the balance between benefit and risk becomes increasingly delicate. ERCP remains a fundamental tool, but its application in older adults requires individualized technical and clinical considerations. The aim of our study was to evaluate the characteristics of elderly patients who underwent ERCP.

Aims & Methods

We conducted a retrospective descriptive study from January 2019 to January 2025, including all patients aged ≥65 years who underwent ERCP. Collected data encompassed demographic characteristics, clinical presentation, procedural indications, technical success, therapeutic approaches, and procedure-related complications.

Results

We recorded 186 patients : 62.36% women (n=116) and 37.6% men (n=70), with a median age of 75 years [IQR: 71–80]. The most frequent presenting symptoms were biliary colic (43.4%, n=79), acute cholangitis (23.6%, n=43), cholestatic jaundice (11.8%, n=22), and acute pancreatitis (10.8%, n=20).
ERCP was indicated for benign pathology in the majority of cases, primarily for choledocholithiasis (56.5%, n=104). Other benign etiologies (11%, n=12) included post-cholecystectomy syndrome, biliary pancreatitis, bile duct injury, and Sump syndrome.
Malignant indications included pancreatic head tumors (20.7%, n=38), hilar cholangiocarcinoma (7.1%, n=13), ampullary carcinoma (6.5%, n=12), and gallbladder carcinoma (3.8%, n=7).
The technical success rate for benign pathology was 97.4% (n=113), with a failure rate of 2.6% (n=3). In malignant indications, the success rate was 90% (n=63), with failures (10%, n=7) primarily due to duodenal obstruction or an intradiverticular papilla.
Stenting strategies included uncovered self-expandable metal stents (33.2%, n=43), covered metal stents (3.8%, n=7), and plastic stents (7.6%, n=14).
Intra-procedural bleeding following sphincterotomy occurred in 2.7% of cases (n=3); two were managed with epinephrine injection and one with hemostatic clipping. No delayed post-procedural complications were reported.

Conclusion

ERCP appears to be a safe, effective, and well-tolerated procedure in elderly patients. When guided by appropriate indications and expert technique, age does not represent a limitation but rather a parameter requiring adapted procedural planning.

Introduction

Periampullary diverticulum (PAD) is associated with a higher incidence of biliary stone formation and common bile duct (CBD) obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) is an effective therapeutic procedure in case of biliary obstruction, however; the presence of PAD and its different types could affect ERCP outcome [1-3].

Aims & Methods

Aim: To study the impact of periampullary diverticulum on the outcome of ERCP regarding the cannulation technique, the procedure time, the success rate and the complications.
Method: A Retrospective study included all patients subjected to ERCP procedures at Qena university hospitals, South Valley University, Qena, Egypt from February 2019 to August 2023. ERCP Will be performed under general anaesthesia with endotracheal intubation according to our centre policy by an expert ERCP endoscopist using Pentax duodenoscopy (ED-3490TK, Pentax Incorporation, Tokyo, Japan). Papilla of vater will be examined endoscopically before starting cannulation trials to evaluate presence of diverticulum, type, size and its relation to the papilla. Data were analyzed using Statistics Package for Social Sciences (SPSS) version 26, p-value < 0.05 was considered significant.

Results

A Total of 686 patients subjected to ERCP procedure for different indications were included in this study, males were 273 patients (39.8%), the mean age was 53.7±17 years, the overall procedure success rate was 91% and the overall complications rate was 6%. Almost all cannulation techniques were used in our cases including wire-guided cannulation (WGC), transpapillary fistulotomy (TPF), double-guidewire technique (DGT), transpapillary papillotomy (TPP), and transpancreatic septotomy with pancreatic stent insertion (TPS). PAD was detected during ERCP procedure in 61 patients (9%). There was statistically significant higher age (65.3 vs 52.6, p< 0.001) and statistically insignificant higher frequency of males (41% versus 39.7%, p₌ 0.8) in patients with PAD compared to patients without PAD. During ERCP procedures, presence of PAD was associated with higher number of cannulation attempts (3.5 versus 2.5, p< 0.005), longer time required for cannulation (8 vs 5.1 minutes, p< 0.01), and amazingly; higher rate of cannulation success (100% vs 98%, p₌ 0.2), and longer total procedure time (50.4 ± 21.9 minutes vs 47.01 ± 24.04, p₌ 0.2). There was no significant predilection of certain cannulation technique in PAD patients; higher WGC: 68% vs 67%, higher TPS (1.8% vs 0.5%), equal chance for WGC: 24.6% vs 24.6% and less chance for TPP: 0.7 vs 0%. The overall procedure success rate was lower in PAD patients (85.2% vs 91.2%, p₌ 0.1). Post-ERCP pain was noticed more frequently in PAD patients (4.9% vs 3.4%, p₌ 0.5) while the overall complication rate with lower (1.6% vs 6.4%, p₌ 0.1).

Conclusion

We concluded that PAD is increasingly detected during ERCP procedure in elderly patients, and despite it requires higher number of cannulation attempts and longer time for cannulation, it has no negative impact on the overall success rate or complication rate of ERCP.

References

1. Chen L, Xia L, Lu Y, Bie L, Gong B. Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol. 2017;29:105–11.
2. Banerjee AK, Celentano V, Khan J, Longcroft-Wheaton G, Quine A, Bhandari P. Practical gastrointestinal investigation of iron deficiency anaemia:i] Expert Rev Gastroenterol Hepatol. 2018;12(3):249-256.
3. Omar MA. Effect of periampullary diverticulum on technical success and complications of endoscopic retrograde cholangiopancreatography: Single center experience. J Dig Endosc. 2015;6:149–57

Introduction

Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for patients with acute cholecystitis at high risk of surgery/percutaneous drainage. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has a higher success rate than ETGBD but has a higher mortality rate as well. Therefore, the more appropriate procedure as emergent endoscopic drainage remains controversial.

Aims & Methods

This study aimed to evaluate the efficacy of endoscopic gallbladder drainage (EGBD); ETGBD and EUS-GBD for patients with technical failure of ETGBD in the same session.
Patients with moderate/severe acute cholecystitis at high risk of surgery who underwent ETGBD alone or EGBD were enrolled. In the EGBD group, patients underwent EUS-GBD after technical failure of ETGBD in the same session. The primary outcome was technical/clinical success rate and procedure-related adverse events by comparing ETGBD and EGBD.

Results

We enrolled 40 ETGBD and 41 EGBD patients. The overall technical success rate was significantly higher in the EGBD group than in the ETGBD group (97.6% vs. 82.5%, P=0.023). No significant difference was in clinical success rates and adverse event rates between both groups (P=0.858 and 0.665, respectively). The length of hospitalization was significantly shorter in the EGBD group (6.5 vs. 10.1 days, P<.001).

Conclusion

EGBD contributed to higher technical/clinical success rate, and shorter length of hospitalization, with similar incidence rate of adverse events, than ETGBD alone. Thus, this rescue strategy of ETGBD with EUS-GBD having a higher global success rate may be ideal for emergency endoscopic gallbladder drainage.

Introduction

Endoscopic removal of common bile duct stones (CBDS) via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. In developed countries, the number of ERCP procedures for CBDS in elderly patients is increasing with the aging population. Elderly patients often present with poor performance status (PS), are frequently on antithrombotic therapy, and have multiple comorbidities. These factors raise concerns about an increased risk of ERCP-related complications; however, the safety and efficacy of ERCP in this population have not been fully evaluated.

Aims & Methods

The aim of this study was to assess the outcomes of ERCP for CBDS in elderly patients. Among 548 patients with symptomatic CBDS treated at our institution between April 2017 and February 2024, we excluded 81 cases involving altered anatomy, use of endosonography-assisted rendezvous technique, spontaneous stone passage, and biliary pancreatitis. The remaining 467 patients undergoing ERCP at our institution were retrospectively analyzed. The patients were divided into an elderly group (E group: ≥75 years, n=241) and a younger group (Y group: <75 years, n=226), and short- and long-term outcomes were compared between the two groups.

Results

Patient Characteristics: The median age was 81 years (range: 75–99) in the E group and 68 years (range: 21–74) in the Y group. Male sex was less frequent in the E group (55% vs. 68%, p=0.006). The E group had significantly higher rates of antithrombotic use (39% vs. 24%, p=0.001), American Society of Anesthesiologists physical status ≥ III (57% vs. 35%, p=0.001), and concomitant cholangitis (52% vs. 41%, p=0.012). Median stone size was slightly larger in the E group (8 mm vs. 6 mm, p=0.14), and the median bile duct diameter was significantly wider (10 mm vs. 9 mm, p=0.001). Comorbidities were more prevalent in the E group: cardiovascular disease (34% vs. 22%, p=0.004), hypertension (52% vs. 39%, p=0.004), malignancy (33% vs. 18%, p=0.001), and dementia (11% vs. 2%, p=0.001). Although endoscopic sphincterotomy (EST) was the most common papillary intervention in both groups, endoscopic papillary large balloon dilation (EPLBD) was more frequently performed in the E group (31% vs. 10%).Lithotripsy rates were similar between groups (22% vs. 16%, p=0.2).
Outcomes: Complete stone removal was achieved in 96% of the E group and 98% of the Y group (p=0.2). The median number of treatment sessions was 1 in both groups (range: 1–3, p=0.13). Overall complication rates were comparable (8% vs. 7%, p=0.63). In the E group, complications included pancreatitis (n=15), bleeding (n=5), perforation (n=1), and aspiration pneumonia (n=1); in the Y group, pancreatitis (n=10) and bleeding (n=5) were observed. No procedure-related mortality occurred in either group. There was no significant difference in the cumulative recurrence rate of stones after complete removal (p=0.29). Multivariate analysis using variables such as age, sex, presence of cholangitis, bile duct diameter, lithotripsy, and gallbladder stones revealed no definite predictors of recurrence.

Conclusion

Although recent studies have reported the potential utility of long-term biliary stenting in elderly patients, stent occlusion leading to cholangitis remains a concern. Repeated hospitalizations in elderly patients can decrease activities of daily living. Therefore, we prioritize complete stone removal in patients with a favorable long-term prognosis. This study demonstrates that even in patients aged 75 years and older, active treatment of CBDS via ERCP might be effective and safe.