Introduction

Radiation exposure to patients and staff is unavoidable during endoscopic retrograde cholangiopancreatography (ERCP). International and contemporary Diagnostic Reference Levels (DRL, 75^th centile) range from a Dose Area Product (DAP) of 3-40 Gy.cm², and fluoroscopy time (FT) over 3 minutes per ERCP¹. Effective doses for patients and high-volume practitioners can approach acceptable annual safety limits.
Our group reports a baseline DAP DRL of 2.81 Gy.cm² from 1857 ERCP over 5 years, the lowest reported for a large series. Dose determinants include fluoroscopy settings, patient/C-arm positioning and patterns of fluoroscopy use². Along the lines of the ALARA principle, we evaluated the implementation of a protocol to optimize these factors. Our study is the first to standardize a language for ERCP fluoroscopy between endoscopist and radiographer.

Aims & Methods

Along the lines of the ALARA principle, we evaluated the implementation of a protocol to optimize these determinant factors. Our study is the first to standardize a language for ERCP fluoroscopy between endoscopist and radiographer.
Endoscopists and radiographers developed a protocol from their collective best practices. Radiographers applied the lowest dose and frame rate settings. Patient positioning was optimized relative to the C-arm. Endoscopists were asked to minimize low-yield images and preference intermittent fluoroscopy. Commands were standardized to streamline communication between endoscopists and radiographers. The protocol was implemented using verbal and written cues in the ERCP suite.
The primary outcome was the effect of the protocol on Air Kerma, DAP and FT compared to the baseline, pre-intervention cohort. The same mobile under-couch C-arm was used, and comparisons were made between the amongst the same core group of surgeon-endoscopists.

Results

The protocol was implemented over 10 months over 274 successful ERCPs.
There was a 75% reduction in median Air Kerma (5.27mGy to 1.33mGy, p<0.0001) and DAP (1.35 Gy.cm² to 0.33 Gy.cm², p<0.0001). The DAP DRL we report is the world’s lowest, at 0.79 Gy.cm². Median FT improved by 41% (42s to 24s, p<0.0001); the FT DRL under protocol conditions was 38s. Sizeable reductions in dose were seen in the upper quartile of cases.
Multivariate analysis of the pre-intervention group identified sphincteroplasty, malignancy and certain endoscopists negatively influence DAP and FT (p<0.001). Use of our protocol minimized the effects of these variables on radiation doses at multiple linear regression.
Temporal analysis showed that the protocol was effective from first implementation, but there were ongoing improvements in reducing the radiation used in the more complex, higher-dose cases.

Conclusion

We demonstrate that a protocol to modify the endoscopist and radiographer behavior is easy to adopt, and results in sizeable percentage improvements from an already low-dose baseline. Thus, we describe the lowest reported doses at ERCP. Such a protocol can be applied to any ERCP environment to achieve similar dose improvement, which will reduce the radiation-risks for patients and staff.

References

1. Hayashi S., et al., Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography. World J Clin Cases. 2018 Dec 26;6(16):1087-1093.
2. Dumonceau, J.M., et al., Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) guideline. Endoscopy, 2012. 44(4): p. 408-21.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased technical difficulty and can potentially contribute to prolonged procedural duration and excess exposure to ionizing radiation.

Aims & Methods

The purpose of the present study was to present descriptive information about fluoroscopy during ERCP from a large reference center and to investigate possible determinants of the radiation dose or fluoroscopy duration during ERCP. We examined a prospectively collected single-center database of adult patients undergoing ERCP between 09/2021 and 12/2023 in a tertiary greek public hospital. Detailed information concerning patient, endoscopist and procedural parameters including ERCP indication, degree of difficulty of ERCP (defined using the Schutz score), types of interventions and fluoroscopy were recorded retrospectively. Non parametric statistical methods were used (Mann–Whitney U-test and Kruskal–Wallis test) for the analysis.

Results

In total, data of 1051 ERCPs were collected at first, while 1028 ERCPs with complete information for fluoroscopy duration and radiation dose were included (mean patient age 72.20 ±14.02years, 49.1% men) in the analysis. The mean procedure time was 34.22 ± 14.9 minutes, carried out by three different endoscopists (n₁=321, 31.4%, n₂=338, 33%, n₃= 363, 35.6%). The majority of ERCPs were performed for treatment of choledocholithiasis (64.5%) and were classified as of intermediate difficulty according to Schutz scoring system [Schutz score 2 (n=523, 53.4%)]. Fluoroscopy was used in 1010 ERCPs (98.2%) and the median fluoroscopy duration was 2.4 minutes (IQR=2.6 min) and the median radiation dose was 1031.6 μGym²(IQR=1237.5 μGym²). ERCPs performed with an indication of biliary tract neoplasm (e.g. cholangiocarcinoma, liver metastases) were associated with prolonged fluoroscopy duration [5.05min (IQR=6.35 min), p=0.008] and increased radiation dose [2372.75 μGym² (IQR=2462.68 μGym²), p=0.003] in comparison to the rest of the indications including choledocholithiasis, pancreatic neoplasm, obstructive jaundice and other indications.ERCP difficulty was also related with increased radiation; ERCPs with Schutz score ≥3 were associated with increased radiation dose and fluoroscopy duration compared with ERCP procedures evaluated as Schutz sore ≤2 [3.3min (IQR=3.9 min) vs. 2.1min (IQR=2.15 min), p<0.001 and 1280.8 μGym² (IQR=1836.8 μGym²) vs. 937.6 μGym² (IQR=820.25 μGym²),p<0.001 respectively]. There was no significant difference of the fluoroscopy duration (p=0.495) and radiation dose (p=0.950) among the three performing endoscopists.

Conclusion

Increased difficulty of ERCP and the indication of biliary tract neoplasm were related to higher radiation dose and prolonged fluoroscopy duration. These factors could be utilized to predict ERCP procedures related to increased radiation exposure and may contribute to adoption of appropriate radiation reduction methods.

Introduction

The increase in life expectancy has led to a more frequent performance of invasive procedures in older patients, including endoscopic retrograde cholangiopancreatography (ERCP). Elderly patients often present with multiple comorbidities and technical challenges, which may lead to the rejection of the procedure due to concerns about morbidity and mortality, as well as the potential futility of treatment. Few series address the safety and efficacy of ERCP in patients aged ≥95 years.

Aims & Methods

To compare the clinical characteristics, techniques, complications, and short- and long-term outcomes of super-elderly (≥95 years) and elderly (65-70 years) patients undergoing ERCP at La Paz University Hospital. A retrospective study was conducted, including all ERCP performed in super-elderly patients between 2018 and 2024. For the elderly group, an equal number of procedures performed during the same period were randomly selected and matched by sex. Data on demographics, comorbidities, indications, technical characteristics, complications, technical success rates and mortality at 30 days, 6 months and 12 months were collected and compared.

Results

A total of 92 procedures were included in each group, with 78.3% women in both groups. Super-elderly patients had a higher frequency of comorbidities, such as hypertension, heart failure, atrial fibrillation, chronic kidney disease and dementia (p<0.01). In terms of frailty, they had a significantly lower Barthel index compared to the elderly (p<0.001). ERCP indications were predominantly urgent in the super-elderly (cholangitis and biliary colic), while the elderly had a higher proportion of elective procedures such as planned choledocholithiasis and tumor-related causes (p<0.01). Most procedures in the super-elderly were performed in a hospital setting, while in the elderly, outpatient procedures predominated (p<0.001). Although no differences were observed in average hospital stay (p=0.59), the elderly had a higher proportion of procedures with 24-hour observation (p<0.001). In terms of techniques performed, the elderly group underwent more complex procedures such as cholangioscopy and radiofrequency ablation than the super-elderly. Technical success and procedure completion rates were similar (95.65% in the elderly and 96.74% in the super-elderly, p>0.05). Globally, immediate complications were slightly more frequent in the super-elderly (32.6%), although without significant differences compared to the elderly (25%, p=0.33); similarly for late complications. Regarding technique-related complications, despite the rates being comparable, the types of complications varied between the groups. In the elderly, mild pancreatitis predominated, whereas the super-elderly experienced a broader range of complications, including moderate pancreatitis, severe cholangitis and perforations, with a tendency towards greater severity, suggesting higher fragility in this group. Despite this, no statistically significant differences were observed in short- or long-term mortality. In the elderly, most deaths at 6 and 12 months were due to biliary causes (77.8% and 70%, respectively), primarily due to tumor-related processes. In the super-elderly, only 26.3% of deaths at 6 months and none at 12 months were due to biliary causes, reflecting the influence of additional comorbidities in this group.

Conclusion

Although super-elderly patients have a higher burden of comorbidities and frailty, the technical success and procedure completion rates are similar to those of 65-70-years-old. The indications and therapeutic approaches vary significantly between the two groups, with a higher proportion of urgent procedures in the super-elderly and a greater frequency of advanced techniques in the elderly. Despite differences in clinical characteristics, no significant differences in short- and long-term mortality were observed, suggesting that ERCP is safe and effective in both age groups, highlighting the importance of not rejecting the indication solely due to advanced age.

References

Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149. doi: 10.1055/a-1075-4080. Epub 2019 Dec 20. PMID: 31863440.

Introduction

There are few studies evaluating the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 90 years and above (nonagenarian). This study's main goal was to compare the technical success and complications of ERCP in patients over 90 years or younger patient group.

Aims & Methods

929 naive patients who underwent ERCP at the tertiary referral center between January 2021 and December 2023 were retrospectively analyzed. The patient's medical records were reviewed for comorbidities, periampullary diverticulum, cannulation time, cannulation method, technical success, procedure duration, and ERCP-related complications.

Results

A total of 929 naive patients underwent ERCP; 895 (96.3%) patients were < 90 years old and 34 (3.7%) patients were≥ 90 years old. The median ERCP procedure time (18.5 min vs. 18 min, P=0.660), and cannulation time (8 min vs. 7 min, P=0.824) did not differ in patients with two groups respectively. The successful cannulation rate in the nonagenarian group was 34 (100%), and in the younger group was 891 (99.6%), there was no significant difference between the two groups (P=1). The main indication of the ERCP procedure was choledocholithiasis in both groups. There was no significant difference in the ERCP-related complications between the two groups. The main cannulation technique was selective sphincterotomy in both groups.

There was no significant difference in cannulation techniques between the two groups. Patients belonging to the nonagenarian group had a higher frequency of periampullary diverticulum (20.6%) compared to the younger group (14.3%). Type 2B diverticula was the most seen in both groups (11.8% vs. 4.9%). However, there was no significant difference in the presence of periampullary diverticulum between the two groups. The number of chronic concomitant diseases (cardiovascular diseases, chronic lung diseases, chronic renal diseases) was significantly higher in the nonagenarian group [13 (38.2%) vs. 114 (12.7%), P<0.001].

Conclusion

In this study, we showed that ERCP was a safe and successful procedure in patients with nonagenarians. Although comorbidities were substantially higher, ERCP was a successful procedure for nonagenarian patients because the rates of complications are similar to those of younger adult patients.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a pioneering procedure in the management of pancreatobiliary diseases. However, access to the common bile duct is not always easy, even in expert hands, with a failure rate ranging between 5% and 10%. A second attempt or alternative cannulation techniques are often required before considering surgery.

Aims & Methods

The aim of this study was to assess the ERCP failure rate in a tertiary care center.
This was a retrospective, descriptive, and analytical study conducted in a hepatogastroenterology department. It included patients who underwent ERCP with failed bile
duct cannulation over a 6-year period.

Results

Out of 801 ERCP procedures performed, 14 failures (1.7%) were recorded. Among these patients, 28.6% (4 patients) underwent a second ERCP attempt, with one of them being
successful. The indications for ERCP were: pancreatic head tumor in 43% of cases (6), common bile ductstones in 36% (5), cholangiocarcinoma in 14% (2), and bile duct trauma in 7% (1). The techniques used for cannulation were primarily guidewire-assisted cannulation in 79% of cases (11) and precut sphincterotomy in 21% (3). 8 patients (62%) had surgical drainage and 5 patients (38%) underwent endoscopic ultrasound-guided drainage after ERCP failure.

Conclusion

Our study demonstrates a low ERCP failure rate, comparable to that of international centers. Surgical intervention was more common early in the experience, prior to the introduction of endoscopic ultrasound-guided drainage in our practice.