Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. However, how to best achieve safe and effective bile duct cannulation is still debated. Endoscopists doing ERCP routinely recognize the differences in the macroscopic appearance of the major papilla. This has led to a conception that certain appearances of the papilla are more difficult to cannulate and, therefore, more prone to adverse events.

Aims & Methods

We aimed to quantify the influence of papilla morphology on ERCP outcomes.
PROSPERO registration number: CRD42022360894. We systematically searched three medical databases from inception in September 2022. Studies detailing the cannulation or the rate of adverse events in the context of papilla morphology were included. For the primary classification of the major papilla, the Haraldsson system was used, differentiating four morphological types. Data on studies using other classification systems were also collected. A pooled event rate with a 95% confidence interval (CI) was used for the effect size measure. For the test of subgroup differences, a "Cochrane Q" test was used. The risk of bias assessment was performed using the Joanna Briggs Institute Critical Appraisal tool for studies reporting prevalence.

Results

A total of 17 studies were eligible, and 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I („regular”) papilla (26%; CI: 18–37), followed by type III („protruding or bulging”) (35%; CI: 25–48) and type II („small”) papilla (39%; CI: 28–52). The highest rate was observed in the case of type IV („creased or ridged”) papilla (41%; CI: 28–55). For post-ERCP pancreatitis, the event rate was the highest in type II („small”) papilla (11%; CI: 8–15) and the lowest in type I („regular”) (6%; CI: 5–8) and III („protruding or bulging”) papilla (6%; CI: 4–8). There was no statistically significant difference in the cannulation failure and post-ERCP bleeding event rates between the different papilla types. Similar trends were observed in the analyses including other classification systems comparable to the Haraldsson's. Most studies carried a low risk of bias.

Conclusion

In conclusion, other types are associated with a higher rate of difficult cannulation compared to the regular papilla type. The small papilla is associated with a higher rate of post-ERCP pancreatitis.

Introduction

Non-variceal gastrointestinal bleeding is a common condition associated with significant morbidity and mortality. Several approaches are available for primary endoscopic treatment. The standard endoscopic approach uses contact thermal methods or hemoclips with or without pre-injection of diluted epinephrine. A newer alternative is the use of an over-the-scope clip (OTSC).

Aims & Methods

The aim of our study was to evaluate the efficacy of these two modalities in the treatment of non-variceal gastrointestinal bleeding.
Methods: PubMed, EMBASSE and the Cochrane Library databases were searched for multicentre randomised controlled trials comparing the efficacy of OTSC with standard endoscopic procedures for the primary treatment of non-variceal gastrointestinal bleeding published up to January 2024. The primary outcome measure was the 7-day re-bleeding rate. We also assessed the presence of persistent bleeding, 30-day rebleeding rate, length of hospital stay and mortality. A systematic review and network meta-analysis was performed for both treatments.

Results

Four trials met the inclusion criteria and were included. Regarding the 7-day rebleeding rate, OTSC showed superior efficacy compared to standard endoscopic therapy in the treatment of non-variceal gastrointestinal bleeding (RR 0.29, 95%CI 0.14-0.62). OTSC was also superior to standard endoscopic therapy in terms of re-bleeding within 30 days (RR 0.43, 95%CI 0.24-0.78). In terms of failure to achieve primary haemostasis, results were similar between the two methods, with a trend in favour of OTSC (RR 0.37, 95%CI 0.37-1.02). Finally, no differences were found in mortality (RR 0.61, 95%CI 0.25-1.51) and length of hospital stay (SMD -0.01, 95%CI -0.20-0.17).

Conclusion

OTSC significantly reduced the 7-day and 30-day re-bleeding rate compared to standard endoscopic therapy. There were no differences in mortality and length of hospital stay.

Disclosure

Julio Iglesias-Garcia: Advisor Fuji

Introduction

Evaluate the predictive factors of failure rate of clearing the biliary system from stones at the initial ERCP.

Aims & Methods

This is a retrospective descriptive and analytical study from September 2004 to September 2023.
All patients with bile duct stones, who underwent ERCP with endoscopic sphincterotomy and stone extraction by standard techniques (extraction balloon or Dormia basket) were included in this study.

Results

A total of 1080 ERCPs were performed to extract biliary duct stones .

The mean age was 58.9 +/- 14.4 years and 59.5% were females.
The mean diameter ofthe Bile duct was 13.4+/- 4.31 mm. The presence of a biliary stricture in 6.3%.
The primary vacuity rate was 75.1%. Supplementary techniques were used in 22.7% of cases.
On univariate analysis, the predictive factors for failure after use of standard techniques were: age(OR: 0.9;CI95%:-0.03- -0.01;p<0.001); gender(OR:0.7;CI95%:-0.5--0.02;p=0.036); previous cholecystectomy (OR:1.3,CI95%:0.02-0.6;p=0.035);presence of angiocholitis(OR: 0.4; CI95%:-1.1- -0.4;p<0.001); dilatation of the CBD >15mm (OR:0,8,CI95%:-0.2-0.1;p<0.001), biliary stricture (OR:0.3;CI95%:-1.7--0.7;p<0.001) and the presence of impacted and/or large stone (OR:0.1;CI95%:-2--1;p<0.001).
On multivariateanalysis, only the presence of angiocholitis (OR:1.9;CI95%: 0.2-1;p=0.001),impacted and/or large stone (OR:2.5;CI95%:0.5-1.3;p<0.001), dilatation ofthe CBD >15mm (OR:0.88;CI95%:-0.17- -0.07;p<0.001), and biliary stricture(OR:2.9;CI95%:0.4-1.7;p=0.002) were significantly associated with failure ofthe primary CBD vacuity rate.
The overall vacuity rate after using the supplementary techniques was 92.4%.

Conclusion

In our study, predictivefactors for failure of the primary CBD vacuity rate were the presence ofangiocholitis, impacted and/or large stone, dilatation of the CBD (>15mm)and biliary stricture.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure. There are multiple clinical guidelines yet practice varies. As part of an on-going BSG Endoscopy Quality Improvement Programme, we aim to describe current ERCP practice in the UK and benchmark this against published guidelines.

Aims & Methods

An anonymised survey link was emailed to all independent ERCP practitioners in the UK and a further survey was sent to all organisations in the UK in which ERCP is carried out. Multiple reminders and individual contacts were used to maximise response rate. Clinical questions covering a range of scenarios were aligned with published guidelines and quality standards including the UK National Institute for Health and Care Excellence (NICE).

Results

171 organisations providing ERCP were identified with a 100% response rate. 491 ERCP practitioners were identified with 78% (n= 386) response rate. In patients with an intermediate likelihood of common bile duct stones (CBDS), 9% of responders would proceed directly to ERCP, 76% would request MRCP or EUS first and 11% would arrange same session EUS +/- ERCP. In patients with normal anatomy and large or difficult to extract stones, 68% would perform sphincterotomy followed by sphincteroplasty and further attempts at duct clearance at the index procedure. After two or more inadvertent guidewire into the pancreatic duct (PD), 25% of individual practitioners always and 51% usually place a PD stent, whereas 19% rarely and 5% never do. In 10% of organisations standard practice is usually not to insert a PD stent.
NICE quality standard in the management of gallstone disease (QS104) stipulate that adults with CBDS causing jaundice have ERCP within 72 hours of diagnosis; 86% of organisations are compliant with this all or most of the time. In patients who need emergency ERCP for CBDS, 66% of organisations are compliant all or most of the time with having an ERCP within 24 hours (QS104).
In 29% of organisations, access to same-day ERCP 5 days a week was not available all/ most of the time. Out of hours ERCP (1800-0800) was not available all or most of the time in 63%, and over weekends it was not available all or most of the time in 59%.ERCP was available out of hours within the hospital in 33% of organisations during weekdays and 36% over the weekends as an unpaid, ad-hoc or goodwill arrangement.
In 26% of organisations there is regular weekly access to a deep sedation / general anaesthetic (DS/GA) list and 60% have access to a DS/GA list on an ad hoc basis or through referral to a different hospital. 55% of ERCPists were aware of the quality of therapeutic intent of any ERCP procedure being affected by suboptimal patient tolerance with endoscopist administered conscious sedation in the past month and 62% would prefer to perform all ERCPs under DS/ GA.

Conclusion

Despite clear guidance, variation in the management of CBDS and placement of pancreatic stents persists. Access to out-of-hours and weekend ERCP is sparse in the UK, and there is a reliance on goodwill to facilitate these cases. The availability of DS/GA is limited and there is a clear desire for improved access to optimise patient tolerance and ERCP outcomes.

Disclosure

Nothing to disclose

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 now the gold standard for the treatment of bile duct stones. However, recurrence stones is frequent after their complete removal by endoscopic treatment.

Aims & Methods

The present study is retrospective, descriptive and analytic, including all patients who underwent ERCP for common bile duct (CBD) stones between January 2008 and January 2024.
Recurrent CBD stone was defined as the finding of a stone at least 6 months after the initial ERCP in which complete stone extraction was performed.
Factors associated with recurrent CBD stones were studied by logistic regression analysis.
Statistical analysis was performed using Jamovi software.
The aim of our study is to identify predictors of recurrent CBD stones after ERCP.

Results

Among 1151 patients who underwent ERCP for lithiasis pathology, 88 patients or 7.7% had recurrent CBD stone.
Mean age of the patients was 64.5 +/-13.4 years, with extremes ranging from 22 to 94 years. Sex ratio (M/F) was 0.69, with a female predominance of 59.1%.
20.5% of patients presented with acute angiocholitis and 6.8% with acute pancreatitis.
A periampullary diverticulum was found in 5.7% of patients (n=5).
In univariate analysis, the risk factors for recurrent CBD stone were: older age (OR :37; IC95% : [10,7- 127,2] ; p<0,001), female gender ( OR :9,9 ;IC95% : [4,49-22,04] ; p<0,001), CBD diameter > 15 mm (OR : 7,36 ;IC95% : [5,51-9,8] ; p<0,001), presence of angiocholitis ( OR : 2.06 ;IC95% : [1,12-3,8] ; p=0,02), number of CBD stones (OR :8,61; IC95% : [6,51-11,39] ; p=0,018), size of CBD stones (OR :2,51 ;IC95% : [1,43-4,39] ; p=0,001), while enlargement EST (OR :0,18; IC95% : [0,08-0,44] ; p<0,001) was a protective factor.
After multivariate analysis, and adjusting for the factors studied, only older age (OR:1.96; CI95%: [1.94-2.93]; p=0.001), number of CBD stones (OR: 1.99; CI95%: [1,2-3,4] ; p=0,037) and size of CBD stones (OR :4,06; IC95% : [3,51-6,72] ; p=0,003) were risk factors, and enlargement EST (OR :0,31; IC95% : [0,11-0,85] ; p=0,024) was protective factor.

Conclusion

In our study, the predictive factors for recurrent CBD stones were advanced age, the presence of impaction and a large stone.

Introduction

The American Society for Gastrointestinal Endoscopy (ASGE) grading system for endoscopic retrograde cholangiopancreatography (ERCP) has been shown to predict success and adverse events rates. We compared ERCP outcomes and adverse events between complex and non-complex procedures using the ASGE-grading system. Our study also sought to assess the impact of the ASGE-grading system on ERCP outcomes with and without trainee involvement.

Aims & Methods

We conducted a retrospective study of 1392 patients who underwent ERCP procedures in a single large tertiary insititution between January 2019 and July 2023. Clinical data were prospectively collected during routine ERCP procedures. Demographics, cholangioscopy, procedure and fluoroscopy time, adverse events, and technical success rates were compared between complex (ASGE Grade ≥3) and non-complex (ASGE Grade <3) ERCP procedures as well as with and without trainee involvement. Categorical variables were compared using Pearson’s chi-square test and continuous variables using a standard t-test. Multivariate regressions were performed to adjust for sex, age, clinical setting, and native papilla.

Results

Approximately 83.3% of ERCPs were ASGE Grade <3 and 16.7% were ASGE Grade ≥3. The mean patient age was 62 years, 53% were male. The ampulla was native in 45.3% of ASGE Grade <3 vs. 34.1% of ASGE Grade ≥3 (P=0.002). Cholangioscopy was needed in 1% of ASGE Grade <3 vs. 58.6% of ASGE Grade ≥3 (aOR: 72.2, P <0.001). Procedure and fluroscopy time were longer by 25.4 mins (aOR: 1.04, P < 0.001) and 5 mins (aOR: 1.24, P < 0.001) respectively for ASGE Grade ≥3 . Adverse events (aOR: 0.44, P= 0.274) and technical success (aOR: 1.00, P= 0.983) were similar in both groups. No significant difference was noted between trainees and attending endoscopist in the odds of ERCP adverse events or technical success for ASGE Grade <3 or ASGE Grade ≥3 respectively.

Conclusion

ERCPs with ASGE Grade ≥3 is associated with increased procedure and fluoroscopy time, and displayed increased odds of requiring cholangioscopy. ERCP technical success and adverse events did not significantly differ with trainee participation regardless of procedural complexity.

Table. ERCP outcomes for complex (ASGE Grade ≥ 3) vs. non-complex procedures (ASGE Grade <3). N=1392.

References

References
1. Sahar, N., La Selva, D., Gluck, M., Gan, S. I., Irani, S., Larsen, M., Ross, A. S., & Kozarek, R. A. (2019). The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surgical endoscopy, 33(2), 448–453
2. Zhou, F., Zhan, X., Song, C., Li, G., Hong, J., Chen, Y., & Zhou, X. (2022). The assessment of the ASGE-grading system of ERCP: a large-sample retrospective study. Surgical endoscopy, 36(9), 6480–6487