Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is essential in the minimally invasive management of biliary and pancreatic disorders. In certain indications, not delaying and carrying out ERCP during the weekend can be important to improve outcomes.

Aims & Methods

We aimed to analyze the outcomes of ERCP performed during weekends and holidays with regular weekday ERCPs. 3260 ERCP cases from 7 tertiary centers were analyzed from the Hungarian ERCP Registry database. 116 ERCPs were performed during weekends or holidays, and 3144 during weekday working hours. The main outcomes were successful biliary cannulation, difficult biliary cannulation, and adverse event rates. Chi-square and Fisher's exact tests were performed as appropriate. Propensity score matching was also performed and the comparisons were also performed in the matched groups.

Results

Weekend ERCPs were mostly carried out for the indication of acute cholangitis and acute biliary pancreatitis (70% of weekend cases), while in the weekday group, only 32% of cases were done for these indications. No difference was found between weekday and weekend ERCPs in the rate of successful biliary cannulation (2891/3144, 92.0% vs. 106/116, 91.4%), difficult biliary cannulation (32.0% vs. 33.6%), and advanced cannulation method use (26.2% vs. 31.0%) (p>0.05). There was a significantly higher number of ASGE grade 3 difficulty cases when ERCP was carried out urgently (30.3% vs. 56.0%, p<0.01), but we found no increase in the number of adverse events (post-ERCP pancreatitis, bleeding, perforations) in the ERCPs carried out during weekends. Additionally, no significant differences were detected between the propensity-matched groups in the outcomes above.

Conclusion

ERCPs carried out during the weekend, no difference was found regarding outcomes compared to weekday ERCPs despite having more difficult procedures.

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].

	Total (n= 929)	Age ≥90 (n=34, 3.7%)	Age ˂90 (n=895, 96.3%)	P-value
Gender, female, n (%)	539 (58)	25 (73.5)	514 (57.4)	0.062
Age, years	63 (47-74)	91 (90-93.25)	61 (47-73)	-
ERCP procedure time, min	18 (12-28)	18.5 (11.75-23.25)	18 (12-28)	0.660
Total cannulation time, min	7 (3-15)	8 (2.75-15.5)	7 (3-15)	0.824
Indications of ERCP procedure, n (%) Choledocholithiasis Malignant biliary strictures Benign biliary strictures Biliary leak Others	667 (71.8) 99 (10.7) 44 (4.7) 100 (10.8) 19 (2)	28 (82.4) 3 (8.8) - 1 (2.9) 2 (5.9)	639 (71.4) 96 (10.7) 44 (4.9) 99 (11.1) 17 (1.9)	0.142
Complications, n (%) Post ERCP Pancreatitis Perforation Bleeding Cholangitis Others (Cardiopulmonary)	42 (4.5) 4 (0.4) 27 (2.9) 3 (0.3) 2 (0.2)	1 (2.9) - 2 (5.9) - -	41 (4.6) 4 (0.4) 25 (2.8) 3 (0.3) 2 (0.2)	0.970
Past surgery history, n (%) History of cholecystectomy Operation Billroth I and II	241 (25.9) 4 (0.4)	10 (29.4) 1 (2.9)	231 (25.8) 3 (0.3)	0.638 0.139
Cannulation techniques, n (%) Selective Precut Needle-knife fistulotomy Double guide wire (DGW) Trans-pancreatic biliary sphincterotomy	608 (65.4) 45 (4.8) 147 (15.8) 63 (6.8) 12 (1.3)	27 (79.4) - 4 (11.8) 3 (8.8) -	581 (64.9) 45 (5) 143 (16) 60 (6.7) 12 (1.3)	0.440
Periampullary Diverticulum type, n (%) 1 2A 2B 3 4A 4B	13 (1.4) 28 (3) 48 (5.2) 25 (2.7) 13 (1.4) 8 (0.9)	1 (2.9) 1 (2.9) 4 (11.8) - 1 (2.9) -	12 (1.3) 27 (3) 44 (4.9) 25 (2.8) 12 (1.3) 8 (0.9)	0.472

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

According to the British Society of Gastroenterology (BSG) guidelines on sedation in gastrointestinal endoscopy (2023), minimal to moderate sedation is typically sufficient for level 1/2 endoscopic retrograde cholangiopancreatography (ERCP). However, deep sedation is not routinely available in many centres, potentially affecting patient comfort and procedure completion. This study investigated factors associated with incomplete ERCP procedures, with a particular focus on patient intolerance.

Aims & Methods

A retrospective review of all ERCP’s performed over six months at our tertiary centre was conducted. Data collected included demographics, indication, ERCP grade, sedation used, cannulation rate and completion of procedure (eg complete duct clearance). Achieving the primary therapeutic or diagnostic goal served as the primary outcome. Univariate and multivariable analyses were used to evaluate factors contributing to incomplete procedures.

Results

475 ERCP’s were analysed (median age 67 years; range 18–92; 49.5% female). Successful cannulation was achieved in 458 of 475 procedures (96.4%). Among the 55/475 (11.6%) incomplete ERCPs, 32 (6.7% of all procedures) were abandoned due to patient discomfort—manifested as pain, restlessness, and inability to tolerate the procedure. Univariate analysis showed significantly higher opiate doses (63.8 mg vs. 56.3 mg, p=0.015) and higher midazolam doses (5.0 mg vs. 4.0 mg, p=0.0003) in incomplete procedures. No significant differences were observed for age, sex, inpatient status, ERCP grade, or use of general anaesthesia. Multivariable analysis revealed no independent risk factors for incompletion. Other contributing factors included prolonged procedures (e.g., EUS prior to ERCP) and challenging anatomy.

Conclusion

Patient discomfort emerged as the primary driver of incomplete ERCPs, highlighting the importance of optimizing sedation strategies and ensuring adequate anaesthetic support. Higher opiate and midazolam doses correlated with incomplete procedures suggesting that deeper sedation may have allowed completion. More detailed research including data from a combination of tertiary and non-tertiary centres is needed to refine sedation practices in line with current BSG guidelines.

Introduction

Previous case reports and studies have shown frailty to be a risk factor for complications and poor outcomes following surgeries and endoscopic procedures. However, limited studies have examined the impact of frailty on endoscopic retrograde cholangiopancreatography (ERCP). Our study aims to compare patients undergoing ERCP with frailty to those without ERCP to understand the impact of frailty on ERCP better.

Aims & Methods

The NIS is a large, publicly available all-payer inpatient care database in the USA and was queried. We retrospectively analyzed the Nationwide Inpatient Sample (NIS) database for 2015-2019. Patients with a principal diagnosis of ERCP with and without frailty were identified using the ICD-10 codes. Multivariate regression analysis was used to calculate the odds ratios of in-hospital mortality, the average length of hospital stay (LOS), and hospital charges (TOTHC) using STATA 17 MP.

Results

Our study identified approximately 1,088,175 patients undergoing ERCP, of which 1,700 were frail.

On multivariate analysis, in patients undergoing ERCP and frailty as a co-morbidity, positive predictors of increased mortality were the following: sepsis (OR: 9.95, p<0.0001, 95% CI: 2.95 - 16.95), acute kidney injury (AKI) (OR 5.63, p<0.0001, CI 4.64 - 6.82), malnutrition (OR 3.28, p<0.0001, CI 2.66 - 4.04), post-procedural bleeding (OR 2.85, p<0.0069, CI 1.95 - 3.70), aspiration (OR 4.94, p<0.0001, CI 2.59 - 6.80), congestive heart failure (CHF) (OR 1.48, p<0.001, CI 1.19 - 1.86).

LOS was increased if patients had any of the following complications: sepsis (+2.86 days, p<0.0001, 95% CI: 2.59 - 3.13), AKI (+3.44 days, p<0.0001, 95% CI: 3.16 - 3.73), malnutrition (+6.44 days, p<0.0001, CI 5.89 - 6.99), post-procedural bleeding (+4.99 days, p<0.0001, CI 3.29 - 6.68), aspiration (+9.87 days, p<0.0001, 95% CI 7.48 - 12.27), or CHF (+1.87 days, p<0.0001, CI 1.53 - 2.22).

TOTHC were increased in patients who had the following complications: sepsis ($46,978, p<0.0001, CI $41,364 - $52,593), AKI ($53,007, p<0.0001, CI $44,221 - $61,793), malnutrition ($85,454, p<0.0001, $64,515 - $106,393), post-procedural bleeding ($114,168, p<0.0001, $61,465 - $166,871), aspiration ($198,071, p<0.0001, $113,911 - $282,230) or CHF ($20,191, p<0.0001, $12,983 - $27,398).

Conclusion

Based on our study results, those with ERCP who had a co-morbidity of frailty had increased mortality, LOS, and TOTHC with the following complications: sepsis, AKI, malnutrition, post-procedural bleeding, aspiration, and CHF. While frailty is not a contraindication to doing an ERCP, our study demonstrates that there must be close monitoring and preparation of these patients before ERCP to avoid complications because many complications significantly increase mortality. This is a high-risk patient population. Randomized trials will be required to further study the impact of frailty on ERCP.

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.

Variable	aOR (95% CI)	P-valueb
Procedure time a	1.040 (1.021- 1.059)	< 0.001
Fluoroscopy time a	1.236 (1.137- 1.343)	< 0.001
Cholangioscopy	72.2 (34.3- 151.6)	< 0.001
ERCP technical success	1.00	0.983
ERCP adverse events	0.438 (0.1-1.9)	0.274

Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; ERCP, endoscopic retrograde cholangiopancreatography.
a. Based on increasing time intervals
b. Adjusting for native papilla

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

Introduction

Acute cholangitis (AC) is an important clinical problem which is associated with mortality upto 10%. The association between timing of ERCP and clinical outcomes of AC are not well studied. The current study is aimed to evaluate whether ERCP within 48 hours is associated with improved clinical outcomes.

Aims & Methods

This is single center retrospective analysis of prospectively maintained database. All patients who admitted with AC at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included in study if they underwent ERCP. Patients satisfying diagnostic criteria of AC according to Tokyo Guidelines and stratified according to severity of AC. We evaluated association between ERCP within 48 hours and length of hospital stay, need for reintervention and re-admissions, mortality in-hospital and at 3 months follow.

Results

A total of consecutive 301 patients underwent ERCP during study period; of which 217 patients (31.3% females; mean age 54.02 ± 14.9 years) underwent ERCP within 48 hours of admission. Remaining 84 (32.1% females; mean age 56.56 ± 13.9 years) underwent ERCP after 48 hours. 58 (26.7%) and 22 (26.2%) patients with severe cholangitis (grade 3 as per Tokyo Guidelines) underwent ERCP within 48hours and beyond 48 hours respectively. The proportion of patients with malignant biliary obstruction was 34.1% (74/217) and 46.6% (39/84) in ERCP within 48 hours and beyond respectively. There was no statistically significant difference for overall mortality (6.45%vs7.14%, p 0.83); need for reinterventions (46.1% versus 54.8%, p 0.53) and readmissions (62.2% versus 58.33%; p 0.18). The length of hospital stay during 1^st admission was significantly higher in ERCP beyond 48hours group (9.48 ± 6.50 versus 12.86 ± 7.25 days; p 0.0001).

Conclusion

The current study indicates that ERCP within 48 hours for AC is associated with decreased length of hospital stay while overall mortality, need for reinterventions, readmissions are comparable. There is unmet need to confirm these findings by randomized controlled study.