Search

The benefit of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of primary sclerosing cholangitis (PSC) remains controversial. To identify predictors of jaundice resolution after ERCP and whether resolution is associated with improved patient outcomes, we conducted a retrospective cohort study of 124 patients with jaundice and PSC. These patients underwent endoscopic biliary balloon dilation and/or stent placement at an American tertiary center, with validation in a separate cohort of 102 patients from European centers. Jaundice resolved after ERCP in 52% of patients. Median follow‐up was 4.8 years. Independent predictors of jaundice resolution included older age (P = 0.048; odds ratio [OR], 1.03 for every 1‐year increase), shorter duration of jaundice (P = 0.059; OR, 0.59 for every 1‐year increase), lower Mayo Risk Score (MRS) (P = 0.025; OR, 0.58 for every 1‐point increase), and extrahepatic location of the most advanced biliary stricture (P = 0.011; OR, 3.13). A logistic regression model predicted jaundice resolution with area under the receiver operator characteristic curve of 0.67 (95% confidence interval, 0.5‐0.79) in the validation set. Independent predictors of death or transplant during follow‐up included higher MRS at the time of ERCP (P < 0.0001; hazard ratio [HR], 2.33 for every 1‐point increase), lower total serum bilirubin before ERCP (P = 0.031; HR, 0.91 for every 1 mg/dL increase), and persistence of jaundice after endoscopic therapy (P = 0.003; HR, 2.30). Conclusion: Resolution of jaundice after endoscopic treatment of biliary strictures is associated with longer transplant‐free survival of patients with PSC. The likelihood of resolution is affected by demographic, hepatic, and biliary variables and can be predicted using noninvasive data. These findings may refine the use of ERCP in patients with jaundice with PSC. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered.Methods: This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula.Results: 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases.Conclusions: The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure with a high risk for adverse events (AEs). Aim: evaluate patient- and procedure-related risk factors for ERCP-related AEs and develop an online app to estimate risk of AEs. Methods: retrospective study of 1,491 consecutive patients who underwent 1,991 ERCPs between 2012 and 2017 was conducted. AEs definition and severity were classified according to most recent ESGE guidelines. Each variable was tested for association with occurrence of overall AEs, post-ERCP pancreatitis (PEP) and cholangitis. For each outcome, 2 regression models were built, from which an online Shiny-based app was created. Results: Overall AE rate was 15.3%; in 19 procedures, >1 AE occurred. Main post-ERCP AE was PEP (7.5%), followed by cholangitis (4.9%), bleeding (1.3%), perforation (1%), cardiopulmonary events (0.9%), and cholecystitis (0.3%). Seventy-eight percent of AEs were mild/moderate; of severe (n = 55) and fatal (n = 20) AEs, more than half were related to infection, cardiac/pulmonary AEs, and perforation. AE-related mortality rate was 1%. When testing precannulation, procedural covariates, and ERCP findings, AE occurrence was associated with age (odds ratio [OR] 0.991), previous PEP (OR 2.198), ERCP complexity grade III/IV (OR 1.924), standard bile duct cannulation (OR 0.501), sphincterotomy (OR 1.441), metal biliary stent placement (OR 2.014), periprocedural bleeding (OR 3.024), and biliary duct lithiasis (OR 0.673). Conclusion: Our app may allow an optimization of the patients' care, by helping in the process of decision-making, not only regarding patient or endoscopist's selection but also definition of an adequate and tailored surveillance plan after the procedure. [ABSTRACT FROM AUTHOR]

Background: Acute cholangitis (AC) requires prompt diagnosis and treatment for optimal management.Aims: To examine whether a putative "weekend effect" impact outcomes of patients hospitalized for AC.Methods: We conducted a retrospective study of patients admitted with AC between 2009 and 2012. After excluding those not meeting Tokyo consensus criteria for AC, the cohort was categorized into weekend (Saturday-Sunday) and weekday (Monday-Friday) hospital admission and endoscopic retrograde cholangiography (ERC) groups. Primary outcome was length of stay (LOS); secondary outcomes included ERC performance, organ failure, and mortality. Groups were compared with Chi-square and t tests; predictors of LOS were assessed with linear regression.Results: The cohort consisted of 181 patients (mean age 63.1 years, 62.4 % male). Choledocholithiasis was the most common etiology of AC (29.4 %). Fifty-two patients (28.7 %) were admitted on a weekend and 129 (71.3 %) on a weekday. One hundred forty-one patients (78 %) underwent ERC, of which 120 (85 %) were on a weekday. There were no significant differences in baseline characteristics, LOS, proportion undergoing ERC, time to ERC, organ failure, or mortality between weekend and weekday admission groups. Similarly, there were no significant differences between weekend and weekday ERC groups. In multivariate analyses, international normalized ratio (p < 0.01) and intensive care unit triage (p < 0.01) were independent predictors of LOS, whereas weekend admission (p = 0.23) and weekend ERC (p = 0.74) were not.Conclusions: Weekend admission and weekend ERC do not negatively impact outcomes of patients hospitalized with acute cholangitis at a tertiary care center. Further studies, particularly in centers with less weekend resources or staffing, are indicated. [ABSTRACT FROM AUTHOR]

Training in endoscopic retrograde cholangiopancreatography (ERCP) requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. So far, there are limited data regarding what constitutes competency in ERCP, including achievement and maintenance. Recent studies have highlighted overall procedural numbers are not enough to warrant competency, although more is better. We performed a comprehensive literature search until June 2017 using predetermined search terms to identify relevant articles and summarized their results as a narrative review. Selective native papilla deep cannulation should be used as a benchmark for assessing successful cannulation. Accurate and validated ERCP performance measures are needed to develop a curriculum that allows transition from numbers-based competency. However, available guidelines fail to state what degree of hands-on involvement is required by the trainee for the case to be counted in their overall procedural numbers. Qualitative assessment of competency should be done by trained raters using specially designed assessment tools. Competence continues to increase with practice following formal training in a fairly steady manner. The learning curve for overall common bile duct cannulation success may be a readily available surrogate for individual trainee progression and may correspond to learning curves for therapeutic interventions. [ABSTRACT FROM AUTHOR]

The Tokyo Guidelines 2013 ( TG13) include new topics in the biliary drainage section. From these topics, we describe the indications and new techniques of biliary drainage for acute cholangitis with videos. Recently, many novel studies and case series have been published across the world, thus TG13 need to be updated regarding the indications and selection of biliary drainage based on published data. Herein, we describe the latest updated TG13 on biliary drainage in acute cholangitis with meta-analysis. The present study showed that endoscopic transpapillary biliary drainage regardless of the use of nasobiliary drainage or biliary stenting, should be selected as the first-line therapy for acute cholangitis. In acute cholangitis, endoscopic sphincterotomy ( EST) is not routinely required for biliary drainage alone because of the concern of post- EST bleeding. In case of concomitant bile duct stones, stone removal following EST at a single session may be considered in patients with mild or moderate acute cholangitis except in patients under anticoagulant therapy or with coagulopathy. We recommend the removal of difficult stones at two sessions after drainage in patients with a large stone or multiple stones. In patients with potential coagulopathy, endoscopic papillary dilation can be a better technique than EST for stone removal. Presently, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography ( BE- ERCP) is used as the first-line therapy for biliary drainage in patients with surgically altered anatomy where BE- ERCP expertise is present. However, the technical success rate is not always high. Thus, several studies have revealed that endoscopic ultrasonography-guided biliary drainage ( EUS- BD) can be one of the second-line therapies in failed BE- ERCP as an alternative to percutaneous transhepatic biliary drainage where EUS- BD expertise is present. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement.Aims: Our hypothesis was that biliary sphincterotomy has no effect on the success rate of transpapillary self-expanding metal stent placement and increases procedure-related complications.Methods: In a retrospective analysis, outcomes of two groups were compared: (1) self-expanding metal stent placement without biliary sphincterotomy, (2) self-expanding metal stent placement with biliary sphincterotomy during the same procedure. Complications and stent patency rates were evaluated.Results: There were 104 subjects included in the study. Post-sphincterotomy bleeding (p = 0.001) was associated with biliary sphincterotomy performed immediately prior to self-expanding metal stent placement. Importantly, self-expanding metal stent placement without biliary sphincterotomy was always technically successful and self-expanding metal stent placement without biliary sphincterotomy was not associated with pancreatitis.Conclusions: Patients who undergo biliary sphincterotomy during transpapillary self-expanding metal stent placement experience more immediate complications than those who do not. Biliary sphincterotomy was not associated with longer stent patency. Self-expanding metal stent placement without a biliary sphincterotomy was not associated with pancreatitis regardless of the type of self-expanding metal stent used (covered or uncovered). Of the patients without a biliary sphincterotomy, 100% had successful stent placement, further arguing against its use in this setting. [ABSTRACT FROM AUTHOR]

Background: The combination of prophylactic pancreatic stent placement (PSP) - a temporary plastic stent placed in the pancreatic duct - and rectal non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Preliminary data, however, suggest that PSP may be unnecessary if rectal NSAIDs are administered. Given the costs and potential risks of PSP, we aim to determine whether rectal indomethacin obviates the need for pancreatic stent placement in patients undergoing high-risk ERCP.Methods/design: The SVI (Stent vs. Indomethacin) trial is a comparative effectiveness, multicenter, randomized, double-blind, non-inferiority study of rectal indomethacin alone versus the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases. One thousand four hundred and thirty subjects undergoing high-risk ERCP, in whom PSP is planned solely for PEP prevention, will be randomized to indomethacin alone or combination therapy. Those who are aware of study group assignment, including the endoscopist, will not be involved in the post-procedure care of the patient for at least 48 hours. Subjects will be assessed for PEP and its severity by a panel of independent and blinded adjudicators. Indomethacin alone will be declared non-inferior to combination therapy if the two-sided 95 % upper confidence bound of the treatment difference is less than 5 % between the two groups. Biological specimens will be obtained from trial participants and centrally banked.Discussion: The SVI trial is designed to determine whether PSP remains necessary in the era of NSAIDs pharmacoprevention. The associated bio-repository will establish the groundwork for important scientific breakthrough.Trial Registration: NCT02476279, registered June 2015. [ABSTRACT FROM AUTHOR]

The article presents a guideline from the European Society of Gastrointestinal Endoscopy for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Key recommendations of the guideline are emphasized. It is inferred that the guideline's aim is to minimize the incidence and severity of PEP. The guideline's methods, definitions used, and data on incidence are provided.

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal 'side-by-side' (SBS) and 'stent-in-stent' (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system. Patients and Methods: This was a single-center, retrospective review of all patients who underwent bilateral placement of Zilver biliary SEMS for malignant hilar obstruction from January 2010 to August 2012. Patients underwent endoscopic retrograde cholangiopancreatography with placement of stents using either the SIS or SBS stent techniques. Results: Twenty-four patients (19 men, mean age 63 years) underwent bilateral stenting for malignant hilar obstruction during the study period. Seventeen and seven patients underwent the SBS and SIS technique, respectively. Cholangiocarcinoma ( n = 14) was the most common cause of hilar obstruction. Initial technical success was achieved in 24/24 (100 %) of patients; however, 12 (50 %) patients required re-intervention during the study period (median 98 days). Comparison of the SBS and SIS groups revealed no statistical difference with respect to need for re-intervention ( P = 0.31), successful re-intervention ( P = 0.60), or procedural length ( P = 0.89). Conclusions: Use of bilateral Zilver SEMS in either the SBS or SIS configuration is safe, technically feasible, and effective for drainage of malignant hilar obstruction; however, duration of stent patency and procedure-free survival remain variable. [ABSTRACT FROM AUTHOR]

Technological advances in ERCP have appeared to plateau. Nonetheless, specific areas within ERCP were well represented at this year's Digestive Disease Week (DDW). These areas are subdivided and discussed in detail. As expected, there remains concern about prevention of post-ERCP pancreatitis (PEP). Although pharmacologic therapy by using nonsteroidal anti-inflammatory drugs (NSAIDs) has clearly emerged as an alternative and/or adjunct to pancreatic duct (PD) stents, stents seem to remain the mainstay in the endoscopists' armamentarium for the prevention of PEP. Other topics covered included the use of cholangioscopy, diagnosis of biliary strictures, and treatment of strictures by using stents and radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Abstract: After selective deep ductal cannulation, mastering different sphincterotomy techniques is a fundamental skill for the safe and effective practice of endoscopic retrograde cholangiopancreatography. In this review, we will discuss the indications, techniques, challenges, alternatives, and adverse events of endoscopic sphincterotomy, with a special focus on techniques. [Copyright &y& Elsevier]

Background: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior Roux-en-Y gastric bypass (RYGB) surgery is challenging. Despite advancements in endoscopic technology, reaching the duodenum and entering the bile duct is still difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach. Objectives: The objective of this study is to evaluate the success rates and complications in patients with prior RYGB anatomy who underwent LAERCP in a tertiary care center. Patients: Consecutive patients undergoing LAERCP between 2005 and 2010 were used for this study. Outcomes: Biliary/pancreatic cannulation, endoscopic/laparoscopic interventions, postprocedure complications, postprocedure hospital stay, and procedure time were observed in this study. Results: Fifteen patients with post-RYGB surgery underwent LAERCP. Endoscopic antegrade access to the papilla was achieved through the gastric remnant in all. Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. Therapeutic interventions included biliary sphincterotomy in 14 and pancreatic sphincterotomy in two patients. There were no postoperative complications related to the endoscopic portion of the procedure. The mean duration of the procedure and the median postprocedure hospital stay were 45 min and 2 days, respectively. Conclusion: Laparoscopic assisted ERC is a useful approach in the diagnosis and treatment of pancreaticobiliary conditions in patients with RYGB. [ABSTRACT FROM AUTHOR]

Background: Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention. Methods: We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded. Results: Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09). Conclusion: EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair. [Copyright &y& Elsevier]

OBJECTIVES:In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary.METHODS:We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first.RESULTS:Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26–48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23–38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22–44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found.CONCLUSIONS:Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4–6 weeks seems to be sufficient and significantly less expensive. [ABSTRACT FROM AUTHOR]

Background & Aims: Prophylactic placement of pancreatic duct (PD) stents reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in high-risk patients. Some endoscopists prefer longer length, unflanged 3Fr PD stents because they are supposedly more effective and have a higher rate of spontaneous dislodgement; we compared outcomes of patients with these 2 types of stents. Methods: Patients at high risk for PEP were randomly assigned to groups given either a straight, 5Fr, 3 cm long, unflanged PD stent (n = 116) or a 3Fr, 8 cm or longer, unflanged PD stent (n = 133). Abdominal radiographs were obtained at 24 hours, 7 days, and 14 days following stent placement to assess spontaneous stent dislodgement. PEP was defined according to consensus criteria. Results: After 14 days, the spontaneous stent dislodgement rates were 98% for 5Fr stents and 88% for 3Fr stents (P = .0001). PEP occurred in 12% of patients. The incidence of PEP was higher in the 3Fr group (14%) than the 5Fr group (9%), although this difference was not statistically significant (P = .3). Placement failure did not occur in any patients in the 5Fr stent group, but did occur in 11 of the 133 patients in the 3Fr stent group (P = .0003). Conclusions: Among patients at high-risk for PEP, the spontaneous dislodgement rate of unflanged, short-length, 5Fr PD stents is significantly higher than for unflanged, long-length, 3Fr stents. This decreases the need for endoscopic removal. A higher rate of PD stent placement failure and PEP was observed in patients with 3Fr stents. To view this article''s video abstract, go to the AGA''s YouTube Channel. [Copyright &y& Elsevier]

Endoscopic biliary sphincterotomy (ES) is the cornerstone of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Bleeding is one of the most frequent complications following ES. Rates of post-ES bleeding vary widely and its presentation may be immediate (intraprocedural) or several days later. Clinically, bleeding can range from insignificant to life threatening. Most bleeding episodes are managed successfully by conservative measures with or without endoscopic therapy. Endoscopic treatment options include injection, thermal, and mechanical methods—alone or in combination. For refractory cases, angiographic embolization, or surgery, is necessary. Both technical risk factors and patient risk factors contribute to the development of post-ES bleeding. When these risk factors are present, measures can be taken to reduce the risk of bleeding. In this manuscript the literature on post-ES bleeding is reviewed. [ABSTRACT FROM AUTHOR]

A 69-year-old man presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography was performed for biliary tree decompression and diagnostic tissue acquisition. Techniques, indications, methodologic considerations, and interpretation of tissue sampling at endoscopic retrograde cholangiopancreatography in patients with biliary/pancreatic strictures are discussed. This case-based educational presentation focuses on the importance of interdisciplinary communication between endoscopists and pathologists for optimal tissue sampling, interpretation, and diagnostic accuracy. [Copyright &y& Elsevier]

Background & Aims: Recent studies have shown a survival advantage using photodynamic therapy (PDT) in patients with unresectable cholangiocarcinoma. Factors associated with increased survival after PDT are unknown. Methods: Twenty-five patients with cholangiocarcinoma who were treated with PDT at the Mayo Clinic Rochester from 1991 to 2004 were studied. Porfimer sodium (2 mg/kg) was administered intravenously to patients with Bismuth type I (3 patients), type III a/b (13 patients), and type IV (9 patients) tumors. Forty-eight hours later, PDT was administered using a 1.5- to 2.5-cm diffusing fiber that was advanced across the tumor by either retrograde (20 patients) or percutaneous (5 patients) cholangiography. Laser light was applied for a total energy of 180 J/cm2 in 1–3 applications. Patients received PDT treatments every 3 months. Plastic biliary stents (10–11.5 F) were inserted to decompress the biliary system after PDT. Survival analysis was performed using Kaplan–Meier curves and Cox proportional hazards models. Results: Patients were 64 (standard error of the mean, ±2.6) years of age; 20 (80%) were men. The median overall survival period was 344 days. The median survival period after PDT was 214 days. The 1-year survival rate was 30%. On multivariate analysis, the presence of a visible mass on imaging studies (hazard ratio, 3.55; 95% confidence interval, 1.21–10.38), and increasing time between diagnosis and PDT (hazard ratio, 1.13; 95% confidence interval, 1.02–1.25) predicted a poorer survival rate after PDT. A higher serum albumin level (hazard ratio, 0.16; 95% confidence interval, 0.04–0.59) predicted a lower mortality rate after PDT. Conclusions: Patients with unresectable cholangiocarcinoma without a visible mass may benefit from earlier treatment with PDT. [Copyright &y& Elsevier]

OBJECTIVES: When administered by endoscopists conventional sedation regimens for endoscopic retrograde cholangipancreatography (ERCP) consist of intravenous (IV) benzodiazepines and opiates. As yet, standardized dosing regimens for individual patients do not exist. The aims of this study were to (a) determine sedative doses in patients with and without a history of narcotic or benzodiazepine use, (b) assess the frequency of reversal agent utilization, and (c) assess potential predictive factors for reversal agent utilization. METHODS: Clinical data from January 1, 2004, to December 31, 2005, were abstracted from a computerized endoscopy database to determine: demographics, median sedation dosages, risk of reversal agent use, and clinical outcome related to sedation. Univariate and logistic regression analysis were performed to assess independent predictive factors for reversal agent utilization. RESULTS: Of 3,179 patients undergoing ERCP, 3,058 received sedation directed by the endoscopists. Meperidine and midazolam IV were given at a median dose of 125 mg and 7 mg, respectively, during a mean procedure time of 42 min. One hundred eighty-six patients reported routine use of narcotics or benzodiazepines (6%). These patients were younger, predominantly female, required higher doses of meperidine and midazolam, and received IV promethazine during procedural sedation more frequently than patients not using narcotics or benzodiazepines. One hundred twenty-four patients required reversal agents (4%). They were relatively older, required significantly higher doses of meperidine and received promethazine more frequently than the nonreversed group. CONCLUSIONS: In a single, high volume ERCP center, endoscopist administered sedation was provided in 96% of cases. Patient age ≥80 yr, dose of meperidine, and the use of promethazine were independent risk factors for the need of reversal agents. [ABSTRACT FROM AUTHOR]

The article provides information about the quality indicators that are particular to endoscopic retrograde cholangiopancreatography (ERCP). Preprocedural quality indicators of ERCP include appropriate indication, assessment of procedural difficulty and informed consent. Intraprocedural quality indicators begins with the administration of sedation and ends with the removal of the endoscope. Postprocedural quality indicators of ERCP include the detachment of the endoscope to patient dismissal.

The traditional endoscopic management of bile leaks involves placement of plastic endoprostheses. The success rate for closure of simple leaks (cystic duct, Luschka’s duct) with this approach is high. We describe 3 patients with complex biliary leaks of the gallbladder bed that were successfully closed by using transpapillary placement of covered self-expandable biliary stents. The stents were endoscopically removed after closure of the leak. All 3 patients had previously undergone open subtotal cholecystectomy for severe acute cholecystitis when complete cholecystectomy could not be performed because of dense acute inflammation. In 2 patients the leaks had not responded to traditional plastic biliary stent placement. This novel approach deserves further evaluation. [Copyright &y& Elsevier]

Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract.In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1–2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm2 using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients.Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1–5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone.Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and management of biliary tract complications after orthotopic liver transplantation (OLT) have been previously demonstrated. However, the role of ERCP in evaluating asymptomatic OLT patients with abnormal liver enzymes with a previously normal biliary tree remains poorly defined. We sought to assess the utility of ERCP in this subset of patients. METHODS: A retrospective analysis of asymptomatic OLT patients with abnormal liver enzymes evaluated by ERCP was undertaken. In addition to ERCP, all these patients had a diagnostic abdominal Doppler ultrasound, and a percutaneous liver biopsy. All patients had choledocho-choledoehostomy at the time of transplant and normal T-tube cholangiograms 3 months postoperatively. A radiologist, blinded to clinical findings, interpreted the ultrasound as normal, biliary dilation, or vascular abnormalities. The same radiologist interpreted ERCP findings. A pathologist, blinded to elinical findings, graded liver biopsies as normal, diagnostic, or abnormal but nondiagnostic. RESULTS: Twenty-two patients underwent 23 ERCPs. Twenty-two of the 23 ERCPs were normal (96%), and one abnormal ERCP finding did not explain the liver enzyme abnormality. Liver biopsy was diagnostic in 13 of 22 (57%) and in each case the ERCP was normal. Tbe remaining 10 liver biopsies were abnormal but nondiagnostic. Ultrasound was abnormal in five of 22 cases, but in the three cases suggesting biliary dilation, the ERCP was interpreted as normal. CONCLUSION: Routine use of ERCP in evaluation of asymptomatic OLT patients with liver function test abnormalities and normal cholangiograms al 3 months was not diagnostically useful. In this subset of patients, liver biopsy was usually abnormal and frequently diagnostic and should be the initial invasive diagnostic procedure. [ABSTRACT FROM AUTHOR]

In this article, the authors comment on a study by N. A. van der Gaag on the preoperative biliary stents of patients with pancreatic cancer. Findings include an initial endoscopic retrograde cholangiopancreatography (ERCP) procedural failure rate of 25 percent and (ERCP)-related complications of pancreatitis, perforation, bleeding and cholangitis. The authors believe that self-expandable metallic stents (SEMS) might have precluded some of the problems designed in the trial.

The article presents a case study of a 81-year-old man presented with upper abdominal pain, nausea, and vomiting after endoscopic retrograde cholangiopancreatography (ERCP).

The article describes a case of bile leak following surgical repair of a grade 3 liver lacerations from a gunshot wound in an 18-year-old male. It discusses how initial bleeding from the wound was controlled. It relates the management of the bile leak through endoscopic retrograde cholangiopancreatography (ERCP) and cholangiography.

Endoscopic retrograde cholangiopancreatography (ERCP), once a popular modality for diagnosing biliary tract and pancreatic disease, has passed its peak utilization. In the current issue of AJG, Jamal and colleagues summarize the trends in ERCP utilization in the United States from 1988 to 2002. While ERCP utilization had increased among certain ethnic groups, its overall use has dropped considerably since 1996. In particular, they report that the use of ERCP as a diagnostic tool and in the outpatient setting has declined. The introduction of less invasive pancreaticobiliary imaging tools, namely, endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), is likely responsible for this trend. However, ERCP is still used widely and appropriately in the therapy of pancreaticobiliary disorders. The complementary nature of alternative diagnostic tools such as EUS suggests that ERCP use will continue at its current rate, rather than fall out of favor. [ABSTRACT FROM AUTHOR]

Background & Aims: Distinction of immunoglobulin G4–associated cholangitis (IAC) from primary sclerosing cholangitis (PSC) or cholangiocarcinoma is challenging. We aimed to assess the performance characteristics of endoscopic retrograde cholangiography (ERC) for the diagnosis of IAC. Methods: Seventeen physicians from centers in the United States, Japan, and the United Kingdom, unaware of clinical data, reviewed 40 preselected ERCs of patients with IAC (n = 20), PSC (n = 10), and cholangiocarcinoma (n = 10). The performance characteristics of ERC for IAC diagnosis as well as the κ statistic for intraobserver and interobserver agreement were calculated. Results: The overall specificity, sensitivity, and interobserver agreement for the diagnosis of IAC were 88%, 45%, and 0.18, respectively. Reviewer origin, specialty, or years of experience had no statistically significant effect on reporting success. The overall intraobserver agreement was fair (0.74). The operating characteristics of different ERC features for the diagnosis of IAC were poor. Conclusions: Despite high specificity of ERC for diagnosing IAC, sensitivity is poor, suggesting that many patients with IAC may be misdiagnosed with PSC or cholangiocarcinoma. Additional diagnostic strategies are likely to be vital in distinguishing these diseases. [ABSTRACT FROM AUTHOR]