In this study, we analyzed the reports of CHS gastroenter- ologists on endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) adverse events to the Risk Management Authority, between January 1, 2000 and December 31, 2006. We aimed to characterize reports of errors or complications in patients’ management by gastro- enterologists performing ERCP and EUS for evaluation of bile duct and pancreatic diseases. Our paper is by all means not a review of procedure complications.
Endoscopic retrograde cholangiopancreatography (ERCP) is a technique developed by McCune et al. in 1968 and Takagi et al. and Ohi in 1969 and subsequently became widely used worldwide . Since then, as an ex- tension of this technique, various treatment methodologies have been developed and evolved. However, adverse outcomes, such as pancreatitis, are not rare, and measures to reduce these complications remain challenging. As to the complications of ERCP, pancreatitis, hemorrhage and gastrointestinal perforation are the primary exam- ples, among which pancreatitis may be severe and/or fatal. Various reports of high-risk groups regarding the development of ERCP-induced pancreatitis have been published. Fisk factors include a young age, female gender, normal pancreatogram findings, previous history of ERCP-induced pancreatitis, recurrent acute pancrea- titis and sphincter of Oddi dysfunction (SOD), etc., while operative risk factors involve the level of experience of the physician performing the operation, frequent pancreatography, precut EST, endoscopic papillary balloon dilatation (EPBD) and difficult intubation  -. Currently, treatment protocols for the treatment of acute pancreatitis based on evidence-based medicine comprise the use of massive transfusions at the early stage of onset and the administration of prophylactic antibiotics only. Furthermore, evidence regarding the efficacy of protease inhibitor therapy does not support the use of continuous arterial drop therapy. Although identifying high-risk groups and administering treatments such as preventive medications and pancreatic duct stent place- ment have been attempted as preventive measures for reducing the incidence of ERCP-induced pancreatitis, no effective strategies have been confirmed -. Therefore, providing sufficient hydration to prevent the onset of dehydration around the time of testing due to the effects of fasting is more critical in patients undergoing en- doscopic screening than in other cases. However, patients undergoing ERCP are normally instructed to fast starting the night before the procedure, similar to that required for normal endoscopy. Therefore, patients fre- quently complain of thirst and hunger at the time of testing and are often dehydrated, raising concern about the potential development of pancreatitis, a common ERCP complication, as well as the vasovagal reflex.
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Abstract: Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for the diagnosis and treatment of pancreatobiliary disease but requires a high level of endoscopic techniques, especially cannulation of the common bile duct (CBD). Peppermint oil has been reported to inhibit the contraction of smooth muscle. We hypothesized that spray of peppermint oil on papilla can shorten the cannulation time of ERCP. Methods: 160 pa- tients suspected of pancreatobiliary disease were randomly assigned to Peppermint oil group (group PO, n = 80) and Normal saline group (group NS, n = 80). After insertion of the duodenoscope and find the duodenal papilla, 20 mL of 1.6% peppermint oil solution (group PO) or Normal saline (group NS) was sprayed on the papilla by syringe via the working channel. The Deep CBD cannulation time, success rate of biliary cannulation and the incidence rate of adverse events were assessed. Results: The average cannulation time for the first 5 minutes was 189.7 (2-300) seconds in group PO and 237.8 (2-300) seconds in group NS (P = 0.03). The final success rate of biliary cannulation was 98.8% in group PO and 100.0% in group NS. The incidence rate of post-ERCP pancreatitis was 2.5% (2/80) in group PO and 6.3% (5/80) in group NS (P = 0.44). The mean amylase concentration was 177.4 (range 36-1067) IU/L in group PO and 267.5 (range 42-1733) IU/L in group NS (P = 0.04). Conclusion: Peppermint oil helps us to cannulate the papilla, shorten the time of cannulation, and reduce the incidence of hyperamylasemia after ERCP.
ERCP was performed in order to confirm bile duct pa- thologies and to provide treatment, after informed con- sent was received from the patients. The equipment used during the ERCP procedures were C-Arm (Siemens, In- dia), bipolar cautery (Olympus, Germany) and duodeno video endoscopy (Olympus, Japan). Every patient was admitted for treatment after fasting for eight hours. Par- enteral Buscopan was administered to all patients. Endo- scopic sphincterotomy (ES) and stone extraction were performed in the cases of stone, debris or parasitosis. In cases of tumoral lesions biopsy was performed for diag- nostic confirmation, and stent placement was carried out where needed. The ERCP procedure took approximately 30 minutes. The Social Security Institution paid TL 284 for ERCP in 2010.
Each patient or his/her relatives provided written informed con- sent after receiving verbal and written explanations of ERCP and possible post-procedure complications. The inclusion cri- teria: patients with age over 18 years old; underwent elective ERCP, the conditions of patients were informed. The exclusion cri- teria were an age of <18 years, pregnancy or breastfeeding, up- per gastrointestinal obstruction, Billroth II operation, severe hypo- xemia with ventilation/perfusion imbalance, acute myocardial in- farction within 3 months before the procedure, coagulopathy, and refusal to participate in the study. All patients’ medical his- tory was recorded, including the indications for ERCP, the pres- ence of concomitant diseases, and current medications. Endoscopic procedure
Pre-procedure evaluations considering complexity and indications are important, to weigh anticipated success rates into decision-making and consent. Prior studies correlating higher difficulty score and lower success were heterogeneous without sufficient adjustment for confounders; Verma et al. found no correlation between conventional cannulation success and procedure diffi- culty for trainees . Our results supported a relation- ship, although the absolute differences seen were small. Overall “case” complexity and difficulty is determined by many factors (of which cannulation is just one), and so, does not necessarily correlate with “cannulation” diffi- culty. The negative randomized trials of ERCP in mild to moderate acute gallstone pancreatitis should already limit its use in active pancreatitis due to limited efficacy ; but pancreatitis also predicted lower success rates in our study, perhaps related to duodenal edema, provid- ing more reason to avoid this context. Obstructive jaun- dice (mostly cancers) predicts lower success than in suspected stone cases; this is in keeping with a recent randomized trial advising against ERCP in obstructive jaundice from surgically resectable tumors mostly be- cause of morbidity related to cannulation/stenting fail- ures and rescue procedures (69%/83% success in drainage at ERCP in community/academic centers, re- spectively) . Post-surgical biliary issues (e.g. leaks, strictures) also predict lower success; this has not been previously reported; anatomic distortion, edema, or need for atypical positioning (e.g. supine) because of surgical wounds may contribute.
The diagnosis of intra-biliary rupture of hydatid cyst (IBRH) was difficult before the introduction of trans- abdominal ultrasound (TAUS), by which the sensitivity for detection of frank rupture is 60% - 90%   and reaching 100%   with the use of comouted tomography scan (CT scan). Some centers also advocate mag- netic resonance image (MRI) in the diagnosis of IBRH, and recently endoscopic ultrasound (EUS) has been in- troduced in the diagnosis of IBRH particularly in India . If obstructive jaundice is present TAUS, CT scan and MRI can show the cyst and the cystobiliary communications, but in patient with no jaundice the correct di- agnosis can be done only in 25% . IBRH is a serious complication of hepatic hydatidosis. High intracystic pressure up to 80 cm water is a predisposing factor . Preoperative ERCP may demonstrate frank rupture, but occult IBRH cannot be demonstrated by ERCP because of high intracystic pressure and small communication . An enlarging cyst may compress the surrounding paranchyma causing atrophy and fibrosis . The increase in the pressure inside the cyst precipitated by trauma, effort, labor or violent cough, could lead to rupture to the biliary tract or even the lung pleura or peritoneum, moreover acute pancreatitis and acutecholycystitis had been reported . Trans-abdominal ultrasonography may suggest the diagnosis of IBRH with the sensitivity from (64% - 94%) and the accuracy increase to (100%) by using CT scan   . There are several TAUS crite- ria for diagnosis of IBRH including the following :
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Initially the HOUSE-classification (Table 1) was developed and launched into clinical practice to gain financial reim- bursement and control of the increasing costs for endo- scopic devices used as well as the prolonged procedure times required to complete the expanding complexity of ERCP examinations done at the Karolinska University Hospital Huddinge, which over time has evolved into a national tertiary-referral center for advanced endoscopy. Concomitantly there was a continuous demand for the es- tablishment of a more accurate system for comparisons between different centers, both regarding results as well as post-procedural complication rates. The well merited opinion was that the more complex that the procedures became the greater was the risk that the results were marred by higher complication rates just because of the complexity of the case-mix among patients leading to higher costs. The original database was scored based on the perceived complexity of each procedure and classified into three groups, where group one represented the least complex procedures and group three the most complex (Table 1). One of the aims of the grading was that HOUSE class 1 procedures would represent the least complex rou- tine procedures as represented by those being performed at every hospital performing ERCP in Sweden; extraction of common bile duct stones, relief of obstructive jaundice due to periampullary cancer and intraoperative rendez- vous ERCP. The HOUSE class 2 represents the technically more advanced procedures mainly performed at the county hospitals like ERCP for intrahepatic stones, mul- tiple metal and plastic stenting and ERCP for Primary Sclerosing Cholangitits. The HOUSE class 3 is represented by ERCP procedures demanding extra resources like intra- ductal cholangioscopy (SpyGlass Direct Visualization Sys- tem, Boston Scientic Corp, Natick, Mass), double-balloon ERCP for Roux-en-Y operated patients or confocal endos- copy, all procedures being performed at the tertiary referral-centers (Table 1). The database of the HOUSE- classification was then compared with corresponding data from the GallRiks ’ database concerning complications in general and pancreatitis rates in particular.
All ERCP procedures were done by experienced endoscopists who car- ried out > 200 ERCP procedures per year. The procedures were performed with Side-viewing duodenoscopes (TJF-240/260V, Olympus). The precut technique was carried out in difficult case of biliary cannulation. Endo- scopic sphincterotomy was carried out if necessary. Endoscopic papillary balloon dilation (EPBD) using a dilator balloon (COOK) was carried out in patients who required anti-thrombot- ic drugs or a stricture in the pancrea- tobiliary system. Endoscopic mechan- ical lithotripsy (EML) was carried out in patients with stones more than 12 mm in dimension. Standard tech- niques, such as basket or extraction balloon or both were used for bile duct stone removal. Patients with pancreatobiliary stricture were biop- sied during the procedure. After the procedure, stents or nasobiliary cath- eters were used as appropriate for duct drainage. Most of the treatments were carried out for up to 30 min after inserting an endoscope. All the patients were hospitalized before the procedure. In the postprocedure recovery period, an endoscopy nurse written the clinical observation and then patients were hospitalized for additional 72 h to assess any post- ERCP complications.
In addition, due to the single-centered and retrospective design, our findings cannot be generalized to other acute care settings. Furthermore, we retrieved hospital records but we do not have information about the post-discharge phases of care of the studied ERCP-treated patients. Finally, a major limitation is the lack of a structured, homogenous assessment of the ERCP candidates pre-operatively, which translates to the selection bias enlightened by our analysis. The only study that tried to assess the ERCP-related risk in the elderly population considering multiple domains suggested to include the Duke Activity Status Index (DASI, ranging from 0 to 58.2) to evaluate the functional capacity of subjects with cardiovascular disorders, with higher scores indicating better functional status. Further studies are necessary to confirm the importance of multidimensional scores, i.e. one or more tools able to describe the older patient comprehensively .
Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive proced ure for diagnosis and treatment of biliary and pancreatic diseases. Even in the best hands, complications may occur in 2% - 10% of the cases, pancreatitis, cholangitis, perforation, and bleeding from papillotomy being the most frequent ones . The overall mortality rate after a diagnostic ERCP is approximately 0.5%, while death rates after therapeutic ERCP are twice as high, and may occur from any of the complications described previously .
Results. Epigastric pain was the most common symptom reported by patients with pancreatolithiasis. The sensitivity of imaging tests in the diagnosis of pancreatic duct stones was as follows: abdominal ul- trasonography – 31%, endoscopic retrograde cholangiopancreatography (ERCP) – 67%, computed tomo- graphy – 71%, endoscopic ultrasonography – 73%. In 6 patients ERCP and sphincterotomy were performed along with stenting of the main pancreatic duct. Three other subjects were qualified for surgical treatment. In 7 selected patients conservative treatment and further observation were applied.
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved into a complex procedure involving spe- cialized operators, equipment and supporting personnel. ERCP was first described in 1965 as a novel method for imaging the pancreatic duct and biliary tree . Successful management of choledocholithiasis with biliary sphincterotomy was described in 1974 by Classen  in Germany and Kawai  in Japan. Advances in compu- terized axial tomography (CT) body imaging, endoscopic ultrasound (EUS), and magnetic resonance cholan- giopancreatography (MRCP) have been essential in the evolution of ERCP applications from diagnostic to the- rapeutic. By 2007, estimated 500,000 ERCPs were performed annually in the US. ERCP utilization has steadily increased over time , with current annual US ERCP volumes expected to exceed those published in 2007 . Analysis of the 2006 National Inpatient Sample Database for US ERCPs found that 90 percent were performed in centers with volumes of less than 200 per year, suggesting a large portion of ERCPs during the study period were performed in a community setting .
Background: Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis.
ACP: Anaplastic carcinoma of the pancreas; AMY: Serum amylase; CK: Cytokeratin; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasonography; EUS- FNA: Endoscopic ultrasound-guided fine-needle aspiration; FNA: Fine-needle aspiration; Gd-EOB-DTPA: Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid; JPS: Japan Pancreas Society; MPD: Main pancreatic duct; MRCP: Magnetic resonance cholangiopancreatography; OCGCs: Osteoclast- like giant cells; P-AMY: Pancreatic amylase; PDAC: Pancreatic ductal adenocarcinoma; PET: Positron emission tomography; S-1: Tegafur/gimeracil/ oteracil; UICC: Union for International Cancer Control
function of the sphincter of Oddi, and fewer ERCP-related complications [20, 21]. Although many studies have proven that LCBDE+LC is both feasible and effective in the management of CCL [22, 23], one retro- spective cohort study performed in the United States showed that the overall use of ERCP+LC for treatment of CCL increased from 52.8% of admissions in 1998 to 85.7% in 2013 and that the percentage of patients with CCL undergoing CBDE (including open CBDE and lap- aroscopic CBDE) decreased from 39.8 to 8.5% in the same period. These results indicate that despite the po- tential benefits of LCBDE+LC over ERCP+LC for man- aging CCL, the current trends in CCL management continue, and CBDE may be at risk of disappearing from the surgical armamentarium . Although the results of various studies strongly support this view, which treatment strategy is more beneficial to patients with CCL, especially those with a history of gastrectomy, still needs further investigation.
The role of IOC in prevention and management of BDI remains controversial [18–20]. The rate of iatro- genic BDIs is 0.4–0.6 % in LC compared to the open procedure (0.2–0.3 %). Although iatrogenic injuries are more readily recognized by IOC, some studies found no difference in the incidence of BDIs between routine and selective IOC, and no association between anatomical anomalies and iatrogenic injuries. Some studies have demonstrated no benefit in preventing BDI using IOC. An Italian study of 56 591 LCs performed during 1998–2000 reported a BDI incidence of 0.42 % . There was no significant difference when IOC was per- formed routinely or selectively (0.32 % vs 0.43 %). In a multicenter retrospective study of 2714 cases, five (0.18 %) had major BDIs requiring surgical repair . Postoperative bile leakage was encountered in seven cases (0.26 %). The authors concluded that LC can be performed safely without IOC, with acceptable rates of biliary complications, provided that there is proper de- tection of silent CBD stones and postoperative ERCP is available. A retrospective cohort study comprising all Texas Medicare patients from 2000 to 2009 compared IOC during LC from multivariate logistic regression models with instrumental variable analyses . The BDI rate was 0.21 % among 37 533 patients with IOC and 0.36 % among 55 399 patients without IOC. How- ever, the association between LC performed without IOC and BDI was no longer significant when confounding was controlled with instrumental variable analysis. In contrast, another systematic review found a protective ef- fect of routine IOC on BDI during LC. The study from Argentina of 11 423 consecutive LCs during 1991–2012 showed that routine IOC in LC was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good out- come .
Another patient family experience issue was the logis- tics on the day of the procedure. Confusion was perpet- uated by virtue of two related yet functionally uncoupled procedures being performed on the same day. The morning of the ESWL, the patient would be asked at the check-in desk, ‘Will you be receiving an ERCP with your ESWL today?’. The patient checked in at the outpatient surgery desk in the first building and walked to the ESWL preprocedural prep area in a second building. Then, the patient would undergo the ESWL procedure and be transported to the surgical recovery area in the second building. After recovery, the patient was transported to the GI procedural area in a third building where, on ERCP completion, the patient was cared for in that proce- dural recovery area (figure 1). During the course of this movement spanning three buildings, the families tended to be unaware of the physical whereabouts of their loved ones and unsure where to wait to hear from the treating physician (urologist or gastroenterologist). The solu- tion to this logistics puzzle was to have the patient check in to one area where all procedures, consultations and recovery would take place.
From January 1999 to December 2014, alltogether 217 consecutive, elective patients with gallbladder stones and concomitant CBD stones were treated in our hospital. The one-stage group consisted of 97 consecutive patients who underwent LCBD exploration and concomitant LC in elective setting, with preoperative or intraoperative confirmation of choledocholithiasis. The two-stage group consisted of 120 consecutive patients with CCL who underwent preoperative ERCP + ES followed by elective LC. The flow chart of patients is presented in Fig. 1. Excluded from the study were patients who were sched- uled for emergency LC due to acute cholecystitis, patients considered unfit for surgery or those few who refused cholecystectomy after ERCP and EST, and patients need- ing urgent ERCP for acute cholangitis.
The small caliber of the cystic duct and its tortuosity make detection difficult with axial CT and US and cholescintigraphy is further limited by low resolution. Optimal visualization of the cystic duct requires direct cholangiography or MR cholangiopancreatography, both of which depict the cystic duct in the coronal plane along its long axis   .