Jo Vandervoort

Risk factors for complications after performance of ERCP

BACKGROUND ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Accuracy and complication rate of brush cytology from bile duct versus pancreatic duct

BACKGROUND The accuracy and complication rates of brush cytology obtained from pancreaticobiliary strictures have not been fully defined. In this study we compared the accuracy and complications of brush cytology obtained from bile versus pancreatic ducts. METHODS We identified 148 consecutive patients for whom brush cytology was done during an ERCP from a database with prospectively collected data. We compared cytology results with the final diagnosis as determined by surgical pathologic examination or long-term clinical follow-up. We followed all patients and recorded ERCP-related complications. RESULTS Forty-two pancreatic brush cytology samples and 101 biliary brush cytology samples were obtained. The accuracy rate of biliary cytology was 65 of 101 (64.3%) and the accuracy rate of pancreatic cytology was 30 of 42 (71.4%). Overall sensitivity was 50% for biliary cytology and 58.3% for pancreatic cytology. Of 67 patients with pancreatic adenocarcinoma, sensitivity for biliary cytology was 50% versus 66% for pancreatic cytology. Concurrent pancreatic and biliary cytology during the same procedure increased the sensitivity in only 1 of 10 (10%) patients. Pancreatitis occurred in 11 (11%) patients (9 mild cases, 2 moderate cases) after biliary cytology and in 9 (21%) patients (6 mild cases, 3 moderate cases) after pancreatic cytology (p = 0.22). In 10 patients who had pancreatic brush cytology, a pancreatic stent was placed. None of these patients developed pancreatitis versus 9 of 32 (28%) patients in whom a stent was not placed (p = 0.08). Pancreatic cytology samples obtained from the head of the pancreas were correct in 13 of 18 (72%) cases, from the genu in 7 of 7 (100%) cases, from the body in 5 of 9 (55%) cases, and from the tail in 4 of 7 (57%) cases. CONCLUSION The accuracy of biliary brush cytology is similar to the accuracy of pancreatic brush cytology. The yield of the latter for pancreatic adenocarcinoma is similar to that of the former. Complication rates for pancreatic cytology are not significantly higher than the rates for biliary cytology. The placement of a pancreatic stent after pancreatic brushing appears to reduce the risk of postprocedure pancreatitis.

Safety of ERCP during pregnancy.

OBJECTIVES:There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy.METHODS:We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential.RESULTS:The mean patient age was 28.9 yr (15–36 yr). The mean duration of gestation was 25 wk (12–33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD ± 1.8). An estimated fetal radiation exposure was 310 mrad (SD ± 164) which is substantially below the accepted teratogenic dose.CONCLUSIONS:ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability. Further controlled clinical studies may be needed to clarify aspects of these statements, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. ESGE guidelines are intended to be an educational device to provide information that may assist endoscopists in providing care to patients. They are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment

Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients

BACKGROUND The self-expandable metal stent (SEMS) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. OBJECTIVE To document performance, safety, and effectiveness of colorectal stents used per local standards of practice in patients with malignant large-bowel obstruction to avoid palliative stoma surgery in incurable patients (PAL) and facilitate bowel decompression as a bridge to surgery for curable patients (BTS). DESIGN Prospective clinical cohort study. SETTING Two global registries with 39 academic and community centers. PATIENTS This study involved 447 patients with malignant colonic obstruction who received stents (255 PAL, 182 BTS, 10 no indication specified). INTERVENTION Colorectal through-the-scope SEMS placement. MAIN OUTCOME MEASUREMENTS The primary endpoint was clinical success at 30 days, defined as the patients ability to maintain bowel function without adverse events related to the procedure or stent. Secondary endpoints were procedural success, defined as successful stent placement in the correct position, symptoms of persistent or recurrent colonic obstruction, and complications. RESULTS The procedural success rate was 94.8% (439/463), and the clinical success rates were 90.5% (313/346) as assessed on a per protocol basis and 71.6% (313/437) as assessed on an intent-to-treat basis. Complications included 15 (3.9%) perforations, 3 resulting in death, 7 (1.8%) migrations, 7 (1.8%) cases of pain, and 2 (0.5%) cases of bleeding. LIMITATIONS No control group. No primary endpoint analysis data for 25% of patients. CONCLUSION This largest multicenter, prospective study of colonic SEMS placement demonstrates that colonic SEMSs are safe and highly effective for the short-term treatment of malignant colorectal obstruction, allowing most curable patients to have 1-step resection without stoma and providing most incurable patients minimally invasive palliation instead of surgery. The risk of complications, including perforation, was low.

Pancreatic duct stents for “obstructive type” pain in pancreatic malignancy

Abstract OBJECTIVE: Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with “obstructive” pain due to pancreatic malignancy. METHODS: Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had “obstructive” type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47–80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients. RESULTS: There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than “obstructive” pain. CONCLUSIONS: Pancreatic stent placement for patients with “obstructive” pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.

Therapeutic ERCP in outpatients

BACKGROUND We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours. METHODS We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution. RESULTS Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death. CONCLUSIONS A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Self-Expanding Metal Stenting for Palliation of Patients with Malignant Colonic Obstruction: Effectiveness and Efficacy on 255 Patients with 12-Month's Follow-up

Background. Self-expanding metal stents can alleviate malignant colonic obstruction in incurable patients and avoid palliative stoma surgery. Objective. Evaluate stent effectiveness and safety on palliation of patients with malignant colorectal strictures. Design. Two prospective, one Spanish and one global, multicenter studies. Settings. 39 centers (22 academic, 17 community hospitals) from 13 countries. Patients. A total of 257 patients were enrolled, and 255 patients were treated with a WallFlex uncovered enteral colonic stent. Follow-up was up to 12 months or until death or retreatment. Interventions(s). Self-expanding metal stent placement. Main Outcome Measures. Procedural success, clinical success, and safety. Results. Procedural success was 98.4% (251). Clinical success rates were 87.8% at 30 days, 89.7% at 3 months, 92.8% at 6 months, and 96% at 12 months. Overall perforation rate was 5.1%. Overall migration rate was 5.5%. Overall death rate during follow-up was 48.6% (124), with 67.7% of deaths related to the patients colorectal cancer, unrelated in 32.3%. Only 2 deaths were related to the stent or procedure. Limitations. No control group. Conclusions. The primary palliative option for patients with malignant colonic obstruction should be self-expanding metal stent placement due to high rates of technical success and efficacy in symptom palliation and few complications.

Use of endoscopic band ligation in the treatment of ongoing rectal bleeding

Lower GI bleeding is self-limiting in the majority of cases and only 15% of patients require further diagnostic evaluation and treatment. Although surgery has been the treatment of choice in severe ongoing bleeding of the colon and rectum, new endoscopic treatment modalities are being evaluated as alternatives. One of these is endoscopic band ligation. We report two patients with severe ongoing rectal bleeding successfully treated by band ligation as an alternative to surgery.

A new technique to retrieve an intrabiliary stent: a case report ☆ ☆☆

Endoscopic placement of stents is routine in obstructive pancreaticobiliary disease. Perforation, pancreatitis, bleeding and cholangitis are early stent-related complications, whereas distal or proximal stent migration may present later. Management of a proximally migrated stent is a challenge for the endoscopist despite the choice of several different techniques. We describe a new technique we used to retrieve an intrabiliary stent whose distal end was embedded in the bile duct wall.