A 61-year-old woman with seropositive rheumatoid arthritis developed numerous ulcers due to pyoderma gangrenosum at suture entry/exit sites following an arthroplasty of the right hip when interrupted silk sutures were used to close the skin. When a subsequent arthroplasty was performed on the left hip and subcuticular Dexon sutures were used to close the skin only two small ulcers developed. Sixteen cases of pyoderma gangrenosum developing in surgical wounds have previously been reported. We recommend that surgery in patients with a history of pyoderma gangrenosum is performed when the pyoderma is clinically quiescent, and that subcuticular sutures are used for skin closure, thus avoiding puncturing the skin surface.

Aims 5-5-1 criteria have been proposed by the European Society of Gastrointestinal Endoscopy to define difficult ERCP cannulation. However, the criteria may be inappropriate for cannulation procedures with trainee involvement. Here we aimed to develop difficult cannulation criteria in trainee involved cannulation. Methods Patients undergoing biliary cannulation with (trainee group) or without trainee involvement (non-trainee group) were eligible. The procedures which might be too easy (e.g. fistula) or too difficult (e.g. altered anatomy) was excluded. The primary outcome was difficult cannulation, which was defined as the values of cannulation time, attempts, or inadvertent PD cannulation exceeding 75% percentile of each variable. Propensity score matching analysis was used. Results After PSM, there were 1596 patients in each group. The trainee group had longer median cannulation time [7.5 (2.2-15.3) min vs. 2.0 (0.6-5.2) min], more median attempts [5 (2-10) vs. 2 (1-4)] and median inadvertent PD cannulation [0 (0-2) vs. 0 (0-1)] compared with the non-trainee group (all p<0.001). 15-10-2 and 5-5-1 difficult cannulation criteria determined by exceeding 75% percentile of cannulation variables were proposed for trainee involved cannulation and were nearly confirmed for non-trainee involved cannulation, respectively. The proportion of difficult cannulation was 35.5% 95%CI [33.2%, 37.9%] and 31.8% 95%CI [29.5%, 34.2%] respectively (OR 1.18 95%CI [1.02-1.37]). The incidence of PEP (7.8% 95%CI [5.7%, 10.3%] vs. 9.8% 95%CI [7.4%, 12.8%]) in difficult patients were comparable. Conclusion By using 75% percentiles of cannulation-related variables as cutoff values, we proposed that 15-10-2 difficult cannulation criteria could be appropriate in trainee involved cannulation.

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