Adverse events associated with ERCP

Chandrasekhara, Vinay; Khashab, Mouen A.; Muthusamy, V. Raman; Acosta, Ruben D.; Agrawal, Deepak; Bruining, David H.; Eloubeidi, Mohamad A.; Fanelli, Robert D.; Faulx, Ashley L.; Gurudu, Suryakanth R.; Kothari, Shivangi; Lightdale, Jenifer R.; Qumseya, Bashar J.; Shaukat, Aasma; Wang, Amy; Wani, Sachin; Yang, Julie; DeWitt, John M.

doi:10.1016/j.gie.2016.06.051

Cited by 610 publications

(588 citation statements)

References 169 publications

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“…The results presented here suggest that a subgroup of physicians does not believe that the use of NSAIDs might have an impact on their own practice; or they do not want to change their habits. Prophylactic pancreatic stenting is indicated in high-risk patients (previous history of PEP, sphincter of Oddi dysfunction, precut, pancreatic sphincterotomy, and multiple PD accesses or injections) [1, 4]. It is difficult to know the real percentage of physicians doing it, but it is probably < 50%, similar to the results of the survey done 8 years ago [8].…”

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confidence: 93%

“…The European Society of Gastrointestinal Endoscopy (ESGE) and American Society of Gastrointestinal Endoscopy (ASGE) published guidelines on PEP prevention in 2014 and 2017, respectively, where both patient- and procedure-associated risk factors are identified, and prophylaxis measures are evidence-based and recommended [1, 4]. These measures may be as simple and safe as the use of rectal nonsteroidal anti-inflammatory drugs (NSAIDs; indometacin, diclofenac) or more technically demanding as the use of protective pancreatic stents.…”

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confidence: 99%

“…These measures may be as simple and safe as the use of rectal nonsteroidal anti-inflammatory drugs (NSAIDs; indometacin, diclofenac) or more technically demanding as the use of protective pancreatic stents. Systemic interventions, such as periprocedural vigorous hydration, may reduce not only the incidence but also the severity of PEP [1, 4]. …”

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confidence: 99%

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Prophylaxis of Post-ERCP Pancreatitis: The Gap between Evidence-Based Guidelines and Clinical Practice

Rio-Tinto

Devière

2018

GE Port J Gastroenterol

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confidence: 93%

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confidence: 99%

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Prophylaxis of Post-ERCP Pancreatitis: The Gap between Evidence-Based Guidelines and Clinical Practice

Rio-Tinto

Devière

2018

GE Port J Gastroenterol

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“…However, ERCP is a challenging technique with a slow learning curve and is associated with complications, some of them life-threatening [4-6]. Post-ERCP pancreatitis (PEP) is the most common and serious complication after ERCP [7].…”

Section: Introductionmentioning

confidence: 99%

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Lopes

Canena

2018

GE Port J Gastroenterol

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Background/Aims: Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods: A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results: Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions: There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message: There is a significant gap between guidelines and routine clinical practice.

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“…Complications of ERCP have been evaluated by meta-analyses with pancreatitis reported at 3.5% of cases, bleeding at 0.3-2%, perforation <0.6% and infection <3%. 1 Complications are also a function of factors associated with the patient, procedure and operator, resulting in variable susceptibility to the adverse outcomes of ERCP. 1,2 Malcolm Gladwell in his book Outliers: The Story of Success suggests that 10 000 h of correctly carrying out a skill is required in order to obtain expertise.…”

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Endoscopic retrograde cholangiopancreatography cannulation in the difficult duct: Which technique should you pull out of your bag?

Ahmed

Wilcox

2017

Digestive Endoscopy

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Golf and endoscopic retrograde cholangiopancreaticography (ERCP) share a commonality where the highs of the successes are balanced by the lows of the frustrations. ERCP cannulation is one of the most difficult maneuvers in gastrointestinal endoscopy and is a requirement for the procedure's therapeutic benefit. As such, many different techniques have been developed to facilitate cannulation. The mission of the procedure is to provide access to the biliary or pancreatic duct typically with a guidewire, which can then be used as a platform for therapeutic and diagnostic procedures. An inherent challenge in ERCP is that the operator must make use of a two-dimensional imaging surrogate through fluoroscopy and navigate the threedimensional biliary or pancreatic duct pathway. The advanced nature of this procedure lends itself to higher complication rates including post-procedure pancreatitis, bleeding, perforation and infection. Complications of ERCP have been evaluated by meta-analyses with pancreatitis reported at 3.5% of cases, bleeding at 0.3-2%, perforation <0.6% and infection <3%.1 Complications are also a function of factors associated with the patient, procedure and operator, resulting in variable susceptibility to the adverse outcomes of ERCP. 1,2Malcolm Gladwell in his book Outliers: The Story of Success suggests that 10 000 h of correctly carrying out a skill is required in order to obtain expertise.3 ERCP as a discipline is one such example, as its mastery requires the experience of over thousands of procedures. Many different techniques, equipment platforms, devices and strategies have been developed to assist ERCP cannulation.Standard cannulation techniques will involve use of a 5-7 Fr cannula or sphincterotome with either a blunt or tapered tip often with a guidewire. That wire will either be long (450 cm) or short (260 cm) with a straight or angled tip and usually 0.035 inches or 0.025 inches in diameter. The catheter would be positioned in front of Vater's ampulla and bowed to align along the biliary duct axis. Sometimes, the devices can be steered for better alignment with the papilla.The papillotome is inserted into the papillary orifice and the guidewire is advanced under fluoroscopic guidance until observed to enter the bile duct. Contrast injection is not always routinely administered prior to advancement of the guidewire into the common bile duct (CBD). Physicians will develop preferences based on their skill sets and that of their teams in order to provide the best outcome for their patients.The European Society of Gastrointestinal Endoscopy (ESGE) defines challenging biliary cannulation as five contacts with the papilla, or more than 5 min after the major ampulla has been located or after unintentional pancreatic duct cannulation or contrast injection. 4 At times, anatomy such as the shape, size or consistency of the ampulla, the position of the ampulla with a nearby diverticulum, gastrointestinal stricture or altered anatomy from prior surgery may contribute to the complexity.In this issue of ...

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Adverse events associated with ERCP

Abstract: This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text

Cited by 610 publications

References 169 publications

Prophylaxis of Post-ERCP Pancreatitis: The Gap between Evidence-Based Guidelines and Clinical Practice

Prophylaxis of Post-ERCP Pancreatitis: The Gap between Evidence-Based Guidelines and Clinical Practice

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Endoscopic retrograde cholangiopancreatography cannulation in the difficult duct: Which technique should you pull out of your bag?

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