Endoclip combined with colonic transendoscopic enteral tubing: a new approach for managing iatrogenic colonoscopy perforation.

BACKGROUND: Iatrogenic colonoscopy perforation (ICP) is a rare but most serious complication during colonoscopy investigation. However, endoscopic closure plays an important role in the dealing with ICP with the development of endoscopic techniques presently, there are still some portion of patients transferred to surgery. METHODS: Once a perforation was detected, endoclips were used to closed the defect of the colon. Then a colonic TET was planted inside the colon. The terminal end of the TET was put proximally to or near the location of the perforation. Then gas and fluid was sucked out through the TET with a syringe every 4 h. RESULTS: Three cases were treated with endoclip closure and colonic TET drainage. Case 1 was caused by urgent immediate perforation during routine colonoscopy, case 2 was delayed perforation after snare resection, and case 3 was ESD-related perforation. All patients got healed, no one transferred to surgery. CONCLUSIONS: A combination of endoclip closure and colonic TET drainage might be an easy and potential method in the dealing with different types of ICP. This study may offer a novel paradigm for addressing endoscopy-related intestinal perforations.

Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience.

BACKGROUND: Periampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty. AIM: This study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events. METHODS: Prospectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models. RESULTS: Significant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation. CONCLUSION: The presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1. Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/.

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation.

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population. AIM: To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events. METHODS: A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events. RESULTS: There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis. CONCLUSION: Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.