Using air cholangiography to reduce postendoscopic retrograde cholangiopancreatography cholangitis in patients with malignant hilar obstruction.

Background: Cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major problem for patients with hilar biliary obstruction. To date, it remains unclear whether air-contrast cholangiography (ACC) can reduce cholangitis in these patients. For this reason, our study assesses the efficacy of reducing cholangitis through ACC. Methods: This paper presents a retrospective study conducted at a tertiary university hospital. We enrolled patients who were diagnosed with hilar structures and underwent ERCP between January 2012 and December 2018. From 2015 onwards, ACC was performed following the successful selective cannulation into the dilated intrahepatic bile duct of these patients. The primary aim was to assess patients with cholangitis in both an ACC group and iodine contrast cholangiography (ICC) group. Results: This study included 80 patients, 35 of whom received ACC and 45 who received ICC. There were no differences between the 2 groups in terms of the number of patients who underwent endoscopic papillotomy, endoscopic nasobiliary drainage, endoscopic biliary stent placement, or other technical procedures or complications. A total of 19 patients (23.8%) presented with fever (cholangitis) after the ERCP procedure (4 ACC, 15 ICC; 11.4% vs. 33.3%, respectively; P=0.03). One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Among the other 18 cholangitis patients, 8 (1 ACC, 7 ICC) were treated with additional ERCP or percutaneous transhepatic biliary drainage (PTBD), while the remaining 10 only received antibiotics. One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Conclusions: We found that ACC significantly reduced the incidence of cholangitis in patients with hilar obstruction.

Dilation Time in Endoscopic Papillary Balloon Dilation for Common Bile Duct Stones.

BACKGROUND: To assess the short-term outcomes after endoscopic sphincterotomy (EST) plus endoscopic papillary balloon dilation (EPBD) versus EPBD alone and appropriate balloon dilation time in EPBD alone. MATERIALS AND METHODS: A total of 413 patients with common bile duct stones (CBDSs) were included in the EST plus EPBD group and 84 were in the EPBD alone group. We retrospectively evaluated the safety and efficacy between EST plus EPBD and EPBD alone group. The patients in EPBD alone group were assigned to dilation time ≥5 minutes group (n=35) and time <5 minutes group (n=49). Further, we preliminarily discussed the influence of balloon dilation time on the procedure-related complications. RESULTS: Compared with EST plus EPBD, the patients in EPBD alone group were younger [56.6 (range: 18 to 95) vs. 65.1 (24 to 92) y; P=0.006], had smaller diameter of the largest stone [10.4 (range: 3 to 20) vs. 12.3 (5 to 30) mm; P<0.001] and were lesser frequently performed with jaundice [22 (26.2%) vs. 189 (45.8%); P=0.001]. The mean duration of postoperative hospital stay in EPBD alone group was significantly shorter than EST plus EPBD group [6.3 (range: 1 to 18) vs. 9.2 (1 to 44) d; P<0.001]. The patients in EPBD alone group had higher risk of post endoscopic retrograde cholangiopancreatography pancreatitis than EST plus EPBD group [11 (13.1%) vs. 22 (5.3%); P=0.009]. Patients in the dilation time <5 minutes group had higher risk to suffer from postoperative pancreatitis than the EST plus EPBD group [9 (18.4%) vs. 22 (5.3%); P=0.002], while patients in the dilation time ≥5 minutes group had less procedure-related hemorrhage than the EST plus EPBD group [0 vs. 36 (8.7%); P=0.047]. CONCLUSION: Long balloon dilation time in EPBD alone is safe and effective in treating CBDSs.

Risk factors for post-ERCP pancreatitis and hyperamylasemia: A retrospective single-center study.

OBJECTIVE: With an increased use of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP complications have attracted much attention. We aimed to identify independent risk factors of post-ERCP pancreatitis (PEP) and hyperamylasemia, and to develop a simple scoring system of the factors contributing to the clinical prevention against PEP. METHODS: A retrospective single-center analysis was performed in 4234 ERCP procedures between September 2007 and December 2012. Patient-related and procedure-related risk factors for PEP and post-ERCP hyperamylasemia were identified by univariate and multivariate regression analyses. A scoring system was developed based on the independent risk factors. RESULTS: PEP occurred in 226 (5.3%) ERCP procedures and hyperamylasemia in 774 (18.3%) procedures. Female gender (odds ratio [OR] 1.449), first-time ERCP (OR 1.745), latent jaundice (OR 1.917), difficult cannulation (OR 3.317) and pancreatography (OR 1.823) were all proven to be significant risk factors for predicting PEP. In addition, difficult cannulation (OR 1.990) and pancreatography (OR 2.009), age <60 years (OR 1.294), prior diabetes (OR 0.614), biliary duct stent placement (OR 1.884) and nasobiliary drainage (OR 1.613) were associated with developing hyperamylasemia. Prophylactic pancreatic duct stent (PS) might prevent against PEP in significantly high-risk patients (score ≥6). CONCLUSIONS: Both patient-related and procedure-related risk factors are important for predicting PEP and post-ERCP hyperamylasemia. Technical procedures, for example, PS, are necessary to prevent PEP in patients at the highest risk.

Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation.

OBJECTIVE: Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC). METHODS: A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups. RESULTS: Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group (P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group (P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group (P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups. CONCLUSIONS: Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty.