Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update.

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Endoscopic ultrasound-guided vs ERCP-guided biliary drainage for malignant biliary obstruction: A up-to-date meta-analysis and systematic review.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being used increasingly as an alternative treatment for malignant biliary obstruction (MBO). However, few studies have compared EUS-BD and endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD). We searched the PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases until 1 November 2020 for studies comparing EUS-BD versus ERCP-BD. The primary outcomes of interest in this study were technical and clinical success. Nine studies involving 634 patients were included in this meta-analysis. Regarding technical and clinical success, there were no significant differences between EUS-BD and ERCP-BD (odds ratio [OR], 0.76; 95% CI: 0.30-1.91; OR, 1.45, 95% confidence interval [CI], 0.66-3.16, respectively). EUS-BD was associated with significantly less reintervention vs ERCP-BD (OR, 0.36, 95% CI, 0.15-0.86). Regarding adverse events, the rates were similar for EUS-BD and ERCP-BD (OR: 0.75, 95% CI, 0.45-1.24). There were no significant differences in the types of adverse events (stent occlusion, stent migration, stent dysfunction, and duration of stent patency) between the two techniques. EUS-BD was associated with lower reintervention rates compared with ERCP-BD, with comparable safety and efficacy outcomes. However, more high-quality randomized trials are required.

Present and future role of endoscopic retrograde cholangiography in primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC) is a rare, inflammatory cholestatic liver disease that causes biliary strictures which can lead to secondary complications. About 30-50% of PSC patients develop dominant strictures (DS) in the biliary tree, which are both the cause of jaundice and bacterial cholangitis as well as predilection spots for development of neoplastic development. Cancer is the most common cause of death in PSC. A central concern is to distinguish malignant from benign strictures, which eventually is done by invasive methods to obtain a brush cytology or biopsy sample, in most cases via endoscopic retrograde cholangiography-pancreatography (ERCP). Since medical therapies, like ursodesoxycholic acid or immunosuppressive drugs have no proven effect, therapeutic ERCP has become the primary management strategy to improve symptoms and in some patients may slow down disease progression. This article aims at outlining the current and emerging methods in ERCP in PSC patients.

What Would Be the Appropriate Number of Clinical ERCP Cases for Trainees to Acquire Basic Competence? A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is technically demanding and carries significant risks. It is performed by gastrointestinal and surgical endoscopists. There is no consensus on the minimum number of ERCPs required during training. This study was conducted to analyze the minimum number of clinical ERCPs that a trainee needs to perform to achieve competency. PubMed, Ovid-Embase, and the Cochrane library were searched systematically for prospective and retrospective studies reporting on trainees' ERCP performance. Mete-analysis was conducted to analyze the success rate of cannulation, other basic techniques, and adverse event rate, using the random-effect model with Review Manager 5.3. Thirteen studies met the inclusion criteria, with 149 trainees performing a total of 18 794 ERCP procedures. The pooled cannulation success rate was 85.7% (95% CI: 78.1%-91.0%) at completion of training. The cannulation success rate was 76.5% (95% CI: 69.2%-82.5%) when the trainees had completed 180 ERCPs, which increased to 81.8% (95% CI: 69.8%-90.6%) after 200 ERCP procedures. Adverse events and post-ERCP pancreatitis rates were 4.7% (95% CI: 2.9%-9.1%) and 2.0% (0.9%-3.9%), respectively. Achieving a cannulation success rate of >90% was considered a quality indicator for ERCP training by most societal guidelines. However, our retrospective analysis indicated that trainees only attained a pooled cannulation success rate of only 81.8% after 200 procedures. Therefore, the minimum number of ERCPs required to achieve competency during training may need to be redefined to meet the basic requirement.

Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models.

Introduction: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) applications are rapidly evolving toward increasingly complex therapeutic approaches alongside with technological innovations. There are no globally agreed indications on the ERCP training path, which often requires too much time and does not always guarantee adequate skills.Areas covered: Frequency and difficulty of execution are the main objective criteria on which to draw up a training program: novel trainees should approach ERCP first through the simplest and most frequent procedures. An extensive use of training models would reduce the patient's performer-related risks. Amongst a wide variety of models, mechanical simulators have received large approval. In fact, they can be best-suited to each trainee's learning curve thanks to their precision and safety and by virtue of the unlimited repeatability of their use. However, more solid evidences are still needed.Expert opinion: Hands-on ERCP training should systematically employ mechanical simulators at least in the early stages of the learning process. An implementation of these models through sensors that objectively detect abnormalities in the movements would provide detailed feedbacks and deeper awareness. Simulators might also be useful for expert endoscopists to refine their skills. Rapid prototyping and 3D printing might be the way to create customized training models for successful training programs.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Patients with Performance Status 4.

BACKGROUND: The risk related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Eastern Cooperative Oncology Group performance status (PS) 4 is uncertain and remains a concern. AIMS: We aimed to examine the safety and efficacy of ERCP in patients with PS4 compared to those in patients with PS0-3. METHODS: A total of 1845 patients met the eligibility criteria for study inclusion between 2014 and 2018. The patients were divided into two groups: PS0-3 and PS4 groups. The adverse event and therapeutic success rates in each group were compared. Propensity score matching was performed to adjust for differences between the groups. RESULTS: The therapeutic success rate was 96% in both groups. The overall adverse event rate was 6% and 10% in the PS0-3 and PS4 groups, respectively, showing no significant difference (P = 0.272). Although the rates of pancreatitis, bleeding, perforation, and cholangitis were equivalent in both groups, the pulmonary adverse event rate was significantly higher in the PS4 group (5% vs. 0.4%; P = 0.006). Severe adverse events were also significantly more frequent in the PS4 group (8% vs. 2%; P = 0.012). Multivariate analyses showed that long procedure time was a significant risk factor for adverse events in patients with PS4 (odds ratio, 10.70; 95% CI 1.30-87.70; P = 0.028). CONCLUSIONS: Although ERCP can be performed effectively in patients with PS4, the risk of pulmonary and severe adverse events is high. Prolonged procedures should be avoided in patients with PS4.

Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA.

BACKGROUND: Our aim was to assess the differences in outcomes of cholecystitis, pancreatitis, gastrointestinal (GI) bleed, GI perforation, and mortality in teaching versus nonteaching hospitals nationwide among therapeutic and diagnostic ERCPs. We hypothesized that complication rates would be higher in teaching hospitals given greater patient complexity. METHODS: Inpatient diagnostic and therapeutic ERCPs were identified from the National Inpatient Sample (NIS) from 2008 to 2012. The presence of ACGME-approved residency programs is required to qualify as a teaching hospital. Nonteaching urban and rural hospitals were grouped together. We identified hospital stays complicated by pancreatitis, cholecystitis, GI hemorrhage, perforation, and mortality. Logistic regression propensity-matched analysis was performed in SPSS to compare differences in complication rates between teaching and nonteaching hospitals. RESULTS: A total of 1,466,356 weighted cases of inpatient ERCPs were included in this study: of those, 367 and188 were diagnostic, 1,099,168 were therapeutic, 766,230 were at teaching hospitals, and 700,126 were at nonteaching hospitals. Mortality rates were higher in teaching hospitals when compared to nonteaching hospitals for diagnostic (OR 1.266, p < 0.001) and therapeutic ERCPs (OR 1.157, p = 0.001). There was no significant difference in rates of post-ERCP cholecystitis, pancreatitis, or perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to nonteaching hospitals (OR 1.181, p = 0.003). Likewise, length of stay was increased in teaching hospitals (7.9 vs 6.9 days, p < 0.001, for diagnostic and 6.5 vs 5.8 days, p < 0.001, for therapeutic ERCPs). CONCLUSIONS: In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates of GI hemorrhage in diagnostic ERCPs, which may be due to a higher comorbidity index in those patients admitted to teaching hospitals.

Society Guidelines-Where Is the Consensus?

With reports of ongoing duodenoscope contamination and pathogen transmission despite strict adherence to manufacturer reprocessing instructions, professional societies continue to release updated recommendations. Despite general guideline similarities, there are differences. Although adherence to guidelines does not entirely eliminate pathogen contamination or transmission, it is critical to strictly adhere to updated guidelines for maximum risk reduction. In the United States, the Food and Drug Administration and Centers for Disease Control and Prevention continue to offer updates regarding improved duodenoscope reprocessing techniques and endoscope design. This article critically analyzes currently available national and international duodenoscope reprocessing guidelines.

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club.

BACKGROUND/OBJECTIVES: This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy. METHODS: An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements. RESULTS: Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis. CONCLUSIONS: This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography.

Endoscopic ultrasound (EUS) was originally devised as a novel diagnostic technique to enable endoscopists to stage malignancies and acquire tissue. However, it rapidly advanced toward therapeutic applications and has provided gastroenterologists with the ability to effectively treat and manage advanced diseases in a minimally invasive manner. EUS-guided biliary drainage (EUS-BD) has gained considerable attention as an approach to provide relief in malignant and benign biliary obstruction for patients when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible. Such instances occur in those with surgically altered anatomy, gastroduodenal obstruction, periampullary diverticulum or prior transampullary duodenal stenting. While ERCP remains the gold standard, a multitude of studies are showing that EUS-BD can be used as an alternative modality even in patients who could successfully undergo ERCP. This review will shed light on recent EUS-guided advancements and techniques in malignant and benign biliary obstruction.

National trends and outcomes in timing of ERCP in patients with cholangitis.

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Restarting gastrointestinal endoscopy in the deceleration and early recovery phases of COVID-19 pandemic: Guidance from the British Society of Gastroenterology.

Many non-emergency clinical services were suspended during COVID-19 pandemic peak. It is essential to develop a plan for restarting services following the peak. It is equally important to protect patients and staff and to use resources and personal protective equipment (PPE) efficiently. The British Society of Gastroenterology Endoscopy Committee and Quality Improvement Programme has produced guidance on how a restart can be safely delivered. Key recommendations include the following: all patients should have need for endoscopy assessed by senior clinicians and prioritised according to criteria we have outlined; once the need for endoscopy is confirmed, patients should undergo telephone screening for symptoms using systematic questionnaires; all outpatients should undergo RT-PCR testing for COVID-19 virus 1-3 days prior to endoscopy; and PPE should be determined by patient risk stratification, the nature of the procedure and the results of testing. While this guidance is tailored to endoscopy services, it could be adapted for any interventional medical discipline.

Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis.

OBJECTIVES: Although early biliary drainage improves outcomes in patients with acute cholangitis, the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) is controversial. Our aim was to evaluate the impact of timing of ERCP on mortality in hospitalized patients with acute cholangitis. METHODS: We searched PubMed, EMBASE, and The Cochrane Library (until February 2019) for studies evaluating the impact of timing of ERCP (<24, <48, and <72 hours from hospitalization) on outcomes in patients with acute cholangitis. The primary outcome was in-hospital mortality. RESULTS: Fourteen observational studies, including 84,063 patients (mean age = 66 ± 18), met the study criteria. The overall pooled in-hospital mortality with acute cholangitis was 1.9% (95% confidence interval [CI] 1.8%-7.6%), which increased to 4.3% (95% CI 1.8%-8.7%) when administrative database studies were excluded. In 9 studies, ERCP performed <24 compared with ≥24 hours decreased in-hospital mortality (odds ratio [OR] = 0.81, 95% CI 0.73-0.90; I = 0%). In 8 studies, ERCP performed <48 compared with ≥48 hours decreased in-hospital mortality (OR = 0.57, 95% CI 0.51-0.63; I = 0%). In 4 studies, ERCP performed <72 compared with ≥72 hours decreased in-hospital mortality (OR = 0.32, 95% CI 0.15-0.68; I = 0%). Furthermore, hospital stay was reduced in patients receiving ERCP <24 compared with ≥24 hours (mean difference [MD] = 3.2 days, 95% CI 2.3-4.1; I = 78%), <48 compared with ≥48 hours (MD = 3.6 days, 95% CI 2.1-5.1; I = 98%), and <72 compared with ≥72 hours (MD = 4.1 days, 95% CI 0.9-7.3; I = 63%). DISCUSSION: In observational studies, earlier ERCP performed in patients with acute cholangitis, even urgently performed <24 hours from presentation, was associated with reduced mortality. A randomized trial evaluating the impact of urgent ERCP on outcomes is needed.

The diagnostic work-up and outcomes of 'presumed' idiopathic acute pancreatitis: A post-hoc analysis of a multicentre observational cohort.

INTRODUCTION: After standard diagnostic work-up, the aetiology of acute pancreatitis remains unknown in 16-27% of cases, a condition referred to as idiopathic acute pancreatitis (IAP). Determining the aetiology of pancreatitis is essential, as it may direct treatment in the acute phase and guides interventions to prevent recurrent pancreatitis. METHODS: Between 2008 and 2015, patients with acute pancreatitis were registered prospectively in 19 Dutch hospitals. Patients who had a negative initial diagnostic work-up with regard to the underlying aetiology of their pancreatitis were labelled 'presumed' IAP. The aim of this study was to assess the use of diagnostic modalities and their yield to establish an aetiology in 'presumed' IAP, and to assess recurrence rates both with and without treatment. RESULTS: Out of the 1632 registered patients, 191 patients had a first episode of 'presumed' IAP, of whom 176 (92%) underwent additional diagnostic testing: CT (n = 124, diagnostic yield 8%), EUS (n = 62, yield 35%), MRI/MRCP (n = 56, yield 33%), repeat ultrasound (n = 97, yield 21%), IgG4 (n = 54, yield 9%) and ERCP (n = 15, yield 47%). In 64 of 176 patients (36%) an aetiological diagnosis was established, mostly biliary (n = 39). In 13 out of 176 of patients (7%) a neoplasm was diagnosed. If additional diagnostic workup revealed an aetiology, the recurrence rate was lower in the treated patients than in the patients without a definite aetiology (15% versus 43%, p = 0.014). CONCLUSION: Additional diagnostic testing revealed an aetiology in one-third of 'presumed' IAP patients. The aetiology found was mostly biliary, but occasionally neoplasms were found. Identification of an aetiology with subsequent treatment reduced the rate of recurrence.

Colangiopancreatografía retrógrada endoscópica: estudio de 8 años en pacientes geriátricos / Endoscopic retrograde cholangiopancreatography: eight-years study in geriatric patients

RESUMEN Introducción: en febrero de 2010 se introdujo la técnica colangiopancreatografía retrógrada endoscópica en la provincia de Matanzas, dando cobertura a los casos con esta indicación, y atendiendo a un importante grupo de pacientes en edad geriátrica. Objetivo: describir los resultados después de ocho años de trabajo. Material y Métodos: se realizó un estudio descriptivo, transversal, en pacientes mayores de 65 años, quienes se realizaron el estudio en el servicio de Cirugía de Mínimo Acceso del Hospital Universitario Clínico Quirúrgico "Comandante Faustino Pérez Hernández", en el período de enero 2010 a enero de 2018. La población de estudio quedó conformada por 698 pacientes, que cumplieron con los criterios de inclusión con 713 informes de colangiopancreatografía retrógrada endoscópica. Resultados: predominó el sexo femenino y la canulación del conducto deseado, se utilizó como técnica complementaria el pre corte, en cuanto a los diagnósticos realizados la litiasis coledociana resultó ser el más frecuente, y la colangiopancreatografía retrógrada endoscópica con acción terapéutica fue la más realizada con la pancreatitis como complicación más encontrada, fallecieron en el período estudiado cuatro pacientes como consecuencia de colangitis aguda grave. Conclusiones: los resultados obtenidos son similares a los realizados, en poblaciones sometidas al proceder en general, independientemente a la edad de los pacientes, resultando ser un proceder seguro en edades geriátricas, siendo la colangiopancreatografía retrógrada endoscópica en este medio un arma con gran utilidad diagnóstica y terapéutica con una frecuencia de morbi-mortalidad que lo garantiza (AU).

SUMMARY Introduction: the endoscopic retrograde cholangiopancreatography technique was introduced in the province of Matanzas in February 2010, for the treatment of the cases with this indication and attending an important group of patients in geriatric age. Objective: to describe the results of this technique after eight years of use. Method: a descriptive, cross-sectional study was carried out in patients aged more than 65 years, who were attended in the service of Minimal Access Surgery of the Clinical Surgical University Hospital "Comandante Faustino Pérez Hernández", in the period January 2010-January 2018. The studied population was 698 patients who fulfilled the inclusion criteria for 713 reports of endoscopic retrograde cholangiopancreatography. Results: female sex and cannulation of the desired duct predominated; pre-cut was used as complementary technique. Choledocholithiasis was the most frequent diagnosis; the most used therapeutic action was endoscopic retrograde cholangiopancreatography, and pancreatitis was the most commonly found complication. In the studied period, four patients died as a consequence of severe acute cholangitis. Conclusions: the obtained results are similar to those obtained in populations undergoing the procedure in general, patients´ age-independent. It is a safe procedure in geriatric ages. The endoscopic retrograde cholangiopancreatography is a tool of a great diagnosis and therapeutic usefulness in our midst, with a morbid-mortality frequency guarantying it (AU).

Outcomes of Endoscopic Sphincteroplasty Using Large Balloon Dilatation for Difficult Common Bile Duct Stone Removal at Dhulikhel Hospital.

Background Endoscopic sphincteroplasty (ESPT) using a large Controlled Radial Expansion (CRE) Wire guided balloon dilatation has gained acceptance in removing a difficult common bile duct (CBD) stones. Objective To evaluate effectiveness and complications of removing large and difficult bile duct stones with sphincterotomy combined with large balloon dilatation. Method A total of 132 patients, from February 2014 to June 2017, who had biliary ductal calculus which was either greater than 15 mm or difficult to remove with standard technique, underwent Endoscopic Retrograde Cholangiopancreaticography (ERCP) with Endoscopic sphincteroplasty using a large Controlled radial expansion wire guided balloon dilatation. The success rate of complete stone clearance and post Endoscopic Retrograde Cholangiopancreaticography complications were analyzed. Result There were 48 (36.4 %) male and 84 (63.6%) female patients with mean age of 55.48 ± 16.36 years. Stones were removed with sphincteroplasty in first attempt in 90 out of 132 (68.2%) patients, 26 out of 37 (70.27%) patients in second session and in all 7(100%) patients in third attempt. Five (11.90%) patients were lost to follow up and 4 were advised for surgery because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 93.18%. Complications were seen in 17 (13.6%) patients; bleeding seen in 9 (6.8%) patients and mild pancreatitis in 8 (6.1%) patients. None of the patients had severe pancreatitis or perforation secondary to the procedure. Conclusion Endoscopic sphincteroplasty after sphincterotomy is an effective and safe technique for a difficult common bile duct stone removal.