Complications of endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed in patients with primary sclerosing cholangitis (PSC). The risk of complications associated with this procedure is not well established in these patients. The aim of this retrospective study was to compare the risk of ERCP complications in PSC vs. non-PSC patients. METHODS: We identified all Mayo Clinic patients who underwent ERCP in 2005. Procedural and clinical data were collected. Complications were defined as hospitalizations for pancreatitis, cholangitis, perforation, and bleeding. RESULTS: A total of 168 patients with PSC and 981 patients without PSC had at least one ERCP examination in the calendar year 2005. PSC patients were younger (48 years+/-15 vs. 60 years+/-19, P<0.000) and had a higher prevalence of portal hypertension (31.5% vs. 4%, P<0.0001). PSC patients had more biopsies (39% vs. 15%, P<0.0001), brushings (37% vs. 8%, P<0.001), balloon dilatations (48% vs. 15%, P<0.0001), duct cytology (20% vs. 3%, P<0.0001) and intraductal ultrasounds (11% vs. 5%, P=0.007) than non-PSC patients. The duration of the procedure was longer in the PSC group (51 min+/-29 vs. 40 min+/-28, P<0.0001). The overall rate of complications in patients with PSC when compared to non-PSC patients was not significantly different (18/168 (11%) vs. 76/981(8%), P=0.2). The incidence of cholangitis was higher in the PSC group (4% vs. 0.2%, P<0.0002) despite routine use of antibiotics before the procedure in PSC patients. The duration of the procedure was longer in PSC patients who developed cholangitis (86 min+/-28 vs. 51 min+/-29, P=0.02). The risks of complications such as pancreatitis, perforation, and bleeding were not significantly different between the two groups despite their demographic and procedural variations. The duration of hospitalization due to complications was also not significantly different between the two groups. CONCLUSIONS: Complications requiring hospitalizations occur in over 10% of PSC patients undergoing ERCP. Cholangitis occurs more often in PSC patients and correlates with the length of the procedure. Further studies to confirm the role of aggressive prophylactic antibiotics in patients with PSC who undergo prolonged procedures are warranted.

Impact of feedback and didactic sessions on the reporting behavior of upper endoscopic findings by physicians and nurses.

BACKGROUND & AIMS: Guidelines for reporting Barrett's esophagus and hiatal hernia measurements and reflux esophagitis grades have been developed to improve consistency, communication, and, ultimately, patient care. Our aims were to assess the percentage of cases in which findings were reported in accordance with guidelines and to assess the impact of education and feedback on reporting behavior. METHODS: Prospective cross-sectional study design was used. Chart reviews were performed for all adult patients who underwent esophagogastroduodenoscopy at a tertiary care center during three 2-month time periods during a 12-month interval: Time 1 (March 1, 2004-April 30, 2004), Time 2 (July 1, 2004-August 31, 2004), and Time 3 (March 1, 2005-April 30, 2005). Standardized educational sessions began 2 years before Time 1. No intervention took place between Time 1 and Time 2; data were collected to examine secular change. Between Time 2 and Time 3, individual and group feedback and refresher sessions were given. RESULTS: Five thousand six hundred nine eligible esophagogastroduodenoscopies were performed, of which 2675 demonstrated Barrett's esophagus, hiatal hernia, and/or reflux esophagitis. At baseline, Barrett's esophagus and hiatal hernia measurements were dictated correctly in a median of 67% and 86% of cases, respectively, improving to 100% (P < .05) and 98% (P < .01) of cases, respectively. The Los Angeles Classification system was used in a median of 100% of cases at baseline and at follow-up. CONCLUSIONS: Anonymous individual and group feedback, in combination with brief, structured didactic educational sessions, significantly improves compliance with established guidelines for the reporting of Barrett's esophagus and hiatal hernia. Once successfully incorporated into clinical practice, adherence to the esophagitis Los Angeles Classification System is easy to maintain.

Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management.

OBJECTIVE: To review our experience with management of pancreaticobiliary and duodenal (PB/D) perforations after periampullary endoscopic interventions. Although pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures are rare, their management has not been well described. PATIENTS: Individuals who experienced pancreaticobiliary and duodenal perforations. MAIN OUTCOME MEASURES: Comorbidities, interventions performed, mechanism/site of perforation, management, and hospital morbidity/mortality. RESULTS: Seventy-five perforations (0.6%) occurred in 12,427 procedures; 20 perforations (27%) occurred during biliary stricture dilatation, 18 (24%) during diagnostic endoscopic retrograde cholangiopancreatography, and 15 (20%) during management of choledocholithiasis. Perforations were caused by guidewire insertion in 24 patients (32%), sphincterotomy in 11 (15%), passage of the endoscope in 8 (11%), or stent migration in 7 (9%) and were identified during the index procedure in 45 patients (60%). Delayed presentations included pain in 33 patients (44%), leukocytosis in 26 (35%), and/or fever in 13 (17%) and were diagnosed using computed tomography in 19 patients (25%) and abdominal radiography in 10 (13%); 9 cases (12%) were diagnosed more than 24 hours after the procedure. Indications for operative treatment were gaping duodenal perforations and perforations in patients with surgically altered anatomy. Indications for nonoperative management included contained bile duct perforations and focal duodenal perforations. Management was nonoperative in 53 patients (71%) and operative in 22 (29%). Patients with duodenal perforations, higher American Society of Anesthesia status (P<.01 each), and older age (mean +/- SEM, 65 +/- 4 vs 55 +/- 2 years; P = .02) were more likely to require operative management. Hospital stay (mean +/- SEM, 16 +/- 4 vs 4 +/- 1 days; P<.05) and mortality (13% vs 4%; P<.05) were greater in operative patients (P<.05 each). CONCLUSIONS: Most (70%) pancreaticobiliary and duodenal perforations secondary to periampullary endoscopic interventions can be managed nonoperatively. Most biliary perforations can be managed nonoperatively; a requirement for operative treatment increases the mortality rate.

Performance standards for therapeutic abdominal paracentesis.

Large-volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure. Our objectives were to determine (1) whether large-volume paracentesis could be performed safely and effectively by gastrointestinal endoscopy assistants and as an outpatient procedure, (2) whether the risk of bleeding was associated with either thrombocytopenia or prolongation of the prothrombin time, and (3) the resources used for large-volume paracentesis. Gastrointestinal endoscopy assistants performed 1,100 large-volume paracenteses in 628 patients, 513 of whom had cirrhosis of the liver. The preprocedure mean international normalized ratio for prothrombin time was 1.7 +/- 0.46 (range, 0.9-8.7; interquartile range, 1.4-2.2), and the mean platelet count was 50.4 x 10(3)/microL, (range, 19 x 10(3)/microL - 341 x 10(3)/microL; interquartile range, 42-56 x 10(3)/microL). Performance of 3 to 7 supervised paracenteses was required before competence was achieved. There were no significant procedure-related complications, even in patients with marked thrombocytopenia or prolongation in the prothrombin time. The mean duration of large-volume paracentesis was 97 +/- 24 minutes, and the mean volume of ascitic fluid removed was 8.7 +/- 2.8 L. In conclusion, large-volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants. Ten supervised paracenteses would be optimal for training the operators carrying out the procedure. The practice guideline of the American Association for the Study of Liver Diseases which states that routine correction of prolonged prothrombin time or thrombocytopenia is not required is appropriate when experienced personnel carry out paracentesis.