Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

Background/Aims@#Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. @*Methods@#One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: “Trainees,” “Consultants group 1” (performed >75 ERCPs per year), and “Consultants group 2” (performed >100 ERCPs per year). @*Results@#Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77–0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74–0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69–0.95). @*Conclusions@#This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.

Pancreas divisum

Objective: To evaluate the complications, technical success, diagnostic evaluation and various endoscopic management options in patients with pancreas divisum

Study Design: Descriptive study

Place and Duration of Study: Endoscopy Suite, Surgical Unit 4, Civil Hospital, Karachi, from January 2007 to December 2013

Methodology: All Endoscopic Retrograde Cholangio-pancreatography [ERCPs] procedure performed in patients with pancreas divisum were analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy for the condition

Results: During the study period, 3600 patients underwent 4500 ERCP procedures. Pancreas divisum was found in 17 patients [0.47%]; 7 ERCPs [41.2%] were performed for diagnostic and 10 [58.8%] for therapeutic purposes. Sixteen [94.1%] had complete PD and one [5.9%] had incomplete PD. Male and Female ratio was 1:1.83 with a mean age of 26.3 years and median symptom duration of 11 months. A total of 23 procedures were performed in 17 patients; 2 had ERCP done thrice, 2 underwent the procedure twice, while the rest had single procedure done. Six [35.3%] patients had chronic pancreatitis, 7 [41.2%] had acute recurrent pancreatitis and 4 [23.5%] had acute pancreatitis. Endoscopic minor papillotomy was performed. There was no procedure-related mortality. ERCP affected management in 88.2% [15/17 procedures]

Conclusion: ERCP is a safe and feasible procedure for pancreas divisum patients

Pneumatic balloon dilation of Achalasia Cardia

Objective: To find out frequency of improvement of symptoms and complications rate following endoscopic esophageal balloon dilation in patients with achalasia cardia

Study design: Case series

Place and duration of study: Department of Surgery Dow University of Health Sciences and Civil Hospital Karachi, from January 2006 to September 2013

Methodology: Patients in whom diagnosis of esophageal achalasia was made on investigations [barium swallow and / or manometry] were included. These patients were subjected to balloon dilation. The procedure was performed using Olympus achalasia balloon dilators. All patients were followed up and their responses were noted. Excellent response was defined as improvement of dysphagia for both solids and liquids. In good response category those patients were included who had improvement of dysphagia for both solids and liquids but problems with food intake persisted. In poor response category patients there was no improvement following balloon dilation. Time to recurrence of symptoms and complications were also noted

Results: A total of sixty patients were included. There were 31males [51.7%] and 29 [48.3%] females. Male to female ratio was 1.07:1. The age of the patients ranged from 13 to 65 year. The mean age was 35.48 +/- 13.36 year. Seventy five dilations were performed [mean 1.25 +/- 0.54]. In 35 [58.33%] patients excellent response was obtained while 19 [31.67%] patients had good response. In 6 [10%] patients no improvement was seen. These were put into poor response category. In one [1.7%] patient esophageal perforation occurred. In six patients [10%] surgery was advised as no improvement following multiple sessions of balloon dilation occurred

Conclusion: Achalasia cardia can be managed effectively with balloon dilation under fluoroscopy

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre

To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography [ERCP] pancreatitis. Cross-sectional analytical study. Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p

An experience of capsule endoscopy from a tertiary care hospital in Pakistan

To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding. A prospective descriptive study was conducted at surgical unit IV, Civil Hospital Karachi over a period of 2 years from December 2007 to November 2009. Twenty eight consecutive patients presenting with obscure gastrointestinal bleeding were included in the study. Patients having history of acute intestinal obstruction were excluded. Study was approved by the hospital ethical committee. Informed and written consent was taken from all the patients included in the study. The procedure was performed as day case. Patients were asked to swallow a capsule with a glass of water after an overnight fast and bowel preparation. Endocapsule [Olympus MAJ-1469] was used in the study. Examination was termed as complete when the capsule reached the caecum or incomplete if capsule failed to enter the caecum or the battery life was exhausted. Computer recordings were read by two examiners and finally results were interpreted. Follow up was done on telephone every 24 hours till the passage of capsule and then monthly for 4 months. In case of failure to pass the capsule after 14 days or adverse effects like vomiting, abdominal pain, an abdominal radiograph was obtained and decision regarding surgical intervention was made. A total of twenty eight patients were included in this study, 15 [53.6%] males and 13 [46.4%] females. Age of the patients ranged from 15-85 years [mean 56.25 +/- 19.6 years]. There were 8[28.6%] diabetics, 8[28.6%] hypertensives and 5[17.9%] hepatitis C positive patients. The indication for the capsule endoscopy was malena in 9 [32.1%], occult bleed in 18 [64.3%] and non specific abdominal pain in 1[3.6%]. Examination was completed in 22/28 [78.6%] patients while 6 [21.4%] patients had incomplete examination. In 2/28 [7.1%] patients endoscopic assistance was required to push the capsule through the pylorus. There was history of abdominal surgery in 3/28 [10.7%] patients prior to capsule endoscopy. Capsule entrapment occurred in 2/28 [7.1%] patients who were subjected to surgery. The results of capsule endoscopy showed ulceration and bleeding in distal ileum in 7 patients followed by Arterio Venous Malformation in 6 patients. The management and follow up was done accordingly. The diagnostic yield of CE in this study was 64.28% [18/28 patients].In a total of 28 patients referred for capsule endoscopy, bleeding was resolved in 13 patients [46.42%]. Capsule endoscopy is a well tolerated and safe examination of the small bowel with a diagnostic yield superior to radiological investigations

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones

To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or "pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18mm Controlled Radial Expansion [CRE] balloons. All procedures were done as day case under conscious sedation. There were 18 [21.4%] male and 66 [78.6%] females. Age of the study population ranged from 16-85 years with a mean of 48.38 +/- 17.07 years. The size of the stone ranged from 10-32mm with a mean of 14.7 +/- 0.44mm. Stones were removed with sphincteroplasty in first session in 52/84 [61.9%] patients, 11/17 [64.4%] patients in the second session and 4/4 [100%] in the third session. Patients who were lost to follow up were 14[16.7%]. Surgery was advised for 2 [2.4%] patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients [8.3%] while one [1.2%] died. Bleeding was encountered in 3 [3.6%] patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients [3.6%]. None of the patients had severe pancreatitis or perforation secondary to the procedure. Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone

Role of pre cut sphincterotomy in difficult biliary cannulation

To assess the success rate and complications of pre cut sphincterotomy [PBS] in achieving deep common bile duct [CBD] cannulation where standard techniques of biliary cannulation failed. Descriptive study Surgical Unit 4, Civil Hospital Karachi from 14 October, 2006 to 18th December, 2007. Thirty five patients, in whom needle knife was done due to difficulty in achieving cannulation by standard means, in a 14 months period were included in the study .The data was entered into the ERCP database, locally developed at the time of ERCP and follow up was done at 24 hours and 15 days. Data was collected prospectively. No randomization was done. The main outcome measures were success and complications of precut sphincterotomy. Success of the PS was defined as the ability to deeply cannulate the CBD. Statistical data was extracted from the SPSS version 11. Variables were compared using Chi-square or t-tests as appropriate. A total of 327 ERCP's were performed during the study period out of which 35 [10.70%] precut sphincterotomies were done. The average age in the PBS group was 44.83 years [range 26- 80 years], and 71.4% [n=25] were females. Biliary cannulation was successful in 60% of the patients in the first attempt and 66.66% at a subsequent attempt. The cumulative success rate was 92.5%. Complication rate was 25.9%. Of seven PBS related complications pancreatitis occurred in four [11.4%], infection in two [5.7%] and bleeding in one patient [2.9%]. Difficulty in PBS should be anticipated in post surgical patients with altered anatomy and collapsed biliary system like CBD leakage and long distal strictures. Complication rate increases with subsequent attempts at cannulation. Overall, in experienced hands, PBS is safe and effective procedure in achieving selective cannulation