Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure associated with a risk of serious complications. This cohort study was designed to assess the accuracy of an endoscopic method aimed at discriminating procedures eligible to teach ERCP: patients with and without significant difficulty of selective deep cannulation (DSDC). METHODS: Clinically relevant variables were analyzed in a cohort of 400 consecutive patients (estimation group = 250 patients; validation group = 150 patients) who underwent an ERCP procedure. RESULTS: Multivariate analysis identified fixated duodenum, inflamed duodenum, soft major papilla, previous biliary surgery, and papilla with ectopion as independent predictors of DSDC. We constructed a model and a score system combining these five variables. The area under the ROC curve was 0.81 for the estimation group and 0.80 for the validation group. Using the best cutoff score (> 1.63), absence of significant DSDC could be excluded with high accuracy (negative predictive value = 89.2%) in 111 (44.4%) of 250 patients. Similarly, it could be excluded with the same certainty in 77 (51.3%) of the 150 patients in the validation group. CONCLUSIONS: A combination of easily accessible variables accurately predicts the absence of significant DSDC in half the patients who underwent the ERCP procedure. This score system discriminates procedures eligible to teach ERCP.

Endoscopic removal of large sessile colorectal adenomas: is it safe and effective?

Large sessile colorectal polyps represent a treatment challenge. Nowadays there are discrepancies regarding how to proceed with them because of morbidity, the possibility of incomplete endoscopic resection, and the high possibility of a coexisting malignancy. This study was performed to determine the safety and effectiveness of endoscopic removal of sessile colorectal adenomas larger than 4 cm. Seventy-four patients with a total of 74 sessile polyps larger than 4 cm in diameter were treated endoscopically. Polyps were removed using argon plasma coagulation (APC) as an adjunct to piecemeal technique. Surgery was recommended in patients with invasive neoplasia. Patients with favorable histology (low-grade dysplasia [LDG] or high-grade dysplasia [HGD]) were followed up with monthly endoscopies untill total ablation of the lesion, and then at 3- to 6-month intervals. LGD was found in 38 patients, HGD in 24, and invasive neoplasia in the remaining 12 patients. A total of 54 patients were followed up for at least 6 months. Recurrence rate of polyps with favorable histology was 9.2% (5/54). Postpolypectomy bleeding was the only complication, observed in 10 patients (13.5%). We conclude that piecemeal polypectomy plus APC without saline injection, performed by an expert endoscopist, is a safe and effective treatment for all LGD or HGD large sessile colorectal polyps.

Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula.

BACKGROUND/AIMS: To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula. MATERIALS AND METHODS: Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls. RESULTS: PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract. CONCLUSIONS: PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.