SASE, Success and Adverse event Score in Endoscopic Retrograde Cholangiopancreatography: a Novel Grading System.

BACKGROUND: Validated, accepted grading tools for preprocedural complexity assessment in ERCP are lacking. We therefore created a grading system for ERCP based on the classification used by the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: Data on ERCP adverse events (AE) and success were collected in a multicenter, prospective uncontrolled study. Multiple logistic regressions were applied to success and AEs in accordance with the ASGE classification. Each procedure suggested by ASGE was tested against different outcomes. Results were used to create a score and were evaluated in a control cohort. RESULTS: 16,327 ERCPs were documented in 27 centers. Analysis of ASGE categorization (10,904 cases) showed that this model fails to adequately predict parameters of complexity; only for cardiopulmonary AEs and perforation was no significant variance evident. Depending on the specific clinical circumstances, probability of success of the intervention sometimes varied significantly in risk, implying a twofold score, one part for probability of success and one for risk. A split score with three levels each was designed and tested in a validation cohort (5,423 procedures). Achieving therapeutic targets / post-ERCP pancreatitis could be correctly predicted in 87.0%/95.3%. CONCLUSIONS: Grading ERCP success and AEs have to be considered independently. Onefold grading systems appear incomplete and unable to provide an adequate classification of severity. SASE (Success and Adverse Event Score in Endoscopic Retrograde Cholangiopancreatography) was created to incorporate these findings. Showing high predictive value, this score could be a potent tool for planning ERCP and training in endoscopy.

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

PROPHYLAXIS: 1:  ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration.Strong recommendation, moderate quality evidence. 2:  ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation).Strong recommendation, moderate quality evidence. 3:  ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction.Weak recommendation, moderate quality evidence. 4:  ESGE recommends against the routine use of antibiotic prophylaxis before ERCP.Strong recommendation, moderate quality evidence. 5:  ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy.Weak recommendation, moderate quality evidence. 6:  ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced.Weak recommendation, low quality evidence. TREATMENT: 7:  ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis.Weak recommendation, low quality evidence. 8:  ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.Weak recommendation, low quality evidence. 9:  ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP.Weak recommendation, low quality evidence.

[Austrian benchmarking project for ERCP: a 10-year report]. / Österreichisches Benchmarking ERCP: 10-Jahresbericht.

The quality assurance program "Benchmarking ERCP", that his been under the patronage of the ÖGGH for ten years (with a one-year break in 2008), in collaboration with the Institute for Applied Statistics University Linz, has followed patient safety measures and successes while undergoing ERCP in Austria. A total of 28 319 examinations were registered. The participating centers all had different ERCP frequency and variable expertise, thereby enabling them to recognise individual problems in terms of success, cannulation and complication rates (3.9 % post-ERCP pancreatitis, 3.8 % bleeding, 0.6 % perforation, 1.2 % cholangitis, 1.0 % cardiopulmonary complications). The aim of quality assurance measures in medicine is to ensure the best possible patient care.

Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

Quality assessment of endoscopic retrograde cholangiopancreatography: results of a running nationwide Austrian benchmarking project after 5 years of implementation.

OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) has a high risk of various complications. The aim of this study is to report the main ERCP outcome, that means complications and success rates, on the basis of the pooled data of a national continuous quality assessment program. METHODS: This study is an uncontrolled prospective survey and provides data from both academic and community-based endoscopy centers with varying case volumes and expertise. Data were collected within a nationwide voluntary ERCP benchmarking project that was initiated by the Austrian Society of Gastroenterology and Hepatology. RESULTS: In total, 42 sites participated in this program for varying periods (1 month up to 5 years) and reported 13 513 procedures within 5 years. The overall complication rate in nonselected patients was 10.1%. Post-ERCP pancreatitis occurred in 4.2%, bleeding in 3.6% (0.4% clinically relevant), cholangitis in 1.4%, cardiopulmonary complications in 1.2%, perforation in 0.6%, and procedure-related deaths in 0.1% of procedures. The overall therapeutic and diagnostic target was achieved in 80.3% (2009-2011) to 84.8% (2006/2007) of procedures. The desired duct was visualized in 90.7% and cannulated in 88.8% of procedures. CONCLUSION: The aim of the running benchmarking project in ERCP is to improve patient care in Austria. The survey reflects the general effectiveness and safety of ERCP. The overall complication and success rates are consistent with the available literature data. It sets an example as a benchmarking program that might result in international or even pan-European projects in high-risk endoscopic procedures.

[Steatohepatitis and cirrhosis: first manifestation 23 years after jejunoileal bypass surgery]. / Steatohepatitis und Leberzirrhose: Erstmanifestation 23 Jahre nach Jejunoilealem Bypass.

Intestinal shunting procedures followed by gastrointestinal bypass surgery have been used as therapeutic modalities in the treatment of morbid obesity since the mid 1950s. Enthusiasm reached its peak in the early 1960s with the introduction of the jejunoileal bypass, however began to wane as various complications were identified in the remote postoperative period and later. Finally, the jejunoileal bypass was abandoned in the 1980s. Apart from renal disorders, it frequently resulted in abnormal liver function and liver failure which are attributed to fatty infiltration. We report a 56-year-old woman, who underwent jejunoileal bypass surgery 23 years ago. She was admitted to our ICU because of hepatic encephalopathy IV, caused by upper gastrointestinal bleeding. Beside hepatic encephalopathy there were signs of severe liver failure (INR 2.8, cholesterol 32 mg/dl, ICG PDR 5%). Liver biopsy showed fatty infiltration and cirrhosis. Excluding other causes of liver disease, severe fatty liver disease following jejunoileal bypass surgery was diagnosed. The very late onset of severe liver disease emphasizes the importance of lifelong follow-up of these patients.