Association between volume of endoscopic retrograde cholangiopancreatography at an academic medical center and use of pancreatobiliary therapy.

BACKGROUND & AIMS: Many advances have been made in pancreatobiliary imaging and endoscopy techniques. However, little is known about trends in use of endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We performed a retrospective cohort study that analyzed data from 33,596 ERCPs performed at Indiana University Medical Center from 1994 to 2009. Data from all patients were entered into an endoscopy database. We compared changes in patient demographics, indications for ERCP, and utilization of specific ERCP therapies during this time period. RESULTS: The annual volume of ECRP increased steadily from 1175 in 1994 to 2802 in 2009 (P < .0001). Of all patients, 33.9% had previously undergone an ERCP at a different facility; 42.3% of these were unsuccessful. The odds of having undergone a failed ERCP at another facility increased slightly each year (odds ratio, 1.02; P < .001). Among patients who had a failed ERCP elsewhere, the success rate at Indiana University Medical Center was 96.1%. The frequency of patients with American Society of Anesthesiologists class ≥3 (odds ratio, 1.12; P < .001) who received anesthesia-administered sedation increased each year (odds ratio, 1.25; P < .001). Most ERCPs were performed for common bile duct stones or strictures and suspected sphincter of Oddi dysfunction (77.2%). The most rapid increase was among procedures for common bile duct strictures or leaks, pancreatic duct stones or strictures, and suspected sphincter of Oddi dysfunction. Rates of biliary sphincterotomy did not change (P = .252), but the frequency of pancreatic sphincterotomy, common bile duct, or pancreatic duct stent placement and pancreatic duct stricture dilation increased during this time (P < .001 for each). CONCLUSIONS: At a referral center, ERCP has become increasingly complex. From 1994 to 2009, increasing numbers of ERCPs have been performed for patients with more comorbidities, higher-grade disease, history of failed ERCPs, and on those receiving endotherapy.

Endoscopic retrograde cholangiopancreatography and manometry findings in 1,241 idiopathic pancreatitis patients.

BACKGROUND: 10-30% of patients with pancreatitis are classified as idiopathic after the initial evaluation. Our aim was to assess the diagnostic yield of endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi manometry in patients with idiopathic pancreatitis in a tertiary referral center. METHODS: A single-center, retrospective study analyzing the ERCP and manometry results of 1,241 patients who were classified as having idiopathic pancreatitis based upon their initial evaluation. RESULTS: A single episode of pancreatitis occurred in 20.4%, acute recurrent pancreatitis in 56.3% and chronic pancreatitis in 23.3% of the patients undergoing ERCP. Sphincter of Oddi dysfunction was found in 40.3% and pancreas divisum in 18.8% of the patients. Biliary stone disease was found in 3.0%. Intraductal papillary mucinous neoplasms were identified in 52 patients with increasing frequency in older age groups. The overall diagnostic yield of ERCP and sphincter of Oddi manometry to elucidate a potential cause of pancreatitis was 65.8%. Of these, 91.9% patients had findings amenable to endoscopic therapy. The complication rate was 11.5%. CONCLUSIONS: In this large series, ERCP with manometry frequently identified conditions which probably caused or contributed to the idiopathic pancreatitis. Long-term studies are awaited to determine outcomes after correctable factors are addressed. and IAP.

Pancreatic duct stent placement prevents post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction but normal manometry results.

BACKGROUND: Placement of a pancreatic duct (PD) stent reduces post-ERCP pancreatitis rates in high-risk patients. Patients with suspected sphincter of Oddi dysfunction (SOD) who are found to have normal manometry results (SOM) are also at high risk for this complication. OBJECTIVE: Our purpose was to determine whether PD stent placement reduces pancreatitis rates in this patient population. DESIGN: Non-randomized, retrospective study. SETTING: Large, tertiary referral center. PATIENTS: From January 1999 to December 2005, patients who underwent ERCP with normal SOM were identified from our ERCP database. Incidence of patient/procedure risk factors for post-ERCP pancreatitis, trainee participation, and prior sphincter therapy were evaluated. INTERVENTIONS: PD stent placement. MAIN OUTCOME MEASUREMENT: Pancreatitis rates. RESULTS: A total of 403 patients were available for analysis: 169 had a PD stent placed (group 1) and 234 did not (group 2). Overall, pancreatitis rates were 2.4% in group 1 and 9.0% in group 2 (P= .006, odds ratio 4.1, 95% CI 1.4-12.0). Other than increased PD opacification in group 1 (P< .001), the incidence of risk factors for pancreatitis, trainee participation, or prior sphincter therapy was similar between the 2 groups. In patients with an intact papilla, stent placement reduced the rate of pancreatitis from 11.5% to 2.7% (P= .012). In patients with prior sphincter therapy, no benefit was seen from stent placement, although there was a trend to decreased pancreatitis rates in stented patients with prior pancreatobiliary sphincterotomy. LIMITATIONS: Nonrandomized, retrospective design. CONCLUSION: Temporary PD stent placement reduces pancreatitis rates in patients with suspected SOD but normal SOM and an intact papilla. Their routine use is recommended when evaluating this difficult, high-risk patient population.

Efficacy of diclofenac in the prevention of post-ERCP pancreatitis in predominantly high-risk patients: a randomized double-blind prospective trial.

BACKGROUND: Pancreatitis is one of the major complications of ERCP and endoscopic sphincterotomy. It has been shown that nonsteriodal anti-inflammatory drugs are potent inhibitors of phospholipase A(2), activity which is increased in pancreatitis. A previous study showed reduction of post-ERCP pancreatitis with administration of rectal diclofenac. OBJECTIVE: The aim of this study was to determine whether prophylactic oral diclofenac will reduce the incidence and the severity of ERCP-induced pancreatitis, especially in high-risk patients. DESIGN: Single-center, randomized, double-blinded, prospective study. SETTING: Indiana University Medical Center. PATIENTS: A total of 207 evaluable patients were randomized to receive either diclofenac 50 mg or placebo by mouth 30 to 90 minutes before and 4 to 6 hours after ERCP. RESULTS: The groups were similar with regard to patient demographics and to patient and procedure risk factors for post-ERCP pancreatitis. The overall incidence of post-ERCP pancreatitis was 16.4%. It occurred in 17 of 102 patients in the control group (16.7%) and in 17 of 105 patients in diclofenac group (16.2%). The pancreatitis was graded mild in 9.8%, moderate in 5.9%, and severe 1.0% of the control group, and mild in 10.5%, moderate in 4.8%, and severe in 1.0% of the diclofenac group. In high-risk patients, the incidence of post-ERCP pancreatitis was 17.3%. It occurred in 18.0% (16/89) in the control group and in 17.8% (16/90) in the diclofenac group. There was no significant difference between the groups in the frequency or severity of post-ERCP pancreatitis in overall and high-risk patients; however, the power of the study was less than 45%. CONCLUSIONS: Prophylactic orally administered diclofenac was not observed to affect the frequency or severity of post-ERCP pancreatitis in high-risk patients.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES: Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS: A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS: Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION: This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Effectiveness of a new long cytology brush in the evaluation of malignant biliary obstruction: a prospective study.

BACKGROUND: Cancer detection rates with biliary brush sampling remain disappointingly low. A low cellular yield is often the limiting factor in making a diagnosis of malignancy. The new Cytolong brush (Cook Endoscopy, Winston-Salem, NC) is 3 mm in diameter, 5 cm long, with stiffer bristles oriented at 45 degrees on a 7F sheath. We hypothesized that this new brush might improve cancer detection rates by increasing cellular yield. METHODS: Patients found to have a biliary stricture suspicious for neoplasia on ERCP were randomized to undergo brush sampling for cytology with a standard Geenen brush (GB; Cook Endoscopy, Winston-Salem, NC) [3 mm in diameter, 1.5 cm long, bristles oriented at 90 degrees on a 6F sheath] or the Cytolong brush (CB). Repeat sampling was then performed with the other brush. Stricture dilation was not performed prior to brushing. Specimen results were considered normal, atypical (considered benign), highly atypical (suspicious for cancer), or malignant. All specimens were assigned a cellularity score (0 to 3, insufficient to excellent). Final diagnosis was based on cytologic results plus surgery, EUS, autopsy, or clinical follow-up. RESULTS: From November 2001 to July 2003, 102 patients had specimens obtained from 94 malignancies (47% pancreatic cancer). The cancer detection rate was 25 of 94 (27%) using CB and 28 of 94 (30%) with GB (p = NS). No patient had positive cytology results with CB and negative cytology results with GB. The yield of the two brushes combined was 28 of 94 (30%). Cancer detection rates of 28% (18 of 64) and 31% (20 of 64) were found for CB and GB, respectively, in distal biliary strictures, and 23% (7 of 30) and 27% (8 of 30) in proximal strictures (p = NS). Insufficient or limited cellularity was seen less frequently with CB (11 of 98) than with GB (17 of 98), and the mean cellular yield was greater with CB than GB (2.6 vs 2.4, p = 0.006). SUMMARY: Despite improved cellularity, cancer detection rates were not improved by using the larger Cytolong brush in this study. There was no statistical difference between the brushes in both proximal and distal biliary strictures. CONCLUSIONS: The yield of biliary brush cytology at ERCP remains low. Increasing brush size and bristle stiffness does not increase detection rates. Newer devices and processing techniques are required to allow detection rates to approach those attained in other GI tract malignancies.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography in children: a large series report.

OBJECTIVES: Our goal is to evaluate the indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children. METHODS: Our database was searched for patients 17 years of age or younger undergoing ERCP between January 1994 and March 2003. Additional information was obtained by chart review. The safety and technical success of ERCP were examined. Complications were classified by the consensus criteria. RESULTS: A total of 245 patients (95 M, 150 F; mean age 12.3 years) underwent 329 examinations. Indications included biliary pathology (n = 93), pancreatic pathology (n = 111), and chronic abdominal pain of suspected biliary or pancreatic origin (n = 41). The ERCP findings were bile duct stone(s) (n = 29), benign biliary stricture (n = 19), primary sclerosing cholangitis (n = 7), anomalous pancreaticobiliary union (n = 8), choledochal cyst (n = 5), bile duct leak (n = 6), malignant biliary stricture (n = 2), biliary atresia (n = 1), chronic pancreatitis (n = 44), pancreas divisum (n = 26), pancreatic duct stricture with (n = 6) or without (n = 9) leak, pancreatic tumor (n = 1), periampullary adenoma (n = 2), and sphincter of Oddi dysfunction (n = 65). Endoscopic therapies were performed in 71% of the procedures and included sphincterotomy, stone extraction, stricture dilation, endoprosthesis placement, snare papillectomy, and cystoduodenostomy. Thirty-two (9.7%) post-ERCP complications occurred and included cholangitis in 1 patient and pancreatitis in 31. The pancreatitis was graded mild in 24, moderate in 5, and severe in 2. No mortality related to ERCP occurred. CONCLUSIONS: Diagnostic and therapeutic ERCP results are similar in children and adults except for a lower incidence of malignant disease in children. Technical success rates are high. However, ERCP-related pancreatitis is not uncommon, and the risk and benefits should be carefully reviewed before proceeding. Outcome data are necessary and is currently being accumulated at our institution.

Oral allopurinol does not prevent the frequency or the severity of post-ERCP pancreatitis.

BACKGROUND: Pancreatitis is the most common major complication of ERCP. Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic allopurinol, an inhibitor of oxygen-derived free radical production, would reduce the frequency and severity of post-ERCP pancreatitis. Methods A total of 701 patients were randomized to receive either allopurinol or placebo 4 hours and 1 hour before ERCP. A database was prospectively collected by a defined protocol on patients who underwent ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS: The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 12.55%. It occurred in 46 of 355 patients in the allopurinol group (12.96%) and in 42 of 346 patients in the control group (12.14%; p = 0.52). The pancreatitis was graded mild in 7.89%, moderate in 4.51%, and severe in 0.56% of the allopurinol group, and mild in 6.94%, moderate in 4.62%, and severe in 0.58% of the control group. There was no significant difference between the groups in the frequency or the severity of pancreatitis. CONCLUSIONS: Prophylactic oral allopurinol did not reduce the frequency or the severity of post-ERCP pancreatitis.

Endoscopic snare papillectomy for tumors of the duodenal papillae.

BACKGROUND: Tumors of the major and the minor duodenal papillae can be malignant or premalignant, and traditionally are treated by surgical excision. This study evaluated the safety and the outcome of endoscopic snare resection of such tumors. METHODS: All patients with tumors of the major or the minor papilla treated by endoscopic snare resection over a 10-year period (1994-2003) were identified from an ERCP database. Patients with tumors that had endoscopic features of malignancy and those proven to be cancerous by biopsy were excluded. Papillectomy was performed by electrosurgical snare resection. A pancreatic stent usually was placed before or after excision. Residual tumor was eradicated by repeated procedures. Endoscopic surveillance was at the discretion of the endoscopist. RESULTS: Seventy snare resections were performed in 55 patients (mean age 59 years). Histopathologic diagnoses were the following: adenoma (45 patients; 7 with focal high-grade dysplasia, 6 with intraductal extension), adenocarcinoma (5), carcinoid tumor (2), gastric heterotopia (1), and normal histology (2). Fourteen patients had familial adenomatous polyposis. Of the 39 patients with isolated extraductal adenoma per cholangiogram, two underwent surgical resection because of persistent high-grade dysplasia, and 37 were successfully treated by endoscopic papillectomy alone. During follow-up (mean 30 months), 18 of 37 patients (49%) had no recurrence, 7 had recurrent adenoma (mean time interval to recurrence 27 months), two died of unrelated illnesses, and 10 are awaiting follow-up. Of the 6 patients with intraductal adenoma per cholangiogram, two underwent surgical resection, two had intraductal photodynamic therapy, and two had endoscopic snare resection. Intraductal tumor in the 4 latter patients was eliminated, although it recurred in one of the patients who had photodynamic therapy. Of the 7 patients with adenocarcinoma or carcinoid tumor, pancreaticoduodenectomy was performed in 3 and palliative papillectomy was performed in 4 unsuitable for surgery. One patient with carcinoid tumor of the minor papilla is alive, without recurrence, at 5 years after papillectomy. There were 10 procedure-related complications (14.5%), including pancreatitis (5), bleeding (4), and mild perforation (1). There was no procedure-related death. CONCLUSIONS: Most adenomas of the duodenal papillae without intraductal extension can be fully resected by snare papillectomy. However, adenoma recurs in about a third of patients. Endoscopic therapy appears to be a reasonable alternative to surgery for management of papillary tumors. Longer follow-up is needed to determine the true recurrence rate and if endoscopic re-treatments are effective.