The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital.

BACKGROUND: The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice. METHODS: Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded. RESULTS: A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58 years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01). CONCLUSION: The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.

The H.O.U.S.E. classification: a novel endoscopic retrograde cholangiopancreatography (ERCP) complexity grading scale.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging endoscopic procedure, harboring a wide range of complexities within every single investigation. Classifications of the complexity of ERCP have been presented, but do not include modern endoscopic treatment modalities. In order to be able to target resources and compare the results of different endoscopic centers, a new complexity grading system for ERCP is warranted. This study launches a new complexity grading scale for ERCP-the H.O.U.S.E.-classification. METHODS: The medical record of every patient undergoing ERCP 2009-2011 at the Karolinska University Hospital was reviewed, regarding the complexity of the procedure, and categorized into one out of three-grades in the HOUSE classification system, and concomitantly graded according to the Cotton grading system. All ERCP-procedures were also registered in the Swedish registry for gallstone surgery and ERCP (GallRiks) and correlations between the grading systems and procedure related variables as well as outcomes were made. RESULTS: Between 2009 and 2011, 2185 ERCPs were performed at the Karolinska University Hospital, Huddinge. One thousand nine hundred fifty-four of those were index-ERCPs. Another 23 patients were excluded due to lack of postoperative complication registrations, leaving 1931 ERCP procedures to be analyzed. The procedure times were 40 ± 0.7, 65 ± 1.5 and 106 ± 3.2 min, respectively (HOUSE 1-3). The corresponding pancreatitis rates were 3.4, 7.0 and 6.8% and the postoperative complication rates 11.1, 15.7 and 12.8%, respectively. CONCLUSIONS: The HOUSE-classification is a novel grading scale for ERCP-complexity. The system can be implemented in clinical practice to allocate resources and allow the comparisons of results between different endoscopic centers. Further studies are warranted to further sharpen this instruments validitity and general clinical relevance.

Assessment of the endoscopic retrograde cholangiopancreatography grading system: A prospective study from a tertiary care center.

BACKGROUND/AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) endoscopic retrograde cholangiopancreatography (ERCP) grading system was proposed but has not been fully evaluated with prospective clinical studies. In this study, we aimed to evaluate the effectiveness of the ERCP difficulty grading system for predicting success and adverse event rates related to the procedure. MATERIALS AND METHODS: A total of 1057 ERCP procedures performed on 752 patients were included in the present study. The complexity grades of the procedures were recorded according to the ASGE grading system. Specific complications of ERCP (pancreatitis, cholangitis, bleeding, and perforation) were also defined and graded. RESULTS: The procedure difficulty was determined as 1st degree in 153 patients (14.4%), 2nd degree in 498 patients (47.1%), 3rd degree in 271 (25.6%), and 4th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1st degree procedures was 99.3%, 97.2% for 2nd degree procedures, 86.7% for 3rd degree procedures, and 46.7% for 4th degree procedures (p<0.005). When the difficulty of the procedures increased from 1 to 4, the adverse event rates increased from 1.3% to 10.4%. CONCLUSION: The findings support the evidence that the difficulty degrees of ERCP procedures can help predict the success and complication rates of the procedure. Because of the increased rates of failure and complications in more difficult cases, the procedures should be performed by experienced endoscopists in advanced centers.

Post-ERCP pancreatitis in pediatric patients.

OBJECTIVES: Pancreatitis is a known complication of endoscopic retrograde cholangiopancreatography (ERCP). Our aim was to assess the prevalence and severity of ERCP-associated pancreatitis using established criteria. MATERIALS AND METHODS: Retrospective review of patients younger than 18 years undergoing ERCP complicated by post-ERCP pancreatitis defined by the 1991 consensus statement. Patients with chronic pancreatitis were studied separately using modified criteria. Risk factors for post-ERCP pancreatitis were analyzed. RESULTS: Three hundred forty-three ERCPs were performed in 224 patients. Two hundred seventy-six ERCPs were performed in patients without chronic pancreatitis, 7 of which were complicated by post-ERCP pancreatitis (prevalence 2.5%). Patients undergoing diagnostic-only ERCP were less likely to develop post-ERCP pancreatitis (P<0.01). Sixty-seven procedures were performed on patients with chronic pancreatitis; 10 developed postprocedure pain requiring or prolonging hospitalization (prevalence 14.9%). Pancreatic duct stenting was a risk factor for post-ERCP pain in this subset of patients (P=0.02). CONCLUSIONS: The prevalence of post-ERCP pancreatitis is low-2.5% excluding patients with chronic pancreatitis and 4.96% overall. Therapeutic procedures and the presence of chronic pancreatitis are risk factors for post-ERCP pancreatitis.

Estudio prospectivo comparativo en el diagnóstico de la patología biliar. Colangiopancreatografía por resonancia magnética frente a colangiografía directa / A prospective, comparative study of magnetic resonance cholangiopancreatography and direct cholangiography in the diagnosis of biliary diseases

Objetivo: Valorar la sensibilidad y especificidad de la colangiopancreatografía por resonancia magnética (CPRM) como técnica diagnóstica no invasiva, frente a la colangiopancreatografía retrógrada endoscópica (CPRE) o colangiografía transparietohepática (CTPH) en el diagnóstico de la patología biliar y específicamente de la coledocolitiasis. Material y métodos: Durante el período comprendido entre junio de 1997 y febrero de 1998, se evaluaron 109 pacientes procedentes de la Corporació Sanitària del Parc Taulí y del Hospital Mútua de Terrassa. En todos los casos se realizaron la CPRM y la CPRE o CTPH en este orden y con un intervalo máximo de siete días entre ambas. Se excluyeron del estudio 24 pacientes por diversas causas, incluyéndose finalmente 85 pacientes. Todos los estudios se realizaron mediante un equipo Siemens Magneton Impact Expert de 1 Tesla realizando secuencias HASTE y RARE en diversas proyecciones coronales y axiales. La lectura de las CPRM fue realizada por dos radiólogos expertos en la valoración de la patología digestiva por el método de consenso. Resultados: En la valoración de los 85 pacientes la CPRM obtuvo una sensibilidad del 98,4 por ciento, una especificidad del 94,7 por ciento, un valor predictivo positivo del 98,4 por ciento y un valor predictivo negativo del 94,7 por ciento en la detección de patología biliar. En relación a la coledocolitiasis se obtuvo una S = 100 por ciento E = 89,5 por ciento, VPP = 88 por ciento y VPN = 100 por ciento. Conclusión: La CPRM tiene una alta precisión diagnóstica en la patología biliar y especialmente en la coledocolitiasis. Su alto valor predictivo negativo permite obviar la realización de otras pruebas diagnósticas invasivas (AU)

Evaluation of a modified cholangiographic classification system for primary sclerosing cholangitis.

BACKGROUND: There is no uniformly accepted classification system for the range of cholangiographic abnormalities encountered in primary sclerosing cholangitis (PSC). The aims of this study were to evaluate a previously developed classification system and to test the hypothesis that the pancreatic duct can be involved in PSC. METHODS: Two observers scored 132 endoscopic retrograde cholangiopancreatographies (ERCPs) from established PSC patients. From 30 patients, subsequent ERCPs were scored and compared with the initial ERCPs. The pancreatic duct was judged with regard to morphologic abnormalities. RESULTS: The classification system was applicable in 107 patients. In 10 ERCPs (7.6%), no clear intrahepatic abnormalities were found; 15 other ERCPs (11.4%) did not show extrahepatic abnormalities. In 30 cases, a subsequent ERCP was judged. The difference in scoring between the initial and the subsequent ERCPs was statistically significant, with the subsequent ERCP having higher intrahepatic and extrahepatic scores. Sixty-four adequately filled pancreatic ducts were analyzed. In two cases (3.1%), morphologic abnormalities were found. CONCLUSIONS: The previously developed scoring system is very applicable for almost all PSC patients when supplemented with a type 0 category. Scoring increased over time, suggesting a correlation with disease severity. The pancreatic duct does not seem to be involved in PSC.

Tratamiento combinado endoscópico-laparoscópico de la coledocolitiasis / Treatment of choledocolithiasis combined endoscopic and laparoscopic

Objetivo. Evaluar los resultados de la colangiopancreatografía retrógrada endoscópica (CPRE), esfinterotomía endoscópica y colecistectomía por laparoscopia en el diagnóstico y tratamiento de la coledocolitiasis. Pacientes y métodos. Entre junio de 1991 y diciembre de 1998, se han estudiado de forma prospectiva 1.667 pacientes sometidos a cirugía laparoscópica. Se observaron criterios clínicos, analíticos o ecográficos de sospecha de coledocolitiasis asociada en 394 pacientes (23 por ciento) y fueron estudiados mediante CPRE preoperatoria. En caso de diagnóstico de coledocolitiasis se practicó esfinterotomía y se intentó su extracción endoscópica. Posteriormente, fueron sometidos a colecistectomía laparoscópica, excepto 25 pacientes, que fueron excluidos. Resultados. El rendimiento diagnóstico fue, para la coledocolitiasis de un 57,7 por ciento (213 pacientes), para la vía biliar dilatada sin litiasis de un 10,5 por ciento (39 pacientes) y para la exploración normal de un 28,7 por ciento (106 pacientes). Se produjo fracaso por imposibilidad de evaluación de la vía biliar principal en el 2,9 por ciento (11 pacientes). Mediante la CPRE se consiguió un tratamiento satisfactorio en el 93,4 por ciento (199/213 pacientes) y fracasó en 14 pacientes (6,6 por ciento). La tasa de complicaciones relacionadas con la CPRE fue de 7,8 por ciento y con la colecistectomía laparoscópica del 10 por ciento. La mortalidad de la serie para la totalidad del procedimiento diagnóstico-terapéutico fue del 0,5 por ciento (2 pacientes). Once pacientes (5 por ciento) presentaron coledocolitiasis residual tras CPRE-colecistectomía laparoscópica tratada con éxito en todos ellos mediante una nueva CPRE. Conclusiones. El abordaje combinado en dos tiempos de la coledocolitiasis utilizando CPRE selectiva, seguida de colecistectomía laparoscópica, es una buena alternativa terapéutica. No obstante, los criterios de sospecha de coledocolitiasis empleados clásicamente implican un considerable número de exploraciones con probabilidad innecesarias, y por tanto, parece necesario modificar la estrategia diagnóstica actual (AU)

Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.

BACKGROUND: Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty. METHODS: A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty. A retrospective pilot study was performed to assess ERCP outcomes at our institution according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period. RESULTS: In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p< 0.05) and less likely to have associated complications (2% vs. 10%, p< 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p<0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant). CONCLUSIONS: Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons.

Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. Cambridge classification.

This article reviews the use of endoscopic retrograde cholangiopancreatography in chronic pancreatitis and discusses the endoscopic and radiologic techniques necessary for good pancreatography, the indications for its use, and the complications that may arise from it. The Cambridge classification is dealt with in detail together with the abnormalities found in chronic pancreatitis. There is also a short section describing methods of endoscopic therapy in chronic pancreatitis.