Complications of ERCP Talukdar, Rupjyoti, MD
Baillière's best practice & research. Clinical gastroenterology,
10/2016, Letnik:
30, Številka:
5
Journal Article
Recenzirano
Abstract Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP ...pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.
Background and Aims EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal ...stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic “step-up approach” for drainage of symptomatic WON. Methods We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN. Results Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2). Conclusions The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.
Background Long-term results of extracorporeal shockwave lithotripsy (ESWL) for large pancreatic duct (PD) stones in patients with idiopathic calcific pancreatitis (CP) are scanty. Objective To ...evaluate intermediate and long-term results of ESWL in a large cohort of patients with idiopathic CP. Design Cross-sectional study; retrospective chart review. Setting A high-volume, tertiary-care center for endoscopy and GI diseases. Patients A total of 636 patients with idiopathic CP who underwent ESWL and ERCP were followed-up. Patients were divided into intermediate (24-60 months) and long-term (>60 months) follow-up groups. Intervention ESWL and ERCP. Main Outcome Measurements Improvement in pain, analgesic use, hospitalization for pain, recurrence of calculi, need for additional intervention, and quality of life. Results A total of 636 of 1006 patients who underwent ESWL between 2004 and 2009 were followed for a maximum of 96 months. There were 364 patients in the intermediate follow-up group and 272 in the long-term follow-up group. After ESWL and ERCP, absence of pain was seen in 250 patients (68.7%), mild-to-moderate pain in 94 patients (25.4%), and severe pain in 20 patients (5.5%) of the intermediate group. In the long-term group, 164 patients (60.3%) had no pain, 97 patients (35.7%) had mild or moderate episodes of pain, whereas 11 patients (4.04%) had episodic severe pain. Recurrence of calculi was seen in 51 patients (14.01%) in the intermediate follow-up group and in 62 patients (22.8%) in the long-term group. Quality of life improved in a significant number of patients in both groups. Limitations Retrospective study, single center, recall bias, and subjective pain and quality-of-life measurement scale. Conclusion ESWL for large PD calculi offers good results in patients of idiopathic CP on intermediate and long-term follow-up.
Background ERCP experience in pancreatic disorders in children is limited. Objective This study evaluated the utility and efficacy of ERCP in children with pancreatic diseases at a tertiary care ...referral center. Patients and Settings Consecutive patients 18 years of age and younger who underwent ERCP for pancreatic diseases from January 2010 to June 2011 were identified. Indications, findings, interventions, adverse events, and outcomes were recorded. Results A total of 221 ERCPs were performed in 172 children (102 boys, mean ± standard deviation age 13.8 ± 3.2 years, 157 therapeutic). A total of 143 children (83.1%) had chronic pancreatitis (CP), 19 (11%) had recurrent acute pancreatitis (RAP), and 10 (5.8%) had acute pancreatitis (AP). Indications included pain (153, 89.4%), pancreatic fistula (11, 6.3%), symptomatic pseudocyst (4, 2.3%), and jaundice (3, 1.7%). In chronic pancreatitis patients, findings included a dilated and irregular main pancreatic duct (92, 64.3%), pancreatic duct (PD) calculi (76, 53%), dominant PD stricture (23, 16%), PD leak (7, 4.9%), pancreas divisum (35, 24.5%), and common bile duct (CBD) stricture (3, 2%). Therapeutic procedures included major papilla sphincterotomy (93, 65%), minor papilla sphincterotomy (32, 22.3%), PD stenting (77, 53.8%), and CBD stenting (3, 2.2%). PD stones larger than 5 mm were retrieved endoscopically after 57 extracorporeal shock wave lithotripsy sessions in 50 patients (34.9%). In patients with RAP, 6 (31.5%) had complete and 1 partial pancreas divisum. All underwent minor papillotomy. In patients with AP, 4 (40%) had stenting for PD leak, 2 (20%) underwent CBD clearance for biliary pancreatitis, and 4 (40%) had transpapillary pseudocyst drainage. During 13 ± 4.7 months (range 6-22 months) of follow-up, improvement of symptoms was seen in 143 of 172 (83%) patients. Procedure-related adverse events were seen in 8 (4.7%) patients. Limitations Retrospective study. Conclusion ERCP is a safe therapeutic option for pancreatic disorders in children.
Pancreatic Endotherapy for Chronic Pancreatitis Talukdar, Rupjyoti; Reddy, Duvvur Nageshwar
Gastrointestinal endoscopy clinics of North America,
10/2015, Letnik:
25, Številka:
4
Journal Article
Recenzirano
Extracorporeal shock wave lithotripsy is recommended as the first-line therapy for large (>5-mm) obstructive pancreatic ductal stones. Dominant pancreatic duct strictures should be initially managed ...with a wide-bore single plastic stent with 3 monthly exchanges for a year, even in asymptomatic patients. Recent studies have evaluated multiple plastic and self-expanding covered metal stents for refractory pancreatic ductal stricture. Pancreatic pseudocysts should be treated endoscopically with or without endoscopic ultrasound guidance.
