The outcomes and safety of patients undergoing endoscopic retrograde cholangiopancreatography combining a single-use cholangioscope and a single-use duodenoscope:A multicenter retrospective international study

Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP),with its clinical ad-vantages of less trauma and faster recovery,has become the primary treatment for choledocholithiasis.AIM To investigate the effects of different ERCP procedures on the sphincter of Oddi.METHODS The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively.The patients were divided into endoscopic sphinc-terotomy(EST,n=24)and endoscopic papillary balloon dilation(EPBD,n=67)groups.The duration of operation,pancreatic development,pancreatic sphinc-terotomy,intubation difficulties,stone recurrence,and incidence of reflux cho-langitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction in the EST and EPBD groups.RESULTS Differences in hypertension,diabetes,increased bilirubin,small diameter of the common bile duct,or ampullary diverticulum between the two groups were not significant.Statistically significant differences were observed between the two groups concerning sex and age(<60 years).Patients with a history of choledocholithiasis,pancreatitis,and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group.The number of cases of pancreatic development,pancreatic duct sphincterotomy,and difficult intubation were higher in the EST group than in the EPBD group.The number of Oddi’s sphincter manometries,ERCP surgical outcomes,and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group.The numbers of stone recurrences,reflux cholangitis,and cholecystitis were higher in the EST group than in the EPBD group.CONCLUSION In summary,common bile duct stones,pancreatitis history,and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD.Based on this evidence,this study can provide actionable insights for clinicians and researchers.

Endoscopic retrograde appendicitis treatment for periappendiceal abscess: A case report

BACKGROUND Acute appendicitis is the most common abdominal emergency.At present,the main treatments for periappendiceal abscess include antibiotics and surgery.However,the complications and mortality of emergency surgery are high.The preferred therapy is conservative treatment with antibiotics first,ultrasound-guided puncture drainage or surgical treatment is followed when necessary.Endoscopic retrograde appendicitis therapy(ERAT)for acute uncomplicated appendicitis have been proved clinically effective,but it is rarely used in periap-pendiceal abscess.CASE SUMMARY We report a patient admitted to hospital because of“right lower abdominal pain for six days”.The computerized tomography(CT)of patient showed that appendicitis with fecaliths and abscess in the pelvis.The patient was treated by CT-guided puncture and drainage of abdominal abscess combined with ERAT to remove appendiceal fecaliths,irrigation and stent placement.CONCLUSION The patient did not receive surgery because of impoverished family.Abdominal pain did not recur during the follow-up period.This case confirms the value of ERAT in the treatment of periappendiceal abscess.

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography:A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography(ERCP)is a rare complication.The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting.The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct.The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography.The patient was successfully treated with percutaneous transhepatic cholangial drainage,endoscopic pyloric stent placement,and conservative management.The causes of splenic injury following ERCP are discussed.CONCLUSION ERCP has the potential to cause splenic injury.If a patient experiences symptoms such as abdominal pain,decreased blood pressure,and altered hematology after the procedure,it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Acute cholangitis with Achromobacter xylosoxidans bacteremia after endoscopic retrograde cholangiopancreatography in hilar cholangiocarcinoma:A case report

BACKGROUND Achromobacter xylosoxidans is a Gram-negative opportunistic aerobe,usually causing nosocomial infections in immunocompromised patients with manifestations including bacteremia,pneumonia,and catheter-related infections.However,A.xylosoxidans have not yet been reported to cause biliary system infections.CASE SUMMARY A 72-year-old woman presented to the outpatient department of our hospital with a chief complaint of jaundice.Computed tomography of her abdomen revealed the presence of a mass of approximately 2.4 cm in the hilar portion of the common hepatic duct,consistent with hilar cholangiocarcinoma.We performed endoscopic retrograde cholangiopancreatography(ERCP)to decompress the obstructed left and right intrahepatic ducts(IHDs)and placed 10 cm and 11 cm biliary stents in the left and right IHDs,respectively.However,the day after the procedure,the patient developed post-ERCP cholangitis as the length of the right IHD stent was insufficient for proper bile drainage.The blood culture of the patient tested positive for A.xylosoxidans.Management measures included the replacement of the right IHD stent(11 cm)with a longer one(12 cm)and administering culturedirected antibiotic therapy,solving the cholangitis-related complications.After the cholangitis had resolved,the patient underwent surgery for hilar cholangiocarcinoma and survived for 912 d without recurrence.CONCLUSION A.xylosoxidans-induced biliary system infections are extremely rare.Clinical awareness of physicians and endoscopists is required as this rare pathogen might cause infection after endoscopic procedures.

Endoscopic ultrasound-guided biliary drainage after failed endoscopic retrograde cholangiopancreatography: The road is open for almighty biliopancreatic endoscopists!

Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery,a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography.This manusc-ript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage(EUS-BD)technologies,weighing their merits and drawbacks against traditional percutaneous methods.Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage(PTCD).These studies revealed that the technical success rate,clinical success rate,and adverse events were similar between EUS-BD and PTCD.Nevertheless,given that most of these studies preda-te 2015,the safety and effectiveness of novel EUS-BD techniques,including ECE-LAMS,compared with those of percutaneous biliary drainage remain elusive.Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous thera-peutic approaches.

Therapeutic endoscopic retrograde cholangiopancreatography in a patient with asplenia-type heterotaxy syndrome:A case report

BACKGROUND Asplenia-type heterotaxy syndrome(HS)is rare and refers to visceral malposition and dysmorphism.It is associated with a high infant mortality rate due to cardiac anomalies,and related digestive endoscopic interventions are poorly understood.With the improved long-term prognosis of these individuals after modern cardiac surgery,intra-abdominal anomalies have become increasingly significant.CASE SUMMARY Herein,we report successful endoscopic retrograde cholangiopancreatography(ERCP)in a 14-year-old male with asplenia-type HS that involved unique imaging findings and technical difficulties.His anatomic anomalies included complex congenital heart disease,midline liver placement,an absent spleen,a left-sided inferior vena cava,and dextroposition of the stomach and pancreas.He suffered from choledocholithiasis with obstructive jaundice,and the stone was successfully extracted with a basket following endoscopic papillary balloon dilation.CONCLUSION Although anatomic anomalies in HS increase the degree of technical difficulty when performing ERCP,they can be safely managed by experienced endosco-pists,as illustrated by the present case.Identifying these variations with imaging modalities and being aware of them before initiating an invasive intervention are crucial to preventing potential complications.

Preoperative gastric retention in endoscopic retrograde cholangiopancreatography

We comment on the article by Jia et al,in the World Journal of Gastrointestinal Surgery.We focus mainly on the factors that impair gastric motility and cause gastric retention in the pre-operative setting of endoscopic retrograde cholan-giopancreatography(ERCP).ERCP is a complex endoscopic therapeutic proce-dure,which demands great skill from the endoscopist but also has recognized complications.Gastric retention impairs the endoscopist’s visibility but also increases the risk of complications,such as aspiration pneumonia.Therefore,identifying the factors that predispose to gastric retention alerts the endoscopists of the possible risks and enables them to take evasive action.The authors in the current study by Jia et al developed and validated a predictive model,which in-corporates five different factors,i.e.,gender,primary disease,jaundice,opioid use,and gastrointestinal obstruction,which were found to influence gastric retention.This model was shown to have a high predictive value to accurately identify pa-tients at risk for gastric retention before a therapeutic ERCP.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is associated with a variety of adverse events(AEs).One of the most important AEs is post-ERCP pancreatitis(PEP),which is most common in cases of difficult biliary cannulation.Although the precut technique has been reported as a PEP risk factor,recent studies indicate that early precut could reduce PEP,and that precut itself is not a risk factor.AIM To evaluate the safety of the precut technique,especially in terms of PEP.METHODS We conducted a retrospective study,spanning the period from November 2011 through December 2021.It included 1556 patients,aged≥20 years,who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center.We compared the PEP risk between the early precut and the delayed precut group.RESULTS The PEP incidence rate did not significantly differ between the precut and nonprecut groups.However,the PEP incidence was significantly lower in the early precut group than the delayed precut group(3.5%vs 10.5%;P=0.02).The PEP incidence in the delayed precut group without pancreatic stent insertion(17.3%)was significantly higher compared to other cases(P<0.01).CONCLUSION Our findings indicate that early precut may reduce PEP incidence.If the precut decision is delayed,a pancreatic stent should be inserted to prevent PEP.

Recognition and management of stent malposition in the portal vein during endoscopic retrograde cholangiopancreatography:A case report

BACKGROUND Portal vein injury is an uncommon complication of endoscopic retrograde cholangiopancreatography(ERCP),for which stent malpositioning in the portal vein is very rare and can lead to fatal events.We report a case of biliary stent migration to the portal vein and a novel method for its safe removal under the guidance of portal angiography.Moreover,we reviewed the literature and summarized reports on the identification and management of this condition.CASE SUMMARY A 59-year-old woman with pancreatic cancer presented with abdominal pain and a high fever 20 days after the placement of two plastic biliary stents under the guidance of ERCP.Blood cultures and laboratory tests revealed sepsis,which was treated with antibiotics.A contrast-enhanced computed tomography scan revealed that one of the biliary stents in the main portal vein was malpositioned.To safely remove the stent,portal angiography was performed to visualize the portal vein and to allow the management of any bleeding.The two stents were removed without obvious bleeding,and an uncovered self-expanding metal stent was placed in the common bile duct for drainage.The patient had an uneventful 6-month follow-up period,except for self-resolving portal vein thrombosis.CONCLUSION The combination of endoscopic and angiographic techniques allowed uneventful management of stent malposition in the portal vein.

Systemic air embolism associated with endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a key procedure for diagnosing and treating biliary and pancreatic disorders.Although effective,it carries risks,including rare but severe complications such as air embolism.CASE SUMMARY We report a case of a 58-year-old man who developed extensive air embolism during ERCP.He previously underwent a Whipple procedure and experienced a sudden drop in vital signs and loss of consciousness.Immediate intervention with hyperbaric oxygen therapy and supportive care led to gradual recovery.Imaging confirmed widespread air embolism,which resolved with continued treatment.CONCLUSION Air embolism is a rare,critical complication of ERCP,especially in patients with prior surgery such as pancreaticoduodenectomy.Early detection and prompt treatment,including hyperbaric oxygen therapy,are crucial for favorable out-comes.

Risk factors of recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography

Background:The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP)have not been well studied.The aim of this study was to explore the risk factors of recurrent choledocholithiasis.Methods:We carried out a retrospective analysis of data collected between January 1,2010 and January 1,2020.Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therapeutic ERCP.Results:In total,598 patients were eventually selected for analysis,299 patients in the recurrent choledocholithiasis group and 299 patients in the control group.The overall rate of recurrent choledocholithiasis was 6.91%.Multivariate analysis showed that diabetes[odds ratio(OR)=3.677,95%confidence interval(CI):1.875-7.209;P<0.001],fatty liver(OR=4.741,95%CI:1.205-18.653;P=0.026),liver cirrhosis(OR=3.900,95%CI:1.358-11.201;P=0.011),history of smoking(OR=3.773,95%CI:2.060-6.908;P<0.001),intrahepatic bile duct stone(OR=4.208,95%CI:2.220-7.976;P<0.001),biliary stent(OR=2.996,95%CI:1.870-4.800;P<0.001),and endoscopic papillary balloon dilation(EPBD)(OR=3.009,95%CI:1.921-4.715;P<0.001)were independent risk factors of recurrent choledocholithiasis.However,history of drinking(OR=0.183,95%CI:0.099-0.337;P<0.001),eating light food frequently(OR=0.511,95%CI:0.343-0.760;P=0.001),and antibiotic use before ERCP(OR=0.315,95%CI:0.200-0.497;P<0.001)were independent protective factors of recurrent choledocholithiasis.Conclusions:Patients with the abovementioned risk factors are more likely to have recurrent CBD stones.Patients who eat light food frequently and have a history of drinking are less likely to present with recurrent CBD calculi.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children:A multicenter randomized controlled trial

BACKGROUND Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography(ERCP).Currently,there is no suitable treatment for post-ERCP pancreatitis(PEP)prophylaxis.Few studies have prospectively evaluated interventions to prevent PEP in children.AIM To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.METHODS This multicenter,randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria.Patients were randomly divided into the external use of mirabilite group(external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP)and blank group.The primary outcome was the incidence of PEP.The secondary outcomes included the severity of PEP,abdominal pain scores,levels of serum inflammatory markers[tumor necrosis factor-alpha(TNF-α)and serum interleukin-10(IL-10)],and intestinal barrier function markers[diamine oxidase(DAO),D-lactic acid,and endotoxin].Additionally,the side effects of topical mirabilite were investigated.RESULTSA total of 234 patients were enrolled,including 117 in the external use of mirabilite group and theother 117 in the blank group.The pre-procedure and procedure-related factors were notsignificantly different between the two groups.The incidence of PEP in the external use ofmirabilite group was significantly lower than that in the blank group(7.7%vs 26.5%,P<0.001).The severity of PEP decreased in the mirabilite group(P=0.023).At 24 h after the procedure,thevisual analog scale score in the external use of mirabilite group was lower than that in the blankgroup(P=0.001).Compared with those in the blank group,the TNF-αexpressions weresignificantly lower and the IL-10 expressions were significantly higher at 24 h after the procedurein the external use of mirabilite group(P=0.032 and P=0.011,respectively).There were nosignificant differences in serum DAO,D-lactic acid,and endotoxin levels before and after ERCPbetween the two groups.No adverse effects of mirabilite were observed.CONCLUSIONExternal use of mirabilite reduced the PEP occurrence.It significantly alleviated post-proceduralpain and reduced inflammatory response.Our results favor the external use of mirabilite toprevent PEP in children.

Real-time continuous image guidance for endoscopic retrograde cholangiopancreatography based on 3D/2D registration and respiratory compensation

BACKGROUND It has been confirmed that three-dimensional(3D)imaging allows easier identification of bile duct anatomy and intraoperative guidance of endoscopic retrograde cholangiopancreatography(ERCP),which reduces the radiation dose and procedure time with improved safety.However,current 3D biliary imaging does not have good real-time fusion with intraoperative imaging,a process meant to overcome the influence of intraoperative respiratory motion and guide navigation.The present study explored the feasibility of real-time continuous image-guided ERCP.AIM To explore the feasibility of real-time continuous image-guided ERCP.METHODS We selected 23D-printed abdominal biliary tract models with different structures to simulate different patients.The ERCP environment was simulated for the biliary phantom experiment to create a navigation system,which was further tested in patients.In addition,based on the estimation of the patient’s respiratory motion,preoperative 3D biliary imaging from computed tomography of 18 patients with cholelithiasis was registered and fused in real-time with 2D fluoroscopic sequence generated by the C-arm unit during ERCP.RESULTS Continuous image-guided ERCP was applied in the biliary phantom with a registration error of 0.46 mm±0.13 mm and a tracking error of 0.64 mm±0.24mm.After estimating the respiratory motion,3D/2D registration accurately transformed preoperative 3D biliary images to each image in the X-ray image sequence in real-time in 18 patients,with an average fusion rate of 88%.CONCLUSION Continuous image-guided ERCP may be an effective approach to assist the operator and reduce the use of X-ray and contrast agents.

Application of endoscopic retrograde cholangiopancreatography for treatment of obstructive jaundice after hepatoblastoma surgery:A case report

BACKGROUND We aimed to investigate the effectiveness of endoscopic retrograde cholangiopan-creatography(ERCP)for treating obstructive jaundice(OJ)post hepatoblastoma(HB)surgery(post-HB OJ)by analyzing the data of a case and performing a literature review.CASE SUMMARY Clinical data of one patient with post-HB OJ treated by ERCP were retrospectively analyzed.Furthermore,clinical characteristics and insights into the diagnosis and treatment of post-HB OJ in children were summarized via searching various databases and platforms,such as China National Knowledge Infrastructure,Wanfang database,CQVIP database,PubMed,Ringer Link,and Google Scholar.The patient reported herein underwent five chemotherapy sessions after the diagnosis of HB and right hemihepatectomy after tumor size reduction;these were followed by two postoperative chemotherapy sessions.Three months postoperatively,the patient developed icteric sclera,strong tea-colored urine,and clay-like stools,and showed signs of skin itchiness;blood analysis showed significantly an increased conjugated bilirubin(CB)level(200.3μmol/L).Following the poor efficacy of anti-jaundice and hepatoprotective treatments,the patient underwent ERCP.Intraoperative imaging showed a dilated bile duct in the porta hepatis with significant distal stenosis.A 5 Fr nasopancreatic tube was placed in the dilated area through the stricture for external drainage,and the patient was extubated on postoperative day 6.Postoperatively,the patient’s stool turned yellow,and the CB level decreased to 78.2μmol/L.Fifteen days later,ERCP was repeated due to unrelieved jaundice symptoms,wherein a 7 Fr naso-biliary drainage tube was successfully placed.Three months post-ERCP,the jaundice symptoms resolved,and the CB level was reduced to 33.2μmol/L.A follow-up examination one year postoperatively revealed no jaundice symptoms and normal CB level.CONCLUSION Post-HB OJ is rare.Compared to biliary tract reconstruction,ERCP is less invasive and has a better therapeutic effect.

Left hepatic artery pseudoaneurysm complicating endoscopic retrograde cholangiopancreatography:A case report

BACKGROUND Pseudoaneurysms of the hepatic artery or its branches have been reported following abdominal trauma,iatrogenic injury at the time of many operations such as percutaneous transhepatic biliary drainage and cholecystectomy.Hepatic artery pseudoaneurysms after endoscopic retrograde cholangiopancreatography(ERCP)are uncommon and potentially life threatening and should be identified and treated rapidly.CASE SUMMARY We report a case of intra-abdominal hemorrhage secondary to a left hepatic artery pseudoaneurysm resulting from guide wire injury at ERCP.The patient primary diagnosis was acute biliary pancreatitis with cholangitis,he underwent ERCP on the third day of admission.During ERCP,the left intrahepatic bile duct was cannulated three times.Over the sixth day,Contrast enhanced computed tomography scan demonstrated left hepatic lobe contusion and a pseudoaneurysm formation.The patient was successfully treated with the embolization of a small branch of left hepatic artery angiographically.CONCLUSION The common complications of ERCP are pancreatitis,bleeding and perforation.False aneurysms occur as a result of damage to the wall of an artery.As far as we know,it is rare complication has been reported following ERCP.We advise urgent referral for angiographic embolization in this situation to avoid aneurysm rupture.

Endoscopic retrograde cholangiopancreatography for diagnosing and treating pediatric biliary and pancreatic diseases

BACKGROUND This study evaluated the safety and effectiveness of endoscopic retrograde cholangiopancreatography(ERCP)in pediatric patients with biliary and pancreatic diseases.A retrospective analysis was conducted on 57 ERCP procedures performed in 41 children,primarily for treating pancreatic diseases.The overall success rate was 91.2%,with no major complications observed.Post-ERCP pancreatitis(PEP)occurred in 8.8%of cases.Follow-up examinations over one year showed no recurrence of biliary or pancreatic diseases.Notably,endoscopic treatment led to a significant increase in body mass index(BMI).These findings demonstrate the valuable role of ERCP in managing such conditions.AIM To evaluate the safety and efficacy of ERCP for the management of biliary and pancreatic diseases in pediatric patients.METHODS We conducted a retrospective analysis of data from children aged 1-18 years who underwent ERCP for biliary and pancreatic diseases at Beijing Children’s Hospital between January 2021 and December 2022.The collected data included procedure time,endoscopic treatment,success rate,and postoperative complications.RESULTS Forty-one children underwent 57 ERCP procedures,including 14 with biliary duct disease and 27 with pancreatic disease.The mean age of the patients was 7.48±3.48 years.Biliary duct-related treatments were performed 18 times,and pancreatic disease treatments were performed 39 times.ERCP was primarily used to treat pediatric pancreatic diseases[68.4%(39/57)of the procedures].The overall success rate was 91.2%(52/57 patients).PEP was noted in five patients(8.8%,5/57),and no instances of bleeding,perforation,or cholangitis were observed.The patients were followed up for over one year,and no recurrence of biliary or pancreatic diseases was detected.Importantly,BMI significantly increased after endoscopic treatment compared to that before treatment(P=0.001).CONCLUSION The high success rate and lack of major complications support the valuable role of ERCP in the management of pediatric biliary and pancreatic diseases in the pediatric population.

Endoscopic retrograde cholangiopancreatography-related early perforations:A study of effects of procedure duration,complexity,and endoscopist experience

BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from centers or analysis of large databases.Although a meta-analysis has shown fewer adverse events as a composite(bleeding,pancreatitis,Perf)during ERCP performed at high-volume centers,there is very little real-world data on endoscopist and center procedural volumes,ERCP duration and complexity on the occurrence of Perf.AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume,ERCP time,and complexity from a national endoscopic repository.Patients from clinical outcomes research initiative-national endoscopic database(2000-2012)who underwent ERCP were stratified based on the endoscopist and center volume(quartiles),and total procedure duration and complexity grade of the ERCP based on procedure details.The effects of these variables on the Perf that occurred were studied.Continuous variables were compared between Perf and no perforations(NoPerf)using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.RESULTS A total of 14153 ERCPs were performed by 258 endoscopists,with 20 reported Perf(0.14%)among 16 endoscopists.Mean patient age in years 61.6±14.8 vs 58.1±18.8(Perf vs.NoPerf,P=NS).The cannulation rate was 100%and 91.5%for Perf and NoPerf groups,respectively.13/20(65%)of endoscopists were high-volume performers in the 4th quartile,and 11/20(55%)of Perf occurred in centers with the highest volumes(4th quartile).Total procedure duration in minutes was 60.1±29.9 vs 40.33±23.5(Perf vs NoPerf,P<0.001).Fluoroscopy duration in minutes was 3.3±2.3 vs 3.3±2.6(Perf vs NoPerf P=NS).50%of the procedures were complex and greater than grade 1 difficulty.3/20(15%)patients had prior biliary surgery.13/20(65%)had sphincterotomies performed with stent insertion.Peritonitis occurred in only 1/20(0.5%).CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers.However,Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.