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.

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.

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.

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.

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.

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.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in recurrent pancreatitis of pediatric asparaginase-associated pancreatitis

BACKGROUND Asparaginase(ASP)is an important drug in combined chemotherapy regimens for pediatric acute lymphoblastic leukemia(ALL);ASP-associated pancreatitis(AAP)is the main adverse reaction of ASP.Recurrent pancreatitis is a complication of AAP,for which medication is ineffective.AIM To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography(ERCP)in treating recurrent pancreatitis due to AAP.METHODS From May 2018 to August 2021,ten children(five males and five females;age range:4–13 years)with AAP were treated using ERCP due to recurrent pancreatitis.Clinical data of the ten children were collected,including their sex,age,weight,ALL risk grading,clinical symptoms at the onset of pancreatitis,time from the first pancreatitis onset to ERCP,ERCP operation status,and postoperative complications.The symptomatic relief,weight change,and number of pancreatitis onsets before and after ERCP were compared.RESULTS The preoperative symptoms were abdominal pain,vomiting,inability to eat,weight loss of 2-7 kg,and 2-9 pancreatitis onsets.After the operation,nine of ten patients did not develop pancreatitis,had no abdominal pain,could eat normally;the remaining patient developed three pancreatitis onsets due to the continuous administration of ASP,but eating was not affected.The postoperative weight gain was 1.5-8 kg.There was one case of post ERCP pancreatitis and two cases of postoperative infections;all recovered after medication.CONCLUSION ERCP improved clinical symptoms and reduced the incidence of pancreatitis,and was shown to be a safe and effective method for improving the management of recurrent pancreatitis due to AAP.

Application Value of Nursing Intervention for Patients with Pancreatitis After Endoscopic Retrograde Cholangiopancreatography(ERCP)

Objective:To explore and analyze the application value of nursing intervention for patients with pancreatitis after endoscopic retrograde cholangiopancreatography(ERCP).Methods:From May 2022 to May 2023,100 patients with pancreatitis after ERCP who were admitted to the General Surgery Department of our hospital were selected as the research objects,they were divided into a research group and a general group by flipping coins,with 50 cases in each group.The research group received nursing intervention,and the general group received general nursing.The postoperative index recovery time,quality of life,and emotional performance were compared between the two groups.Results:The blood amylase recovery time,abdominal pain recovery time,white blood cell recovery time,and hospitalization time in the research group were significantly lower than those in the general group(P<0.05).Before intervention,the physical function,social factors,physiological performance,emotional state,and other quality of life indicators were compared between the groups,and there was no statistically significant difference(P>0.05);after intervention,the mentioned quality of life indicators were significantly better than that of the general group(P<0.05).Before intervention,the Self-Rating Anxiety Scale(SAS)and Self-Rating Depression Scale(SDS)scores between the groups were compared,and there was no statistically significant difference(P>0.05);after intervention,the SAS and SDS scores of the research group were significantly better than those of the general group(P<0.05).Conclusion:The application of nursing intervention in patients with pancreatitis after ERCP has high clinical value and specific practical significance.

Comparison of the impact of endoscopic retrograde cholangiopancreatography between pre-COVID-19 and current COVID-19 outbreaks in South Korea:Retrospective survey

BACKGROUND The coronavirus disease 2019(COVID-19)outbreak has markedly influenced the endoscopic patterns.Endoscopic retrograde cholangiopancreatography(ERCP)is an essential technique for pancreatobiliary disease but increases the risk of exposure to the virus-containing body fluid;however,the impact of COVID-19 on ERCP is unknown.AIM To compare the number of endoscopic activities and to analyze the clinical outcomes of ERCPs before and during the COVID-19 outbreak in Daegu,South Kore.METHODS This retrospective cohort study included patients aged≥18 years who underwent ERCP between February 18 and March 28,2020,at a tertiary hospital.ERCP indications and endoscopic details were compared with those from the same period in 2018 and 2019 as control groups.RESULTS Of the 269 ERCP procedures,113(42.0%)cases were performed as emergency procedures.The number of ERCP procedures in 2018 and 2019 decreased by 20.2%and 56.6%,respectively,compared with that in 2020(P<0.01);among the 113 emergency ERCPs,the observed numbers in 2018(n=42)and 2019(n=55)dramatically dropped by 61.9%and 70.9%,respectively,compared with that in 2020(n=16).Of the 16 cases in 2020,stone removal was performed in five,biliary stenting in five,sphincterotomy in five,and nasobiliary drainage in one.No case of ERCP-related infection in medical workers or other patients has been reported.CONCLUSION The COVID-19 outbreak significantly reduced the number of ERCPs;however,there is no difference in the indications and endoscopic interventions before and during the COVID-19 outbreak.

Pancreatitis after endoscopic retrograde cholangiopancreatography:A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP)is a feared and potentially fatal complication that can be as high as up to 30%in high-risk patients.Pre-examination measures,during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events.Several studies have debated on the subject,however,numerous topics remain controversial,such as the effectiveness of prophylactic medications and the amylase dosage time.This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

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.

Sequential therapy with combined trans-papillary endoscopic nasopancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

BACKGROUND Endoscopic retrograde pancreatic drainage(ERPD)and stent implantation has become the major treatment method for pancreatic pseudocysts.However,it is associated with a high recurrence rate and infection.AIM To manage pancreatic pseudocysts by sequential therapy with endoscopic nasopancreatic drainage(ENPD)combined with ERPD and evaluate the treatment outcome.METHODS One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed.There were 152 cases of intubation via the duodenal papilla,of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD(two-step procedure).The success rate of the procedure,incidence of complications(infection,bleeding,etc.),recurrence,and length and cost of hospitalization were compared between the two groups.RESULTS The incidence of infection was significantly higher in the ERPD group(12 cases)than in the two-step procedure group(2 cases).Twelve patients developed infection in the ERPD group,and anti-infection therapy was effective in five cases but not in the remaining seven cases.Infection presented as fever and chills in the two-step procedure group.The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group(P<0.05).Similarly,the recurrence rate was significantly higher in the ERPD group(19 cases)than in the two-step procedure group(0 cases).CONCLUSION Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.

Dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography

BACKGROUND:In general,the dose requirement and complications of propofol are lower when used in the diluted form than in the undiluted form.The aim of this study was to determine the dose requirement and complications of diluted and undiluted propofol for deep sedation in endoscopic retrograde cholangiopancreatography.METHODS:Eighty-six patients were randomly assigned to either group D (diluted propofol) or U (undiluted propofol).All patients were sedated with 0.02-0.03 mg/kg midazolam (total dose ≤2 mg for age <70 years and 1 mg for age ≥70) and 0.5-1 μg/kg fentanyl (total dose ≤75 μg for age <70 and ≤50 μg for age ≥70).Patients in group U (42) were sedated with standard undiluted propofol (10 mg/mL).Patients in group D (44) were sedated with diluted propofol (5 mg/mL).All patients in both groups were monitored for the depth of sedation using the Narcotrend system.The primary outcome variable was the total dose of propofol used during the procedure.The secondary outcome variables were complications during and immediately after the procedure,and recovery time.RESULTS:All endoscopies were completed successfully.Mean propofol doses per body weight and per body weight per hour in groups D and U were 3.0 mg/kg,6.2 mg/kg per hour and 4.7 mg/kg,8.0 mg/kg per hour,respectively.The mean dose of propofol,expressed as total dose,dose/kg or dose/kg per hour and the recovery time were not significantly different between the two groups.Sedation-related adverse events during and immediately after the procedure were higher in group U (42.9%) than in group D (18.2%) (P=0.013).CONCLUSIONS:Propofol requirement and recovery time in the diluted and undiluted propofol groups were comparable.However,the sedation-related hypotension was significantly lower in the diluted group than the undiluted group.

Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography

BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.

The incidence of Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND:Mirizzi syndrome is a rare complication of cholelithiasis,characterized by the narrowing of the common hepatic duct as a result of mechanical compression and/or inflammation due to biliary calculus impacted in the infundibula of the gallbladder or in the cystic duct.In this study,we aimed to describe the clinical presentations,investigations,operative details,and complications of seven patients who underwent endoscopic retrograde cholangiopancreatography and were finally diagnosed with Mirizzi syndrome in our center. METHOD:We performed a retrospective analysis of the records of 7 patients with Mirizzi syndrome who underwent endoscopic retrograde cholangiopancreatography. RESULTS:The incidence of Mirizzi syndrome was 1.07% of 656 patients given endoscopic retrograde cholangiopan- creatography.Ultrasonography was able to diagnose one case.Endoscopic retrograde cholangiopancreatography suggested the diagnosis in five cases and helped further in the management of these patients.Four patients had cholecystectomy and T-tube placement,and two had cholecystectomy and choledochoduodenostomy.One patient with typeⅠMirizzi syndrome according to the Csendes classification successfully underwent laparoscopic cholecystectomy. CONCLUSIONS:In the study,the incidence of Mirizzi syndrome was 1.07%of patients who underwent endoscopic retrograde cholangiopancreatography. Preoperative diagnosis of Mirizzi syndrome by endoscopicretrograde cholangiopancreatography is important to prevent complications.

Sedation and safety of propofol for therapeutic endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancrea tography(ERCP) is the most complex gastrointestinal procedure,which needs patients' cooperation. The aim of this study was to observe the quality and safey of sedation with propofol in patients undergoing therapeutic ERCP. METHODS:Seventy patients who had undergone therapeutic ERCP were randomly divided into two groups.One group, given intravenously propofol, and the other sedated with routine method, served as the control. Blood pressure, heart rate,oxygen saturation were monitored and cardiorespiratory event was observed. Patient cooperation,performance, recovery time and amnesia served as variables postoperation. RESULTS:Blood pressure elevated in four patients in the propofol group, less than in the control group(P<0.01). Seven patients showed decreased blood pressure after administration of propofol,but none in the control group (P<0.01). Twelve patients in the control group showed mild or significant resistance, but none in the propofol group (P<0.01). The time for performance in the propofol group(P<0.05) was shorter than in the control group. Patient recovery was quicker in the propofol group than in the control group (P<0.01). The degree of amnesia better in the propofol group than in the control group ( P<0.01). The degree of amnesia was also better in the propofol group than in the control group (P<0.01). CONCLUSIONS:Propofol proves to be an excellent sedative for therapeutic ERCP. Being effective and safe, it shows a shorter ERCP duration but quick recovery and better amnesia. It is better than other routine sedatives.