Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe postprocedure complications. Hormonal changes during pregnancy promote cholelithiasis, but there are limited clinical data available on the outcomes of ERCP in pregnant women. ERCP techniques without irradiation were recently introduced as potential alternative. We performed a systematic review and meta-analysis to assess the safety of ERCP in pregnancy and to compare outcomes of radiation versus nonradiation ERCP.

A systematic search of PubMed, Medline/Ovid, Web of Science, and Google Scholar through April 18^th, 2018 using PRISMA and MOOSE guidelines identified 27 studies reporting the outcomes of ERCP in pregnancy. Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I², and meta-regression analysis was conducted. Adverse outcomes were divided into fetal, maternal pregnancy-related, and maternal nonpregnancy-related.

In all, 27 studies reporting on 1,307 pregnant patients who underwent ERCP were identified. Median age was 27.1 years. All results were statistically significant (P < 0.01). The pooled event rate for overall adverse outcomes was 15.9% (95% CI = 0.132-0.191) in all studies combined, 17.6% (95% CI = 0.109-0.272) in nonradiation ERCP (NR-ERCP) subgroup and 21.6% (95% CI = 0.154-0.294) in radiation ERCP subgroup. There was no significant difference in the pooled event rate for fetal adverse outcomes in NR-ERCP 6.2% (95% CI = 0.027-0.137) versus 5.2% (95% CI = 0.026-0.101) in radiation ERCP group. There was no significant difference in maternal pregnancy-related adverse outcome event rate between NR-ERCP (8.4%) (95% CI = 0.038-0.173) and radiation ERCP (7.1%) (95% CI = 0.039-0.125). Maternal nonpregnancy-related adverse outcome event rate in NR-ERCP was 7.6% (95% CI = 0.038-0.145), which was half the event rate in radiation ERCP group of 14.9% (95% CI = 0.102-0.211).

ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy-related complications, but not of fetal and pregnancy-related complications.

Resource-intensive endoscopic procedures have shown to generate more costs than revenue under the current reimbursement system in the USA. Single-balloon enteroscopy (SBE), a resource-intensive procedure, has never been evaluated for its financial impact at tertiary care hospitals, and thus, our aim was to determine the sources of revenue that SBE procedures generate.

Retrospective review of all procedures performed using the SBE system during the first year of implementation at a single tertiary referral center. Financial data from two subspecialties in the form of revenues for physician and facility fees were collected and analyzed. Revenues were analyzed in total and as a function of payer (insurance) and physician type.

Fifty-two procedures using the SBE system were identified during the first year of implementation at a single tertiary care center. Total revenue generated for all SBE procedures was $123,714 including $64,475 dollars from physician fees and $59,239 dollars from the facility fees. Revenue generated by anesthesia physician fees was higher from Medicare cases compared to private insurance cases (p < 0.01); however, revenues from facility fees were higher for private insurance cases compared to Medicare (p < 0.01). Revenues from anesthesiology physician fees were significantly more than revenues from GI physician fees (p < 0.01). Of the three referred cases, one generated additional downstream revenues from other non-SBE-related services totaling $4727.

A large proportion of revenues generated from SBE cases come in the form of ancillary services provided by anesthesia. Projected revenue generation (and it sources) should be considered when establishing a device-assisted enteroscopy program.

Gallstone diseases are common during pregnancy. In most cases, patients are asymptomatic and do not require any treatment. However, choledocholithiasis, cholangitis, and gallstone pancreatitis may potentially become life-threatening for both mother and fetus and often require urgent intervention. Although endoscopic retrograde cholangiopancreatography (ERCP) has become the standard technique for removing common bile duct stones, it is associated with ionizing radiation that could carry teratogenic risk. Non-radiation ERCP (NR-ERCP) is reported to be effective without incurring this risk. Two techniques have been described to confirm bile duct cannulation: bile aspiration and image guidance. With bile aspiration, biliary cannulation is confirmed by applying suction to the cannula to yield bile, thus confirming an intrabiliary position. Image guidance involves using ultrasound or direct visualization (choledochoscopy) to confirm selective biliary cannulation or duct clearance. Once cannulation is achieved, the stones are removed using standard ERCP techniques and tools. Case series and retrospective studies have reported success rates of up to 90% for NR-ERCP with complication rates similar to standard ERCP. Pregnancy outcomes are not adversely affected by NR-ERCP, but whether the avoidance of radiation carries benefit for the baby is unknown. Prospective comparative trials are lacking. NR-ERCP is technically demanding and should be attempted only by skilled biliary endoscopists in properly equipped and staffed health-care institutions, in a multidisciplinary setting.

To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP).

Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naïve patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient's clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test.

Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m(2), 159-5039 cGy/m(2) vs 1296 cGy/m(2), 202.2-6421 cGy/m(2), P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires.

ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

When calculating differences between interventions, direct cost comparisons are typically based on Medicare reimbursement rates. The additional out-of-pocket costs of the patient have been little studied in endoscopy.

To determine out-of-pocket costs for patients undergoing ERCP.

Between June and August 2009, all outpatients referred to our tertiary care university hospital for elective ERCP were prospectively interviewed regarding out-of-pocket costs for procedures. Patients were asked regarding any costs to undergo the procedure including co-pay, driving, parking, meals, child care or equivalent, and any additional expenses related to subsequent procedures or admissions related to the ERCP.

Over the study period, 94 outpatients (mean age 57 ± 16 years, 48% male) underwent ERCP. Mean/median out-of-pocket costs for the procedure were $177.97/72.54 and ranged from $0 to $2,033.54. The largest single expense for the procedure was related to copayment (median $75). Eleven patients required hospitalization for post-procedural complications resulting in additional median out-of-pocket costs of $25. Median hotel, food, and travel expenses were $171.00, $20.00, and $23.54, respectively.

Out-of-pocket ERCP costs are not insignificant from the patient's perspective and should be added to the direct costs to calculate true procedure costs.

Prospective evaluation of the new 0.025 in. Visiglide(®) guidewire to facilitate endoscopic retrograde cholangiopancreaticography using the Olympus V-scope.

Interventional endoscopic retrograde cholangiopancreaticography was performed in 9 patients with the Olympus V-scope and the 0.025 in. Visiglide(®) guidewire (VS group), whilst 9 other patients underwent endoscopic retrograde cholangiopancreaticography with a conventional Olympus duodenoscope using 0.035 in. conventional guidewires (controls). Exchange time of accessories, X-ray time, dose and endoscopic retrograde cholangiopancreaticography examination time were investigated.

The VS group showed a significantly lower exchange time of endoscopic retrograde cholangiopancreaticography accessories (9; 4-10s, p<0.0001) than controls (29; 19-44s). The Visiglide(®) guidewire was complete fixable by the elevator in 35/36 instrument exchanges (97%) compared to 16/31 exchanges (52%) using conventional guidewires.

Single-centre study, small patient numbers, two investigators.

Endoscopic retrograde cholangiopancreaticography using the Olympus V-scope with the new 0.025 in. Visiglide(®) guidewire enables a 3-fold faster exchange of accessories due to a nearly complete fixation of the guidewire.

Endoscopic ultrasonography (EUS) has emerged as an accurate diagnostic alternative to endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review of all randomized controlled trials of EUS-guided ERCP versus ERCP alone in patients with suspected choledocholithiasis.

The search for eligible studies was carried out using the MEDLINE, Cochrane Central Register of Controlled Trials, and Science Citation Index electronic databases. Meta-analysis was conducted using a random-effects model.

Four trials containing 213 patients randomized to EUS-guided ERCP and 210 to ERCP alone were selected. In the EUS-guided ERCP group, ERCP was avoided in 143 patients (67.1 per cent) when EUS did not detect choledocholithiasis. The use of EUS significantly reduced the risk of overall complications (relative risk 0.35 (95 per cent confidence interval (c.i.) 0.20 to 0.62); P < 0.001) and post-ERCP acute pancreatitis (relative risk 0.21 (95 per cent c.i. 0.06 to 0.83); P = 0.030).

By performing EUS first, ERCP may be safely avoided in two-thirds of patients with common bile duct stones. Application of EUS in the selection of patients for therapeutic ERCP significantly reduces the complication rate.

Recent research has demonstrated that resource-intensive endoscopic procedures are not financially viable if performed without the need for further clinical care.

To determine whether the net income from downstream clinical activities makes resource-intensive endoscopy a financially viable activity.

Retrospective database review.

Tertiary-referral medical center.

Patients whose initial contacts with the medical center were as outpatients who underwent EUS, EMR, or ERCP in 2004.

Hospital charges, the cost of providing services, revenue, and net income from all services provided through June 2006.

A total of 120 patients were reviewed whose initial procedure was EUS (48), ERCP (53), or EMR (19). Although income was lost by performing the endoscopic procedures, revenue was generated by the subsequent clinical care derived from EUS (mean $7093 per patient, standard deviation [SD] $23,686, range $12,316-$117,984 per patient); a loss of revenue was incurred in the clinical care of both patients who underwent ERCP (mean -$5028 per patient, SD $12,565, range -$33,648-$47,481) and patients who underwent EMR (mean -$931 per patient, SD $6515, range -$11,245-$12,196). The most lucrative activity arising from initial endoscopic referral was surgery. Revenue was lost for these procedures in Medicare patients compared with non-Medicare patients.

Indirect costs are institution specific and may not be generalizable to other centers.

EUS is the most remunerative resource-intensive endoscopic procedure. Centralizing these resource-intensive procedures into multispecialty practice sites that provide surgical and oncologic care allows downstream revenue from patient treatment to offset procedural losses. Even taking account of downstream revenues, performing these procedures on Medicare patients is not financially viable. Any future cuts in Medicare physician payment rates will further increase this Medicare/non-Medicare reimbursement imbalance and likely have consequences on the performance of these procedures.

Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies.

We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures.

Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036).

Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.