Here, we report a case of a 74-year-old woman treated for acute cholecystitis. She initially underwent percutaneous transhepatic gallbladder drainage; however, cholecystitis recurred when the drain was clamped. Therefore, endoscopic transpapillary gallbladder drainage (ETGBD) was performed. Endoscopic sphincterotomy was performed, and a transpapillary gallbladder stent was placed. Additionally, a pancreatic spontaneous dislodgment stent (PSDS) was inserted to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. Cholecystitis resolved, and the patient was discharged seven days later. Twenty-five days after ETGBD, she experienced abdominal pain, and computed tomography revealed ascending colon perforation by the migrated PSDS. She underwent laparoscopic surgery, in which the perforation was sutured, and an ileostomy was performed. The postoperative course was uneventful, and colonoscopy performed two months after surgery revealed multiple diverticula in the ascending colon. PSDS-induced gastrointestinal perforations are extremely rare. Previous case reports have suggested that perforation is caused by long-term stent retention in the gastrointestinal tract due to obstructions, such as peritonitis carcinomatosa or postoperative adhesions. We believe that in this case, the PSDS was retained because of multiple colonic diverticula. PSDS should be used with caution in patients with multiple colonic diverticula, peritonitis carcinomatosa, and postoperative adhesions.

Endoscopic ampullectomy is the preferred treatment for selected periampullary lesions, yet up to 10.6% of patients may experience delayed bleeding post-procedure. This study aims to identify predictors for bleeding, which remain poorly understood.

This was a single-center retrospective cohort study of adult patients who underwent endoscopic ampullectomy (EA) between January 2011 and September 2023. The primary outcome was the risk factors for delayed bleeding, defined as post-procedural bleeding that necessitated either an emergency department visit, hospital admission, blood transfusion, or re-intervention. Secondary outcomes included adverse events, such as perforation and pancreatitis.

A total of 113 patients underwent EA, and 25 (22.1%) experienced delayed bleeding. Of these, 20 (80%) required repeat endoscopy, six (24%) needed blood transfusions, and three (12%) were managed conservatively. Multivariable logistic regression analysis identified international normalized ratio ≥1.2 (odds ratio [OR] 3.32, 95% confidence interval [95% CI] 1.03-10.74, p = 0.05), presence of high-grade dysplasia or intramucosal cancer (OR 3.76, 95% CI 1.20-11.81, p = 0.03), female sex (OR 3.14, 95% CI 1.11-8.93, p = 0.03), size of lesion (OR 1.04, 95% CI 1.01-1.08, p = 0.03) and procedure duration (OR 0.98, 95% CI 0.97-0.99, p = 0.04) as independent predictors of delayed bleeding.

Several factors, including features of high-grade dysplasia-intramucosal cancer, international normalized ratio ≥1.2, female sex, lesion size, and procedure duration are associated with delayed post-ampullectomy bleeding. These factors should be taken into consideration when strategizing the reduction of post-ampullectomy bleeding.

Acute pancreatitis is a commonly encountered pathology in the emergency department. We presented a clinical review summarizing the contemporary emergency medicine approach to managing acute pancreatitis. Although the diagnostic criteria for acute pancreatitis are straightforward, it has many possible causes, several treatment options, and both short- and long-term sequelae. We discussed diagnostic, intervention, and disposition considerations relevant to emergency clinicians and considered risk assessment using available clinical decision tools. We also discussed changes to traditional treatments and ongoing investigational therapies, including steroids, monoclonal antibodies, and calcium release-activated calcium channel inhibitors.

Covered self-expandable metallic stents (CSEMS) are effective for managing malignant distal biliary obstruction (MDBO). However, migration is a significant problem, which requires prevention. The novel multihole fully CSEMS (MHSEMS), which features multiple small holes on the covered membrane, is expected to prevent migration. This study aimed to evaluate the efficacy and safety of MHSEMS for MDBO.

This multicenter retrospective cohort study included 111 patients with MDBO who underwent MHSEMS placement between September 2022 and August 2023. The primary outcome was the recurrent biliary obstruction (RBO) rate. The secondary outcomes were adverse event (AE) rates, removability, technical and clinical success rates, and time to RBO.

The technical success rate was 100%, and the clinical success rate was 94.6%. AEs occurred in 34.2% of patients, with RBO in 21.0% and non-RBO AEs in 17.1%. RBO included stent migration in 1.9%, stent occlusion in 11.7% (including ingrowth in 5.7%, biliary debris in 2.9%, hemobilia in 1.9%, and food impaction in 1.0%), and nonocclusion cholangitis (requiring biliary drainage) in 5.7%. Non-RBO AEs included post-endoscopic retrograde cholangiopancreatography pancreatitis in 11.7%, cholecystitis in 2.7%, and nonocclusion cholangitis in 2.7%. Stent removal was successful in 88.9% of attempts. The median time to RBO was 446 days.

The placement of MHSEMS for MDBO was effective and feasible, demonstrating low migration rates, acceptable AEs, and removability.

Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.

Achieving competence in endoscopic retrograde cholangiopancreatography (ERCP) requires extensive training. Recognizing the potential of simulator-based education for safe and effective skill development, we aimed to assess whether initial training with the Boškoski-Costamagna ERCP Trainer (BCT) is beneficial compared with conventional training alone (i.e. predictive validity).

A prospective multicenter randomized trial involving 16 novice ERCP trainees, randomly assigned to intervention or control groups, was performed. Both underwent hands-on training, with the intervention group receiving additional simulation training during the first 3 months. Each trainee was required to complete a minimum of 60 ERCPs in up to 1 year. The TEESAT score evaluated rates of global overall competence (primary outcome), biliary cannulation, and adverse events (AEs; secondary outcomes). Mixed-effect logistic regression models assessed differences in between-group ERCP procedure competence and success. Learning curves were generated cumulatively over the training period.

1106 ERCPs (562 simulator group; 544 control group) were included. Although no statistically significant difference in global overall competence was observed between the groups, possibly owing to data heterogeneity, simulation training demonstrated higher success for native biliary cannulation (52% vs. 42%; P<0.001) and faster median (interquartile range) biliary cannulation times (3 [6] vs. 5 [8] minutes; P<0.001). The simulator group also showed faster improvements in overall performance, native biliary cannulation, and sphincterotomy. No statistical difference was found in overall AEs between the groups.

Early simulation training with the BCT improved technical competence in native biliary cannulation and accelerated overall ERCP learning. This approach has the potential to enhance ERCP training programs.

Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and health care expenditure. We aimed to assess incidences and comparisons of ERCP AEs.

We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence.

A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence interval [CI], 0.1%-0.3%; I2, 44%; n = 47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI, 4.0%-5.1%; I2, 96%; n = 293,378) among all-comers and 6.5% (95% CI, 5.9%-7.1%, I2, 89%; n = 88,809) among first-time patients. Pancreatitis incidence remained stable between 2000 and 2023 (average annual percent change 0.06, 95% CI, -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%; 95% CI, 1.2%-1.7%; I2, 93%; n = 229,655), cholangitis (2.5%; 95% CI, 1.9%-3.3%; I2, 96%; n = 121,619), cholecystitis (0.8%; 95% CI, 0.5%-1.2%; I2, 39%; n = 7799), and perforation (0.5%; 95% CI, 0.4%-0.6%; I2, 90%; n = 306,378).

ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies.

Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors.

This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP.

In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages.

DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP), their optimal dosage is unknown. Given possible interindividual variability in the pharmacodynamics of NSAIDs, we hypothesized that the dose required to achieve adequate PEP prophylaxis varies with body weight.

We conducted an analysis using single-center, prospective, observational cohort study data. The primary outcome was PEP incidence by NSAID dosage per body weight (mg/kg). Patients meeting the inclusion criteria were classified into 3 groups.

We included 891 patients, with 400, 454, and 37 patients in the control group with no NSAID therapy, the NSAID <1.0 mg/kg group, and the NSAID ≥1.0 mg/kg group, respectively. In the adjusted cohort, the odds ratio of PEP was 0.18 (95% confidence interval: 0.041-0.79; P = 0.023) for NSAID ≥1.0 mg/kg and 1.3 (95% confidence interval: 0.76-2.3; P = 0.31) for NSAID <1.0 mg/kg compared to the control group without NSAID.

PEP was not prevented by NSAID dosages below 1.0 mg/kg body weight whereas a dosage above 1.0 mg/kg body weight had a significant prophylactic effect. An NSAID dosage adjusted to body weight may be necessary to achieve an adequate prophylactic effect against PEP.

 Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to assess potential etiologic associations between intra-/post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. METHODS : Prospective data from a multicenter collaborative were used. A 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP, and follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and AEs and UHU as outcomes, with a priori selected covariates. Odds ratios (ORs) and 95 %CIs for each PREM domain were reported.

 From 2018 to 2023, 3434 patients were included. A post-procedural abdominal pain score > 3 was associated with pancreatitis (OR 3.71 [95 %CI 2.37-5.73]), while a score > 6 was associated with perforation (OR 9.54 [95 %CI 1.10-59.37]). Post-procedural pain was also associated with UHU within 30 days when used as a continuous exposure (OR 1.08 per point [95 %CI 1.01-1.16]), and when partitioned at a score > 3 (OR 1.79 [95 %CI 1.13-2.74]) and a score > 6 (OR 1.93 [95 %CI 1.02-3.46]). No other intra- or post-procedural PREMs were associated with any AEs or UHU.

 Patient-reported abdominal pain from a Likert-based PREM at the time of discharge from ERCP was associated with pancreatitis, perforation, and UHU within 30 days. Applying PREMs could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs.

Although endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be a safe and effective approach in treating these diseases while carrying lower morbidity than traditional surgical treatments, ERCP has associated risks, with post-ERCP pancreatitis (PEP) being the most common serious adverse event and carries significant morbidity and health care cost. PEP results from multifactorial factors involving trauma to the pancreatic duct and papilla, leading to subsequent obstruction and impairment of pancreatic drainage. Important risk factors for PEP include history of prior PEP, suspected sphincter of Oddi dysfunction, difficult cannulation, pancreatic duct contrast injections, and pancreatic sphincterotomy.

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

The rising incidence of hilar malignant bile duct strictures poses challenges for diagnosis and treatment. While endoscopic treatment is essential for relieving obstruction, it carries a high risk of postoperative cholangitis. Sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may emerge as an effective strategy to mitigate these complications.

This study aimed to evaluate the efficacy and safety of nasobiliary tube cutting after nasobiliary drainage versus conventional stent placement in reducing postoperative cholangitis in patients with hilar malignant biliary strictures.

A retrospective cohort study.

From 2015 to 2023, 208 patients were divided into two groups: nasobiliary tube cutting group (n = 103) and conventional stent group (n = 105). The primary outcome was postoperative cholangitis, with secondary outcomes including drainage success, bilirubin reduction, re-interventions, complications, and hospital stay.

Cholangitis occurred in 11.7% of the nasobiliary tube cutting group and 26.7% of the conventional stent group (p = 0.006). Successful drainage was achieved in 84 patients (81.6%) in the nasobiliary tube cutting group and 78 patients (74.3%) in the conventional stent group, with no statistically significant difference (p = 0.207). Patients whose total bilirubin reduction >50% within 7 days were significantly higher in the nasobiliary tube cutting group (48.5% vs 27.6%, p = 0.002). There were no significant differences between the groups in the number of endoscopic retrograde cholangiopancreatography procedures or re-interventions required (p > 0.05). Except for postoperative cholangitis, other postoperative complications were comparable between the groups (p > 0.05). The postoperative hospital stay was significantly longer in the nasobiliary tube cutting group, with a median duration of 10.0 (7.0, 14.0) days compared to 7.0 (5.5, 12.5) days in the conventional stent group (p = 0.024). Bismuth-Corlette Type IV was identified as an independent risk factor for cholangitis (OR = 3.207, 95%CI: 1.253-8.210, p = 0.015).

For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it may result in a prolonged postoperative hospital stay. Bismuth-Corlette Type IV is an independent risk factor for the development of postoperative cholangitis.

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the "sequential approach". The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation.

To assess the safety and efficacy of treatment for intraductal papillary mucinous neoplasm (IPMN) involving the main pancreatic duct (MPD) using endoscopic retrograde cholangiopancreatography (ERCP) combined with digital single-operator pancreatoscopy and radiofrequency ablation (RFA). A retrospective analysis was performed. Patients with episodes of acute pancreatitis at the First Affiliated Hospital of Chongqing Medical University were screened. When the diagnosis of IPMN was confirmed by ERCP with pancreatoscopy, patients who underwent endoluminal RFA treatment were enrolled. The most frequent complications were monitored to assess the safety of treatment. Disease progression and recurrence of pancreatitis symptoms were regarded as the indicators of treatment efficacy. In total, 50 patients were screened, and 14 patients who undertook the lesion ablation using RFA were enrolled. Mild adverse events occurred, while they were relieved under symptomatic treatment. No severe complications were recorded. All patients received regular follow-ups, during which an episode of IPMN-related pancreatitis occurred in 1 patient, and disease progression was found in 1 patient who successively underwent pancreaticoduodenectomy. Regional treatment of IPMN lesions in the MPD exhibited satisfactory effect in preventing lesion progression and relieving pancreatitis symptoms through the combined use of ERCP with pancreatoscopy and RFA, without causing severe complications.

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers, characterized by late diagnosis, rapid progression, and limited therapeutic options. Despite advancements, only 20% of patients are eligible for surgical resection at diagnosis, the sole curative treatment. Multidisciplinary evaluation is critical to optimize care, stratifying patients based on resectability into resectable, borderline resectable, locally advanced, and metastatic stages. Preoperative imaging, such as computed tomography (CT) and endoscopic ultrasound (EUS), remains central for staging, for vascular assessment, and tissue acquisition. Endoscopic and systemic approaches are pivotal for addressing complications like biliary obstruction and improving outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered for years the gold standard for biliary drainage, although EUS-guided drainage is increasingly utilized due to its efficacy in both resectable and unresectable disease. Systemic therapies play a key role in neoadjuvant, adjuvant, and palliative settings, with ongoing trials exploring their impact on survival and resectability chance. This review highlights the evolving multidisciplinary approaches tailored to the disease stage, focusing on biliary drainage techniques, systemic therapies, and their integration into comprehensive care pathways for PDAC. The continuous refinement of these strategies offers incremental survival benefits and underscores the importance of personalized, multidisciplinary management.

In recent years, the detection of the duodenal papilla and surgical cannula has become a critical task in computer-assisted endoscopic retrograde cholangiopancreatography (ERCP) cannulation operations. The complex surgical anatomy, coupled with the small size of the duodenal papillary orifice and its high similarity to the background, poses significant challenges to effective computer-assisted cannulation. To address these challenges, we present a deep learning-driven graphical user interface (GUI) to assist ERCP cannulation.

Considering the characteristics of the ERCP scenario, we propose a deep learning method for duodenal papilla and surgical cannula detection, utilizing four swin transformer decoupled heads (4STDH). Four different prediction heads are employed to detect objects of different sizes. Subsequently, we integrate the swin transformer module to identify attention regions to explore prediction potential deeply. Moreover, we decouple the classification and regression networks, significantly improving the model's accuracy and robustness through the separation prediction. Simultaneously, we introduce a dataset on papilla and cannula (DPAC), consisting of 1840 annotated endoscopic images, which will be publicly available. We integrated 4STDH and several state-of-the-art methods into the GUI and compared them.

On the DPAC dataset, 4STDH outperforms state-of-the-art methods with an mAP of 93.2% and superior generalization performance. Additionally, the GUI provides real-time positions of the papilla and cannula, along with the planar distance and direction required for the cannula to reach the cannulation position.

We validate the GUI's performance in human gastrointestinal endoscopic videos, showing deep learning's potential to enhance the safety and efficiency of clinical ERCP cannulation.

Acute pancreatitis is a frequent, burdensome adverse event of endoscopic retrograde cholangiography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have reduced post-ERCP pancreatitis (PEP) risk by about 50 % and show greater efficacy over parenteral or oral administration, although the mechanism for its superiority remains unclear. To probe this question, we investigated in a preclinical model, the pharmacokinetics in the blood, pancreas and other tissues of the NSAID diclofenac given via the rectal, intravenous, or intragastric routes.

The data on diclofenac was extracted from a larger study that examined a combination of diclofenac and tacrolimus. 20.8 mg diclofenac/kg body weight, which is the mouse equivalent dosing used in clinical practice for PEP prophylaxis, was administered to C57BL/6J mice via the rectal, intravenous and intragastric (oral) routes. Cross-collection of blood and tissues was done at various timepoints after administration for the evaluation of drug levels and pharmacokinetic parameters.

Rectal diclofenac demonstrated favorable blood pharmacokinetics and systemic bioavailability as well as sustained pancreas penetration. The total pancreas exposure to diclofenac over 24 h following rectal dosing was not significantly different as compared to intravenous and oral dosing.

Our findings suggest that the efficacy of rectal diclofenac in PEP prevention relates more to its higher and consistent systemic exposure than its absolute pancreas levels. The implications are that the rectal route provides both systemic and pancreas exposure for the full duration of PEP vulnerability.

When cannulation is challenging during endoscopic retrograde cholangiopancreatography (ERCP), and the standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques can be used to access the biliary tree. The purpose of this study was to compare the incidence of adverse events and cannulation success rates between transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS).

Data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), collected from 2011 to 2022, were analyzed. A total of 105,303 ERCP procedures were recorded in GallRiks during the study period. After exclusions, the study population consisted of 47,486 ERCP procedures. Of these, 4547 received PCS and 3273 received TPS. The remaining 39,666 ERCP procedures with conventional sphincterotomy served as the control group. The primary endpoints were successful cannulation and adverse events within 30 days.

Successful cannulation was more frequent with the TPS technique than with the PCS technique (86.5% vs. 69.7%), but both groups had a lower cannulation rate than the control group (92.4%; OR-PCS 0.20, 95% CI 0.18-0.21; OR-TPS 0.58, 95% CI 0.52-0.64). The TPS group had a higher incidence of adverse events than the PCS group (24.1% vs. 18.8%) and both groups had a higher incidence of adverse events than the control group (15.5%; OR-PCS 1.25, 95% CI 1.15-1.36; OR-TPS 1.71, 95% CI 1.57-1.87). Adverse events for TPS were driven by a higher incidence of pancreatitis (10.5% vs. 6.4% vs. 4.5%; OR 2.53, 95% CI 2.23-2.86) and perforation (1.6% vs. 0.8% vs. 0.5%; OR 2.99, 95% CI 2.20-4.06) compared to both PCS and control.

TPS is more successful at cannulation than PCS; however, this success comes at a higher cost in terms of adverse events, particularly pancreatitis and perforation.

Nonexpert endoscopists cannot achieve high-quality performance during difficult biliary cannulation, representing a significant challenge; precutting is an effective approach for managing these cases. Transpancreatic biliary sphincterotomy (TPBS) is considered more effective than needle-knife precutting owing to its wire-guided technique, which may be suitable for nonexpert endoscopists; however, comparisons between nonexpert and expert endoscopists performing TPBS are not well documented.

Consecutive patients who underwent TPBS between January 2010 and April 2024 were evaluated. Rates of successful biliary duct cannulation, time to TPBS and bile duct cannulation, and adverse events were compared between both groups. Logistic regression analysis was conducted to identify factors associated with successful bile duct cannulation using TBPS.

The study included 140 patients (77 and 63 in the nonexpert and expert groups, respectively). The rates of successful biliary cannulation and overall adverse events (including pancreatitis, 9.1% vs. 9.5%) were 88.3% and 93.7% (p = .38) and 15.6% and 9.5% (p = .32) in the nonexpert and expert groups, respectively. Multivariate analysis revealed that early TPBS (<22 min) was a significant predictive factor for successful bile duct cannulation.

TBPS may be an effective technique for nonexpert endoscopists; additionally, early TPBS is a significant predictive factor for successful bile duct cannulation.

In biliary cancer, the indication of endoscopic intervention might be diagnostic as well as therapeutic, in the latter situation with the aim to relieve biliary obstruction e.g. by stenting. Our aim was to investigate the use of endoscopic biliary interventions during the diagnostic workup of biliary cancers in a national cohort, and to evaluate their complications, especially cholangitis and pancreatitis.

This is a registry-based study of national cohort of patients with biliary cancers in Sweden 2010-2020. The use of endoscopic retrograde cholangiopancreatography (ERCP) during the diagnostic work up period before treatment onset, and risk of complications were evaluated in patients with gallbladder cancer, intrahepatic-, perihilar- and distal cholangiocarcinoma. The risk of complications was compared depending on age, sex, comorbidity, in relation to stage and curative intent, endoscopy unit size, and with relation to survival.

Forty percent of the patients with biliary cancer underwent ERCP during the diagnostic workup, with variations depending on diagnosis. There was a 20% overall risk of periprocedural complications, a 9% risk of post-ERCP-pancreatitis (PEP), and a 6% risk of cholangitis. Increasing tumor stage did not increase risk, nor did comorbidity. The complication rates were slightly higher for younger patients and those undergoing curative treatment. For perihilar cholangiocarcinoma (pCCA) treated with curative intention, the risk of periprocedural complications was as high as 30.7%. No association between post-ERCP complications and survival was found.

Irrespective of type of biliary cancer, ERCP is frequently used during diagnostic workup. The complication risk indicates that primary biliary cancers are complication prone, regardless of stage. Notably the risk of complications was the highest for younger patients with low comorbidity scores, as well as for patients undergoing curatively aiming treatment.

Management of hemobilia is often challenging. Recently, endoscopic hemostasis with a self-expandable metal stent (SEMS) has shown promising efficacy for controlling bleeding at the endoscopic sphincterotomy site. This study aimed to assess efficacy and feasibility of endoscopic hemostasis as bridge therapy for hemobilia.

Patients with hemobilia between 2008 and 2023 were retrospectively reviewed. We compared efficacy of hemostasis between the initial endoscopic hemostasis group (ENDO group) and the initial angiographic embolization group (EMBO group). The primary outcome was initial hemostasis success rate and the secondary outcomes were delayed bleeding rate, subsequent embolization rate, 28-day mortality, transfusion amount, time to first hemostasis, total hemobilia time, and incidence of hypovolemic shock.

A total of 26 patients with hemobilia were included in this study and 17 patients (65.4%) were identified as the ENDO group and nine patients (34.6%) were classified as the EMBO group. The success rate of initial hemostasis was 88.2% (15/17) in the ENDO group and 100% (9/9) in the EMBO group ( P = 0.529). The rate of delayed bleeding in the ENDO group was 17.6% (3/17) and 0.0% (0/9) in the EMBO group ( P = 0.529). Total hemobilia time was shorter in the ENDO group than in the EMBO group (mean: 281.5 ± 1022.4 minutes vs. 5002.8 ± 7982.6 minutes; P < 0.001) Stent insertion depth was associated with successful hemostasis without delayed bleeding. ( P = 0.015).

Endoscopic hemostasis using SEMS for hemobilia appeared to be a feasible bridge therapy.

Endoscopic papillary balloon dilation (EPBD), small endoscopic sphincterotomy (EST), and small EST plus EPBD are commonly used as rescue techniques to remove bile duct stones. However, we often encountered challenging cases with non-dilated distal bile ducts, especially in those undergoing EPBD. We aimed to explore the reasons by assessing whether patients without the dilated bile duct had a higher risk of early complications and whether it was impacted by the rescue techniques.

We performed a retrospective cohort study by frequency matching design in patients diagnosed with stones in non-dilated distal bile duct who received rescue techniques from July 2016 to June 2022. Besides, patients with stones and without dilatation of the distal bile duct (DDBD) were divided into 3 subgroups according to the rescue technique received. Outcomes were compared between the subgroups.

The non-DDBD group was more likely to develop post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and hyperamylasemia (HP) than the DDBD group (P < 0.05). Some cases had mild or moderate pancreatitis, but no one in either group developed severe pancreatitis. For subgroup analysis, each technique resulted in complete stone removal; the EPBD group had a higher HP rate than the other subgroups and reached statistical significance: the EPBD group versus the small EST group (P = 0.013) and the EPBD group versus the EPBD plus small EST group (P = 0.008). Although there was no statistical significance, PEP incidence in the EPBD group was 13.7% higher than in other subgroups (P > 0.05/3).

Non-DDBD patients have a higher risk for endoscopic retrograde cholangiopancreatography-related pancreatic inflammation. EPBD should be used cautiously due to the significant association with increased rates of PEP and HP. Conversely, small EST and combination therapy are suitable for non-dilated bile duct stones because of their high safety profile and efficacy.

Endoscopic retrograde cholangiopancreatography (ERCP) training remains challenging. This study used 3D printing techniques to develop and optimize a portable ERCP training simulator and to implement basic and advanced practical techniques. Subsequently, we aimed to determine whether endoscopy trainees acquired proficiency in ERCP techniques and assess any improvements in their skill levels from using this model. An ERCP training model was generated using 3D printing techniques, including five distinct interchangeable and transparent ampullar-common bile duct (CBD) modules. A prospective study using this model was conducted with ten trainees. The technical success rate and examination times for duodenoscope insertion and biliary cannulation were evaluated. In addition, the successful plastic-stent insertion rate and trainee satisfaction were measured. The success rates for duodenoscopy, cannulation, and plastic stent insertion were 94, 100, and 92%, respectively. The mean satisfaction scores for duodenoscope insertion, cannulation, and plastic stent insertion were 4.4, 4.7, and 4.6 on a 5-point scale, respectively. Five attempts decreased the insertion time (R = - 0.591, P < 0.001) and cannulation time (R = - 0.424, P = 0.002). This ERCP-training silicon model is durable, simulates ERCP techniques easily, and helps trainees improve their ERCP techniques.

Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk.

To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement.

This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up.

Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality.

This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement.

NL5130.

Pathological evaluation is crucial for diagnosing biliary lesions and determining appropriate treatment strategies. However, tissue sampling via the transpapillary route can be difficult. In this study, we aimed to assess the efficacy and safety of a novel tapered-tip sheath system for tissue sampling from biliary strictures.

This single-center, randomized, parallel-group clinical trial included patients aged 20 to 85 years admitted to Kyoto University Hospital for biliary strictures. The patients were randomly assigned (1:1) to a new or conventional method group. The primary outcome was technical success of biopsy at the target bile duct using the assigned method, as determined in accordance with the intention-to-treat principle. Adverse events were assessed in all eligible patients.

Fifty-six patients were assessed for eligibility between September 2020 and March 2023; 50 patients were enrolled. The patients were randomly divided into the new (n=25) method group and the conventional (n=25) method group. Technical success was achieved in 96.0% (24/25) and 48.0% (12/25) of patients in the new and conventional method groups, respectively (risk ratio, 2.00; 95% confidence interval [CI], 1.32 to 3.03; risk difference, 48.0%; 95% CI, 27.0% to 69.0%; p<0.001). Adverse events occurred in 4.0% (1/25) and 36.0% (9/25) of patients in the new and conventional method groups, respectively (risk ratio, 0.11; 95% CI, 0.02 to 0.81; risk difference, -32.0%; 95% CI, -52.3% to -11.7%; p=0.005).

The novel tapered-tip sheath system is a promising option for precisely and safely delivering biopsy forceps to target sites, thereby facilitating the diagnosis of biliary strictures.

Needle-knife precut papillotomy (NKP) is typically performed freehand. However, it remains unclear whether pancreatic stent (PS) placement can improve the outcomes of NKP.

To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.

This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation. In cases with incidental pancreatic duct cannulation during conventional biliary cannulation, the decision for pre-NKP PS placement was made at the endoscopist's discretion. The primary outcome was the difference in the NKP success rate between patients with and without PS placement; the secondary outcome was the adverse event rate.

Among the 190 participants, 82 received pre-NKP PS (PS-NKP group) whereas 108 did not [freehand or freehand NKP (FH-NKP) group]. Post-NKP selective biliary cannulation was successful in 167 (87.9%) patients, and the PS-NKP had a significantly higher success rate than the FH-NKP group (93.9% vs 83.3%, P = 0.027). The overall adverse event rates were 7.3% and 11.1% in the PS-NKP and FH-NKP groups, respectively (P = 0.493). A periampullary diverticulum (PAD) and significant intraoperative bleeding during NKP were independently associated with NKP failure; however, a pre-NKP PS was the only predictor of NKP success. Among the 44 participants with PADs, the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group (87.5% and 65%, respectively; P = 0.076).

PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.

This study aimed to investigate the integrative effects and mechanisms of transcutaneous electrical acustimulation (TEA) on postprocedural recovery from endoscopic retrograde cholangio-pancreatography (ERCP).

A total of 86 patients for elective ERCP were randomly ordered to receive TEA (n = 43) at acupoints PC6 and ST36 or Sham-TEA (n = 43) at sham points from 24 hours before ERCP (pre-ERCP) to 24 hours after ERCP (PE24). Scores of gastrointestinal (GI) motility-related symptoms and abdominal pain, gastric slow waves, and autonomic functions were recorded through the spectral analysis of heart rate variability; meanwhile, circulatory levels of inflammation cytokines of tumor necrosis factor-α (TNF-α) and interleukin (IL)-10 and GI hormones of motilin, ghrelin, cholecystokinin (CCK), and vasoactive intestinal peptide (VIP) were assessed by enzyme-linked immunosorbent assay.

1) TEA, but not Sham-TEA, decreased the post-ERCP GI motility-related symptom score (2.4 ± 2.6 vs 7.9 ± 4.6, p < 0.001) and abdominal pain score (0.5 ± 0.7 vs 4.1 ± 2.7, p < 0.001) at PE24, and decreased the post-ERCP hospital day by 20.0% (p ＜0.05 vs Sham-TEA); 2) TEA improved the average gastric percentage of normal slow waves and dominant frequency by 34.6% and 33.3% at PE24, respectively (both p < 0.001 vs Sham-TEA); 3) TEA, but not Sham-TEA, reversed the ERCP-induced increase of TNF-α but not IL-10 at PE24, reflected as a significantly lower level of TNF-α in the TEA group than in the Sham-TEA group (1.6 ± 0.5 pg/mL vs 2.1 ± 0.9 pg/mL, p ＜ 0.01); 4) compared with Sham-TEA, TEA increased vagal activity by 37.5% (p ＜ 0.001); and 5) TEA caused a significantly higher plasma level of ghrelin (1.5 ± 0.8 ng/ml vs 1.1 ± 0.7 ng/ml, p ＜ 0.05) but not motilin, VIP, or CCK than did Sham-TEA at PE24.

TEA at PC6 and ST36 accelerates the post-ERCP recovery, reflected as the improvement in GI motility and amelioration of abdominal pain, and suppression of the inflammatory cytokine TNF-α may mediate through both autonomic and ghrelin-related mechanisms.

Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a frequent complication, and its pathogenesis remains unclear, with various patient and procedural factors proposed as potential contributors. This study aimed to assess the predictive value of pancreatic to splenic density ratio on computed tomography (CT) for PEP in patients with inadvertent pancreatic duct cannulation.

This retrospective study involved 2556 patients undergoing ERCP from January 2014 to December 2020. Inclusion criteria comprised patients with choledocholithiasis, preprocedural CT imaging, and inadvertent pancreatic duct cannulation during ERCP. Demographics, preprocedural laboratory values, pancreatic to splenic density ratios from CT scans, and pancreatic stent usage were analyzed in relation to the development of PEP.

A total of 90 patients were included in the study. Of all patients, 51.1% were female (n = 46), and 48.9% were male (n = 44). The mean (±standard deviation) age was 58.93 (±17.01). Significant differences in sodium levels and the pancreatic to splenic density ratio were noted between the PEP and non-PEP groups. Pancreatic to splenic density ratio <0.74 (odds ratio: 8.253; P = 0.020) was identified as an independent risk factor for PEP.

Pancreas to spleen density ratio on CT imaging serves as a potential predictive marker for PEP, offering insights into risk stratification and guiding prophylactic measures in high-risk patients.

Oxidative stress has been considered a factor in the development of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The present clinical trial evaluated whether adding intravenous mesna to rectal indomethacin could prevent or alleviate PEP.

An open-labeled clinical trial was done on 698 participants undergoing endoscopic retrograde cholangiopancreatography (ERCP). Eligible patients received 100 mg indomethacin suppository 30 min before undergoing ERCP. Randomly, the participants received 400 mg intravenous mesna or nothing 30 min before doing the procedure. The PEP incidence and degree were measured in the patients as the main outcome.

The total rate of PEP was equal to 13.7%. No significant difference was seen in the rate and severity of PEP between the mesna plus indomethacin and indomethacin alone arms (14% vs. 13.4%, respectively, p = 0.671). In high-risk patients, PEP rate and severity were lower in the mesna plus indomethacin group compared with indomethacin alone group and the statistical analysis showed that the difference was significant (41.7% vs. 51.8%, respectively, p = 0.033).

In high-risk patients undergoing ERCP, a combination of intravenous mesna plus rectal indomethacin may decrease the PEP rate and severity.

To develop the personalized model for predicting the risk of acute pancreatitis after endoscopic transpapillary interventions.

A retrospective analysis of treatment outcomes included 366 patients with benign and malignant pancreaticobiliary diseases who underwent endoscopic transpapillary interventions. Risk factors associated with patients, underlying diseases and interventions were analyzed. Logistic regression analysis was used to present the personalized model for predicting the risk of acute pancreatitis.

Female gender (p=0.028), age <40 years (p=0.001-0.018), calculous cholecystitis (p=0.010) and stenosis of the major duodenal papilla (p=0.008) are patient-associated risk factors of acute postoperative pancreatitis. Stenting of the main pancreatic duct and thoracic epidural analgesia reduced this risk by 6.5 and 4.6 times, respectively. We developed significant (p<0.001) regression model to determine the likelihood of acute post-manipulation pancreatitis.

Original prediction model is valuable to determine the risk of acute pancreatitis after endoscopic transpapillary interventions. This model justifies various methods to prevent this complication.

Despite technical advances, endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and potentially lethal outcomes. Sarcopenia, a complex syndrome mainly associated with aging, has been recognized as a predictor of poor surgical outcomes. Thus far, the impact of sarcopenia on ERCP remains unknown. The present study evaluates the role of sarcopenia as a predictor of ERCP-related outcomes in a cohort of elderly patients.

Patients who underwent ERCP between June 2019 and January 2023 were retrospectively included. Demographic and procedure-associated data were collected. Sarcopenia was assessed using the skeletal muscle index (SMI) measured from a single axial slice through the L3 vertebra on a CT scan. ERCP-related outcomes were recorded. Univariate and multivariate analyses were used to assess the correlation between sarcopenia and procedural outcomes.

In total, 256 patients were enrolled, of whom 30 (11.7%) were sarcopenic. Cardiopulmonary complications of ERCP occurred in 3.5%. Sarcopenia was associated with higher 30-day and 12-month post-ERCP mortality (OR 3.45, p = 0.03; OR 3.87, p = 0.004) and longer hospitalization time (7 vs. 11 days, p = 0.003).

SMI is an easy and objective index of sarcopenia that could be used to predict ERCP outcomes. Indeed, sarcopenia was independently associated with prolonged hospitalization and increased mortality in a retrospective cohort of elderly patients.