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Risk Factors for Infectious Complications After Index-ERCP and Repeated ERCP Procedures
Abstracts
W1446 Establishing a True Assessment of Endoscopic Competence in ERCP During Training and Beyond: A Single Operator Learning Curve for Deep Biliary Cannulation in Patients with Native Papillary Anatomy Dharmendra Verma, Christopher J. Gostout, Bret T. Petersen, Michael J. Levy, Todd H. Baron, Douglas G. Adler Objective: Deep cannulation of the common bile duct in patients with native papillary anatomy can be used as a marker of competence at ERCP. The number of ERCP procedures needed to gain competence in this setting is still not defined. This study aims to analyze a single operator learning curve to determine the number of supervised ERCPs needed to gain competence in this setting. Posttraining outcomes were evaluated as proof-of-training. Methods: 1097 ERCP procedures were analyzed, of which 697 were performed under supervision during ERCP training (Jul 2002-Jul 2003) and 400 were performed post-training as an independent operator. Of these, 499 and 303 procedures for training and post training periods, respectively, were performed with the intent of deep cannulation of the common bile duct in patients with native papillary anatomy. These procedures were chronologically grouped into subsets, and success rates were plotted against time. Results: The successful cannulation rate increased from 45% at the beginning of training to 80% and above after 350-400 supervised procedures. The success rate continued to improve post-training with an aggregated success rate of O96% for the next 300 procedures performed as an independent operator. Conclusion: The achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy may require more procedures than has been previously described. We propose that the consistent achievement of deep biliary cannulation in such patients should become a standard for other ERCP training programs in order to produce skilled and competent therapeutic biliary endoscopists.
W1447 Risk Factors for Infectious Complications After Index-ERCP and Repeated ERCP Procedures Thomas Rabenstein, Martin Radespiel-Troeger, Andreas Bachmann, H. Thomas Schneider, Eckhart G. Hahn Erlangen Endoscopists and the To investigate risk factors for the developement of infectious complications after ERCP. Methods: Prospective study of consecutive ERCP procedures over a three years period (n Z 2349; 1016 f; 1333 m; 58 C/16 y). Definition and classification of complications according to standard criteria. Use of adequate statistical methods for multivatiate analysis of risk factors (multiple logistic regression analysis for Index-ERCP procedures (n Z 882) and Generalized Estimating Equations (GEE-) Analysis for repeated ERCP procedures (n Z 2349). Results: Overall 161 complications (6.9%) were detected (Index-ERCP: n Z 87; 9.9%; p ! 0.01). The overall incidence of infections was 2,0%; 46/2349 (Index-ERCP: 2.2%; n.s.). 19 variables representing typical patient characteristics, clinical picture before ERCP, technical performance of ERCP, and final diagnosis were tested. In Index-ERCP procedures the risk of infections was significantly increased in case of prior cholecystectomy (Odds Ratio (OR): 5.2); p Z 0.004) and low-volume endoscopist !100 ERCP/y (OR: 4.4: p Z 0.02). In tendency the risk was decreased in case of continous antibiotic therapy (OR: 0.3; p Z 0.08). No other variable showed significane. In case of repeated ERCP procedures the risk of infections was increased for liver cirrhosis (OR: 2.8; p Z 0.04), prior pancreatitis (OR Z 2.5; p Z 0.03), low-volume endoscopist !100ERCP/y (OR: 2.5: p Z 0.01), malignancy (OR Z 3.3; p Z 0.02) and inadequate biliary drainage (OR Z 3.5; p Z 0.01). In tendency the risk was increased in case of prior cholecystectomy (OR: 1.9; p Z 0.07). The risk was significantly decreased in case of continous antibiotic therapy (OR: 0.4; p Z 0.02). Single shot antibiotic therapy did not decreased the incidence of infections. No other variable showed significance (jaundice, prior biliary infection, gallbladder stones, emergency ERCP, low-experienced endoscopist !250 ERCP, difficult cannulation, needle-knife papillotomy, sphincterotomy, cholangiography performed, biliary drainage, pancreatic drainage, benign biliary stenosis). Conclusions: Only a few variables significanty influenced the risk of infections after ERCP. They should be considered prior to the procedure and anticipated by continous antibiotic treatment (at least 1 day before and 1 day after ERCP), which decreased the risk of infections significantly.
www.giejournal.org
W1448 Serial Incremental Stenting of Symptomatic Common Bile Duct Strictures Secondary to Pancreatitis Adam A. Bailey, Paul M. Lynch, Eric Y. Lee, Theresa L. Lee, Stephen J. Williams, Michael J. Bourke Background: Common bile duct (CBD) strictures, many of which are symptomatic, occur in up to one third of patients with chronic pancreatitis. Operative management carries significant morbidity and potential mortality. Single endoscopically placed CBD stents are associated with early symptomatic stricture recurrence after removal. Aim: Our aim was to determine the clinical and biochemical benefit of multiple simultaneous stents for symptomatic distal CBD strictures due to pancreatic fibrosis. Methods: Patients with symptomatic distal CBD strictures secondary to pancreatitis were managed by a standardised protocol of serial incremental stenting at ERCP; the therapeutic goal being placement of two 10F biliary stents side by side. Stent exchanges were performed three monthly over 12 months. The stents were then removed and the patients were followed with three monthly LFTs. Three 10F stents were placed for refractory or recurrent strictures. Results: From July 2000 to May 2005 ten patients with symptomatic CBD stricture related to pancreatic fibrosis were included (chronic pancreatitis: n Z 8; severe acute pancreatitis: n Z 2). All patients were male (mean age 57 yrs; range 39-77 yrs). Clinical features at presentation were indicative of biliary obstruction (abdominal pain, jaundice, acute pancreatitis and cholangitis). Eight patients had 2 (10F) stents placed simultaneously, whilst two patients with refractory strictures required 3 (10F) stents. At mean follow-up (15 months; range 2-46) after initial stent placement there was a significant reduction in mean ALP level from 282 to 106 U/L (p Z 0.012). Abdominal pain was a presenting symptom in 8 patients and this persisted in only one patient post treatment. Mean initial distal CBD stricture diameter was 2.0 mm. In all cases a 15 mm balloon could be drawn through the stricture at stent removal. Six patients have completed the treatment protocol with a mean stent free follow-up of 12 months. One of these patients had recurrent CBD stricturing at 1 year after stent removal and required reintervention with triple stenting. Conclusions: Our results suggest that serial incremental stenting for symptomatic distal biliary stricture related to pancreatic fibrosis results in symptom resolution, biochemical improvement and radiographic improvement in CBD diameter with minimal complications.
W1449 The First 20 Millimeters of an Endoscopic Retrograde Cholangiopancreatografy (E.R.C.P) Juan C. Ayala, Maria E. Casanova, Victor Pena Introduction: In spite of the technological development and advancement of hydrophilic wire guides and triple lumen catheters or using Precut, it does not substantially increase the success percentages of gaining access to the CBD, nor has it been proven to significantly decrease the morbidity-mortality rate. For that reason, papillotomy continues to be the most dangerous of endoscopy procedures. One of the first problems with ERCP is to get into the wanted conduit, which can generate failure and complications leading the professional to abort the procedure. Objective: To acquire greater knowledge of the internal anatomy of the Major Duodenal Papilla in order to select a better instrument and technique to gain access into the desired duct, this is the first step in the resolution of problems related to the cannulation of the biliary-pancreatic ducts, to maximize the benefits and to minimize the risks. Material and Methods: Histology studies were performed on 15 major duodenal papillas, from cadavers age 22-76 years. The deaths were not related to biliary-pancreatic pathology and the samples extracted within 1.5 to 12 hours after death. The sagitals and coronals were processed and digital photographic reconstruction from pore to biliary-pancreatic union. Results: All papillae presented a common conduit and a single pore until the duodenum. The average length of the common conduit was 20 mm. (9-30 mm.). 100% ended in the second portion of the duodenum. The presence of Valves of Santorini in 100% with variations ranging from 8-34 with funds sacks, which vary in size and depth and an average length of each Valve of 3.2 mm. (2-5 mm.). In 6.5% (1) has three different axes through the window of the duodenal wall and the remaining 93.5% has one to two axes within the intraduodenal axis and the other one, through the duodenal window. There were two peripapillary musculatures identified in 100% of the papillae. Conclusions: It is important to have appropriate training in therapeutic Endoscopy as well as the knowledge of the anatomical area being accessed. Understanding the natural axes of the papilla will help determine intensity, pressure, and election of the instruments to use to generate this pressure. The axes, fronds, sack funds and the muscular constriction are present barriers in any canulation intent. Finally, the lesion of the Valves of Santorini for the instruments cause the production of Histamine and Serotonin starting the cascade of inflammation, which would have repercussions in terms of edema and possible adverse effects on the success of the cannulation and derived secondary complications that we already know.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB301
W1446 Establishing a True Assessment of Endoscopic Competence in ERCP During Training and Beyond: A Single Operator Learning Curve for Deep Biliary Cannulation in Patients with Native Papillary Anatomy Dharmendra Verma, Christopher J. Gostout, Bret T. Petersen, Michael J. Levy, Todd H. Baron, Douglas G. Adler Objective: Deep cannulation of the common bile duct in patients with native papillary anatomy can be used as a marker of competence at ERCP. The number of ERCP procedures needed to gain competence in this setting is still not defined. This study aims to analyze a single operator learning curve to determine the number of supervised ERCPs needed to gain competence in this setting. Posttraining outcomes were evaluated as proof-of-training. Methods: 1097 ERCP procedures were analyzed, of which 697 were performed under supervision during ERCP training (Jul 2002-Jul 2003) and 400 were performed post-training as an independent operator. Of these, 499 and 303 procedures for training and post training periods, respectively, were performed with the intent of deep cannulation of the common bile duct in patients with native papillary anatomy. These procedures were chronologically grouped into subsets, and success rates were plotted against time. Results: The successful cannulation rate increased from 45% at the beginning of training to 80% and above after 350-400 supervised procedures. The success rate continued to improve post-training with an aggregated success rate of O96% for the next 300 procedures performed as an independent operator. Conclusion: The achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy may require more procedures than has been previously described. We propose that the consistent achievement of deep biliary cannulation in such patients should become a standard for other ERCP training programs in order to produce skilled and competent therapeutic biliary endoscopists.
W1447 Risk Factors for Infectious Complications After Index-ERCP and Repeated ERCP Procedures Thomas Rabenstein, Martin Radespiel-Troeger, Andreas Bachmann, H. Thomas Schneider, Eckhart G. Hahn Erlangen Endoscopists and the To investigate risk factors for the developement of infectious complications after ERCP. Methods: Prospective study of consecutive ERCP procedures over a three years period (n Z 2349; 1016 f; 1333 m; 58 C/16 y). Definition and classification of complications according to standard criteria. Use of adequate statistical methods for multivatiate analysis of risk factors (multiple logistic regression analysis for Index-ERCP procedures (n Z 882) and Generalized Estimating Equations (GEE-) Analysis for repeated ERCP procedures (n Z 2349). Results: Overall 161 complications (6.9%) were detected (Index-ERCP: n Z 87; 9.9%; p ! 0.01). The overall incidence of infections was 2,0%; 46/2349 (Index-ERCP: 2.2%; n.s.). 19 variables representing typical patient characteristics, clinical picture before ERCP, technical performance of ERCP, and final diagnosis were tested. In Index-ERCP procedures the risk of infections was significantly increased in case of prior cholecystectomy (Odds Ratio (OR): 5.2); p Z 0.004) and low-volume endoscopist !100 ERCP/y (OR: 4.4: p Z 0.02). In tendency the risk was decreased in case of continous antibiotic therapy (OR: 0.3; p Z 0.08). No other variable showed significane. In case of repeated ERCP procedures the risk of infections was increased for liver cirrhosis (OR: 2.8; p Z 0.04), prior pancreatitis (OR Z 2.5; p Z 0.03), low-volume endoscopist !100ERCP/y (OR: 2.5: p Z 0.01), malignancy (OR Z 3.3; p Z 0.02) and inadequate biliary drainage (OR Z 3.5; p Z 0.01). In tendency the risk was increased in case of prior cholecystectomy (OR: 1.9; p Z 0.07). The risk was significantly decreased in case of continous antibiotic therapy (OR: 0.4; p Z 0.02). Single shot antibiotic therapy did not decreased the incidence of infections. No other variable showed significance (jaundice, prior biliary infection, gallbladder stones, emergency ERCP, low-experienced endoscopist !250 ERCP, difficult cannulation, needle-knife papillotomy, sphincterotomy, cholangiography performed, biliary drainage, pancreatic drainage, benign biliary stenosis). Conclusions: Only a few variables significanty influenced the risk of infections after ERCP. They should be considered prior to the procedure and anticipated by continous antibiotic treatment (at least 1 day before and 1 day after ERCP), which decreased the risk of infections significantly.
www.giejournal.org
W1448 Serial Incremental Stenting of Symptomatic Common Bile Duct Strictures Secondary to Pancreatitis Adam A. Bailey, Paul M. Lynch, Eric Y. Lee, Theresa L. Lee, Stephen J. Williams, Michael J. Bourke Background: Common bile duct (CBD) strictures, many of which are symptomatic, occur in up to one third of patients with chronic pancreatitis. Operative management carries significant morbidity and potential mortality. Single endoscopically placed CBD stents are associated with early symptomatic stricture recurrence after removal. Aim: Our aim was to determine the clinical and biochemical benefit of multiple simultaneous stents for symptomatic distal CBD strictures due to pancreatic fibrosis. Methods: Patients with symptomatic distal CBD strictures secondary to pancreatitis were managed by a standardised protocol of serial incremental stenting at ERCP; the therapeutic goal being placement of two 10F biliary stents side by side. Stent exchanges were performed three monthly over 12 months. The stents were then removed and the patients were followed with three monthly LFTs. Three 10F stents were placed for refractory or recurrent strictures. Results: From July 2000 to May 2005 ten patients with symptomatic CBD stricture related to pancreatic fibrosis were included (chronic pancreatitis: n Z 8; severe acute pancreatitis: n Z 2). All patients were male (mean age 57 yrs; range 39-77 yrs). Clinical features at presentation were indicative of biliary obstruction (abdominal pain, jaundice, acute pancreatitis and cholangitis). Eight patients had 2 (10F) stents placed simultaneously, whilst two patients with refractory strictures required 3 (10F) stents. At mean follow-up (15 months; range 2-46) after initial stent placement there was a significant reduction in mean ALP level from 282 to 106 U/L (p Z 0.012). Abdominal pain was a presenting symptom in 8 patients and this persisted in only one patient post treatment. Mean initial distal CBD stricture diameter was 2.0 mm. In all cases a 15 mm balloon could be drawn through the stricture at stent removal. Six patients have completed the treatment protocol with a mean stent free follow-up of 12 months. One of these patients had recurrent CBD stricturing at 1 year after stent removal and required reintervention with triple stenting. Conclusions: Our results suggest that serial incremental stenting for symptomatic distal biliary stricture related to pancreatic fibrosis results in symptom resolution, biochemical improvement and radiographic improvement in CBD diameter with minimal complications.
W1449 The First 20 Millimeters of an Endoscopic Retrograde Cholangiopancreatografy (E.R.C.P) Juan C. Ayala, Maria E. Casanova, Victor Pena Introduction: In spite of the technological development and advancement of hydrophilic wire guides and triple lumen catheters or using Precut, it does not substantially increase the success percentages of gaining access to the CBD, nor has it been proven to significantly decrease the morbidity-mortality rate. For that reason, papillotomy continues to be the most dangerous of endoscopy procedures. One of the first problems with ERCP is to get into the wanted conduit, which can generate failure and complications leading the professional to abort the procedure. Objective: To acquire greater knowledge of the internal anatomy of the Major Duodenal Papilla in order to select a better instrument and technique to gain access into the desired duct, this is the first step in the resolution of problems related to the cannulation of the biliary-pancreatic ducts, to maximize the benefits and to minimize the risks. Material and Methods: Histology studies were performed on 15 major duodenal papillas, from cadavers age 22-76 years. The deaths were not related to biliary-pancreatic pathology and the samples extracted within 1.5 to 12 hours after death. The sagitals and coronals were processed and digital photographic reconstruction from pore to biliary-pancreatic union. Results: All papillae presented a common conduit and a single pore until the duodenum. The average length of the common conduit was 20 mm. (9-30 mm.). 100% ended in the second portion of the duodenum. The presence of Valves of Santorini in 100% with variations ranging from 8-34 with funds sacks, which vary in size and depth and an average length of each Valve of 3.2 mm. (2-5 mm.). In 6.5% (1) has three different axes through the window of the duodenal wall and the remaining 93.5% has one to two axes within the intraduodenal axis and the other one, through the duodenal window. There were two peripapillary musculatures identified in 100% of the papillae. Conclusions: It is important to have appropriate training in therapeutic Endoscopy as well as the knowledge of the anatomical area being accessed. Understanding the natural axes of the papilla will help determine intensity, pressure, and election of the instruments to use to generate this pressure. The axes, fronds, sack funds and the muscular constriction are present barriers in any canulation intent. Finally, the lesion of the Valves of Santorini for the instruments cause the production of Histamine and Serotonin starting the cascade of inflammation, which would have repercussions in terms of edema and possible adverse effects on the success of the cannulation and derived secondary complications that we already know.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB301