UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Medline ® Abstracts for References 2-7

of 'Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis'

2
TI
Endoscopic sphincterotomy complications and their management: an attempt at consensus.
AU
Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, Liguory C, Nickl N
SO
Gastrointest Endosc. 1991;37(3):383.
 
Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.
AD
Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710.
PMID
3
TI
Complications of endoscopic biliary sphincterotomy.
AU
Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM
SO
N Engl J Med. 1996;335(13):909.
 
BACKGROUND: Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes.
METHODS: We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994.
RESULTS: Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure).The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01).
CONCLUSIONS: The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
AD
Hennepin County Medical Center, Minneapolis, MN 55415, USA.
PMID
4
TI
25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients.
AU
Rabenstein T, Schneider HT, Hahn EG, Ell C
SO
Endoscopy. 1998;30(9):A194.
 
BACKGROUND AND STUDY AIMS: The aim of the study was to investigate the evolution of endoscopic sphincterotomy (EST) over a period of 25 years at its birthplace in Erlangen, Germany.
PATIENTS AND METHODS: A total of 3498 consecutive ESTs between 1973 and the end of 1997 were reviewed with respect to indications, technology, success, complications, therapy of complications and mortality. In order to demonstrate changes in the course of time, the results have been compiled separately for four time periods (A-D).
RESULTS: During the 25 years' practice of EST in Erlangen the frequency of ETSs has increased constantly and significant changes have been observed concerning the spectrum of indications: Bile duct stones (total 55.1%) decreased continuously from 91.1% (period A) to 35.7% (period D). In contrast, the proportion of ESTs applied for malignant obstruction (total 22.1%) rose successively from 1.1% (period A) to more than 25% (periods B-D). Chronic pancreatitis as an indication for EST was established in period B (1.0%) and accounted for 20.2% of all procedures in period D (total 8.0%). Several new indications (summarized as "others") increased from 1.8% in period A to 11.9% in period D (total 6.7%) whereas biliary pancreatitis and scarred papillary stenosis remained constantly below 5%. Whereas the "Erlangen sphincterotome" was the only sphincterotome used in period A, it was almost completely replaced by guide-wire sphincterotomes in period D. With the introduction of the needle knife the precut technique became popular and was used with increasing frequencies: period B 31.9%, period C 34.1%, period D 41.9%. The success rate in total was 95.2%. For each time period the highest success rate of EST was obtained for bile duct stones (96-98%), whereas EST appeared to be more difficult in case of malignant obstruction (93.3%) or chronic pancreatitis (90.2%), but for both indications growing experience resulted in an increase in the success rates (85.7% to 94.9% and 90.9% to 94.0%, respectively). Complications occurred in 7.9% of cases. The complication rate declined significantly from 10.5% in period A over 7.6% in period B to 6.3% in period C. Prospective data acquisition in period D revealed a significant increase in the detection of mild forms of acute pancreatitis, resulting in a slight increase of the complication rate (8.4%). Needle-knife papillotomy did not significantly increase the complication rate. Whereas in period A 41% of all complications were managed by surgery, this value dropped over 28% (period B) and 7.5% (period C) to ultimately 1.6% in period D. The method-related mortality was nearly constant over the whole period of time (0.6%).
CONCLUSIONS: Despite a continuous shift of indications and a changing mixture of learning endoscopists and EST experts over 25 years, the practice of EST at its birthplace in Erlangen has shown a constantly high success rate, a decreasing complication rate and an acceptable but mainly unchanged mortality rate. Currently, nearly all complications can be successfully managed nonoperatively.
AD
Dept. of Medicine I, Friedrich-Alexander-Universität Erlangen-Nuremberg, Germany.
PMID
5
TI
Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.
AU
Trap R, Adamsen S, Hart-Hansen O, Henriksen M
SO
Endoscopy. 1999;31(2):125.
 
BACKGROUND AND STUDY AIMS: Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed.
PATIENTS AND METHODS: Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus.
RESULTS: Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP.
CONCLUSIONS: ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.
AD
Dept. of Surgery A, Hillerød Hospital, Denmark.
PMID
6
TI
Analysis of 59 ERCP lawsuits; mainly about indications.
AU
Cotton PB
SO
Gastrointest Endosc. 2006;63(3):378.
 
BACKGROUND: This study reports the analysis of a personal series of 59 cases in which ERCP malpractice was alleged.
METHODS: Half of the cases involved pancreatitis; 16 suffered perforation after sphincterotomy (8 of which involved pre-cutting), and 10 had severe biliary infection. There were 2 esophageal perforations. Fifteen of the patients died. The most common allegation (54% of cases) was that the ERCP, or the therapeutic procedure, was not indicated. Most of these patients had pain only, usually after cholecystectomy. Negligent performance was alleged in 19 cases, with corroborating evidence in 8. Inadequate postprocedure care was alleged in 5 cases, including 3 with a delayed diagnosis of perforation. Disputes about the extent of the education and consent process were common.
RESULTS: The final outcome was available in 40 cases. Sixteen were withdrawn, and 14 were settled. Of the 10 that came to trial, half were defense verdicts.
CONCLUSIONS: The lessons are clear. ERCP should be done for good indications, by trained endoscopists with standard techniques, with good documented patient informed consent and communication before and after the procedure. Speculative ERCP, sphincterotomy, and pre-cuts are high-risk for patients and for practitioners.
AD
Digestive Disease Center, Medical University of South Carolina, Charleston, 29425, USA.
PMID
7
TI
Death after endoscopic retrograde cholangiopancreatography: findings at autopsy.
AU
Kerr SE, Kahaleh M, LeGallo RD, Stelow EB
SO
Hum Pathol. 2010;41(8):1138.
 
More than half a million endoscopic retrograde cholangiopancreatography (ERCP) procedures are performed annually in the United States. The risk of severe complications after ERCP is less than 1%; however, autopsy pathologists see a select group of patients having fatality. Thirty-five autopsies were performed after ERCP over a 13-year period. Fourteen of these 35 patients died of ERCP complications. The remaining patients formed the control group. Fatal complications of ERCP included acute pancreatitis (7), sepsis (5), gastrointestinal/biliary perforation (3), bleeding (2), myocardial infarction (2), and cardiac arrhythmia (1). Cancer (14) and chronic pancreatitis (4) were the most reported causes of death in the control group. Median times to death after ERCP in ERCP-related deaths versus controls were 9.5 and 40 days, respectively. The most common indications for the procedure in ERCP-related deaths were suspected choledocholithiasis and jaundice/biliary obstruction; in controls, jaundice/biliary obstruction and chronic pancreatitis were more common. Patients having fatal ERCP complications had more cannulations reported as "difficult" (69% versus 20%; P = .003). The Klöppel chronic pancreatitis score was lower (mean, 2.6 versus 6.6; P = .03), and the percentage of nonfibrotic pancreatic parenchyma was higher (mean, 85% versus 56%; P = .02) in ERCP-related death group versus controls. Although patients rarely die after ERCP, our findings suggest that healthy acinar tissue is a risk factor for ERCP-related death, especially in the setting of difficult cannulation.
AD
Department of Pathology, University of Virginia Health System, Box 800214, Charlottesville, VA 22908, USA.
PMID