Clinical Research On Endoscopic Retrograde Cholangiopancreatography In The Management Of Pancreaticobiliary Diseases

Efficacy and safety of transpancreatic septotomy,needle-knife fistulotomy or both selected based on unintentional pancreatic access and papillary morphologyObjectives: Precut sphincterotomy has been widely employed to facilitate selective biliary access when standard cannulation attempts failed during ERCP.However,scarce data are available on different precut techniques for difficult biliary cannulation.This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS),needle-knife fistulotomy(NKF)or both selected based on the presence of unintentional pancreatic access and the papillary morphology.Methods: Between March 2008 and December 2016,157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified.Precut techniques were chosen depending on whether repetitive inadvertent pancreatic cannulation occurred and the papillary morphology.We retrospectively assessed the rates of selective cannulation success and procedure-related complications among three groups,namely TPS,NKF and TPS followed by NKF.Results: A total of 157 patients who received precut sphincterotomy in difficult biliary cannulation were included in the final analysis.There were 113 patients with TPS,36 patients and 8 patients with TPS followed by NKF.The baseline characteristics and therapeutic manipulations of the three groups were comparable.The overall success rate of biliary cannulation reached 98.1%(154/157),including 111(98.2%)with TPS,35(97.2%)with NKF and 8(100.0%)with NKF following TPS,without significant difference among groups(P=0.630).The incidences of total complications and post-ERCP pancreatitis(PEP)were 9.6%(15/157)and 7.6%(12/157),respectively.Bleeding and perforation occurred in 2(1.3%)patients and 1(0.6%)patient,respectively.All of them improved after appropriate treatment.There was a trend towards less frequent PEP after NKF(0%)compared with 11(9.7%)cases after TPS and one(12.5%)case after NKF following TPS,without reaching statistical significance(P=0.070).In multivariate analysis,previous pancreatitis,previous failed ERCP,previous cholecystectomy,normal serum bilirubin and initial failed biliary access were independently associated with a higher PEP rate.Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.Long-term outcomes of therapeutic ERCP in pediatric patients with symptomatic pancreas divisumObjectives: Endoscopic retrograde cholangiopancreatography(ERCP)has been increasingly used in the management of pancreaticobiliary disorders in children.Data on therapeutic ERCP for symptomatic pancreas divisum(PD)are scarce in pediatric patients.The aim of this study was to evaluate the long-term outcomes of endoscopic therapy for pediatric patients with PD presenting with acute recurrent pancreatitis(ARP)or chronic pancreatitis(CP).Methods: Between May 2008 and August 2017,patients with symptomatic PD who received therapeutic ERCP at Ruijin Hospital,with the age of 18 years or younger at initial procedure,were identified and grouped according to clinical presentation,namely ARP and CP.Follow-up was conducted by telephone contact together with face-to-face interview and reexamination during return visits to our outpatient department.Primary success was defined as patients' improvement in symptoms after index ERCPs,without further endoscopic or surgical intervention,or any analgesic usage during the period of follow-up.Results: A total of 74 ERCP procedures were performed in 38 pediatric patients.There were 14 patients presenting with ARP and 24 patients diagnosed with CP.Patients with CP required more ERCP sessions than those with ARP(2.4±1.7 vs.1.1±0.4,P=0.005).ERCPrelated complications occurred following 11(14.9%)procedures,including pancreatitis in 10(13.5%)and hemorrhage in 1(1.4%).There was no significant difference between two groups in the incidence of any complication.All of them improved following conservative or endoscopic treatment.After a median follow-up duration of 41 months(range,12-123 months),the average number of pancreatitis episodes per year decreased significantly from 2.31 to 0.45(P<0.0001).During the follow-up period,20 patients(54.1%)had no further episodes of pancreatitis or pain after index ERCPs.The remaining 17 patients(45.9%)experienced recurrence of pancreatitis or pain and 7 of them required further endoscopic intervention.There was a nonsignificant trend toward a higher primary success rate in patients with ARP than those with CP(92.9% vs.69.6%,P=0.123).After repeated ERCPs,91.3% patients with CP achieved clinical improvement.Conclusions: Therapeutic ERCP is an effective and safe intervention for management of symptomatic PD in the pediatric population.Although patients with CP have a relatively poor response to initial endotherapy,they are likely to benefit from additional ERCPs in long term.