Precut sphincterotomy is often performed when bile duct cannulation is difficult; however, the former has a higher risk of complications than conventional methods. Early precut reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This study aimed to determine the appropriate timing for precut sphincterotomy to minimize the incidence of PEP.

This retrospective study analyzed 320 patients who underwent precut sphincterotomy during their first endoscopic retrograde cholangiopancreatography at a single center. The optimal precut timing was identified using receiver operating characteristic analysis. Patients were divided into an optimized precut group (≤12 min, n = 198) and a delayed group (>12 min, n = 122). The incidence and risk factors of PEP were evaluated using multivariate analyses.

Receiver operating characteristic analysis identified 12.5 min as the optimal cutoff for transitioning to precut sphincterotomy (area under the curve, 0.613; sensitivity, 61.5%; specificity, 63.9%). The incidence of PEP was significantly lower in the optimized precut group than in the delayed precut group (5.1% vs. 13.1%, p = 0.02). Multivariate analysis identified delayed precut timing (odds ratio [OR], 3.134; p = 0.04) and the absence of endoscopic pancreatic stenting (OR, 0.284; p = 0.01) as independent risk factors for PEP.

Precut sphincterotomy within 12.5 min of a cannulation attempt reduces the risk of PEP while maintaining procedural safety. Additionally, endoscopic pancreatic stenting can reduce PEP, even in precut scenarios.

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications. This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct (CBD) stones.

This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022. Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae (types I-IV). Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

A total of 596 patients with CBD stones were enrolled. The proportion of patients with type I papilla was the highest (n = 231, 38.8%), followed by type III papilla (n = 175, 29.4%), type IV papilla (n = 101, 16.9%) and type II papilla (n = 89, 14.9%). Difficult cannulation occurred in 188 of 596 patients (31.5%), with most cases occurring in those with type III papilla (71/175, 40.6%, P = 0.020). Multivariate logistic analysis revealed that age [odds ratio (OR) = 1.034, 95% confidence interval (CI): 1.021-1.047, P < 0.001], type III papilla (OR = 2.255, 95% CI: 1.439-3.535, P < 0.001), gallbladder in situ (OR = 2.486, 95% CI: 1.346-4.590, P = 0.004), and CBD diameter < 10 mm (OR = 1.600, 95% CI: 1.049-2.441, P = 0.029) were risk factors for difficult cannulation. The total incidence of PEP was 10.9%. Compared with the other types of papillae, the rate of PEP was the highest in those with type I papilla (15.2%, P = 0.030). Multivariate analysis demonstrated that PEP was associated with difficult cannulation (OR = 1.811, 95% CI: 1.044-3.143, P = 0.035) and white blood cells (WBCs) < 10 × 109/L (OR = 2.199, 95% CI: 1.051-4.600, P = 0.036).

The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes. Type III papilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.

To review the literature within the past 5 years on risk factors and prophylactic measures for avoiding the complications of endoscopic retrograde cholangiopancreatography (ERCP), including post-ERCP pancreatitis (PEP), post-ERCP cholangitis, bleeding, and perforation.

Despite advances in endoscopic technique and numerous clinical trials, complications of ERCP still occur frequently, particularly PEP. Recent findings are concentrated in the PEP domain and include the following: the discovery of pancreatic steatosis as a potential novel risk factor, machine learning models to predict PEP, combination prophylactic strategies including rectal NSAIDs, aggressive intravenous fluid hydration and pancreatic duct stents, potential novel pharmacotherapies, and enhanced endoscopic techniques for difficult biliary cannulation.

Endoscopists should be familiar with the complications of ERCP and prophylactic strategies. PEP carries a significant morbidity and economic burden, but its occurrence is par for the course when performing ERCP. Future studies should concentrate on elucidating further the pathophysiology of PEP and predicting cases that result in severe complications (severe if hospitalization was greater than 10 days along with the presence of pseudocyst, pancreatic necrosis, need for percutaneous drainage or surgery, or death).

Biliary drainage in patients with distal malignant biliary obstruction (DMBO) carries a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). After the failure of standard cannulation, endoscopists may proceed with advanced cannulation techniques and/or with endoscopic ultrasound-guided biliary drainage (EUS-BD).This was a retrospective study of consecutive patients with DMBO and a dilated common bile duct (CBD; >12 mm) who underwent ERCP for endoscopic biliary drainage in four European centers. The rates of DBC, technical and clinical success, and procedure-related adverse events (AEs) were assessed. The predictive factors for AEs were also investigated through regression analysis. The EUS-BD approach was considered either as the first option after standard cannulation failure or as the final option after advanced cannulation failure.1016 patients with DMBO were included in the study, with 524 (51.6%) matching the definition of DBC. Clinical success was achieved in 956 patients (94.1%). Procedure-related AEs were experienced by 167 patients (16.4%). Patients with DBC had a higher risk of AEs (P=0.003); however, patients undergoing "early" EUS-BD showed a risk of AEs comparable with those managed with standard cannulation (P=0.38). An attempt at any advanced cannulation technique was independently associated with the occurrence of AEs (P=0.001).The risk of AEs is higher in patients with DMBO and DBC, this appears to be mainly related to the advanced cannulation techniques. In patients with a dilated CBD (>12 mm), "early" EUS-BD may minimize the risk of AEs.

Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation.

We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).

Detecting gastric precancerous lesions (GPLs) is critical for the early diagnosis and treatment of gastric cancer. Endoscopy combined with tissue examination is an important method for detecting GPLs. However, negative biopsy results often increase patients' risks, economic burdens, and lead to additional healthcare costs. Improving the detection rate of GPLs and reducing the rate of negative biopsies is currently a key focus in endoscopic quality control.

To explore the relationships between the endoscopist biopsy rate (EBR), qualifications of endoscopists and endoscopic assistants, and detection rate of GPLs.

EBR, endoscopists, and endoscopic assistants were divided into four groups: Low, moderate, high, and very high levels. Multivariable logistic regression analysis was used to analyze the relationships between EBR and the qualifications of endoscopists with respect to the detection rate of positive lesions. Pearson and Spearman correlation analyses were used to evaluate the correlation between EBR, endoscopist or endoscopic assistant qualifications, and the detection rate of positive lesions.

Compared with those in the low EBR group, the odds ratio (OR) values for detecting positive lesions in the moderate, high, and very high EBR groups were 1.12 [95% confidence interval (CI): 1.06-1.19, P < 0.001], 1.22 (95%CI: 1.14-1.31, P < 0.001), and 1.38 (95%CI: 1.29-1.47, P < 0.001), respectively. EBR was positively correlated with the detection rate of gastric precancerous conditions (atrophic gastritis/intestinal metaplasia) (ρ = 0.465, P = 0.004). In contrast, the qualifications of the endoscopists were positively correlated with GPLs detection (ρ = 0.448, P = 0.005). Compared to endoscopists with low qualification levels, those with moderate, high, and very high qualification levels endoscopists demonstrated increased detection rates of GPLs by 13% (OR = 1.13, 95%CI: 0.98-1.31), 20% (OR = 1.20, 95%CI: 1.03-1.39), and 32% (OR = 1.32, 95%CI: 1.15-1.52), respectively. Further analysis revealed that the qualifications of endoscopists were positively correlated with the detection rates of GPLs in the cardia (ρ = 0.350, P = 0.034), angularis (ρ = 0.396, P = 0.015) and gastric body (ρ = 0.453, P = 0.005) but not in the antrum (ρ = 0.292, P = 0.079). Moreover, the experience of endoscopic assistants was positively correlated with the detection rate of precancerous lesions by endoscopists with low or moderate qualifications (ρ = 0.427, P = 0.015).

Endoscopists and endoscopic assistants with high/very high qualifications, but not EBR, can improve the detection rate of GPLs. These results provide reliable evidence for the development of gastroscopic quality control indicators.

The rescue techniques available for cannulation failure are few in number and have severe limitations. We recently described partial ampullary endoscopic mucosal resection (PA-EMR) as a novel technique for difficult biliary cannulation. We aimed to demonstrate the efficacy and safety of PA-EMR for patients with difficult biliary cannulation in a larger cohort.We conducted a prospective cohort study at our tertiary care referral hospital. We recorded demographic factors, procedure-related characteristics, and adverse event rates in patients with difficult biliary cannulation who underwent PA-EMR.Between June 2021 and June 2022, we performed 1073 consecutive endoscopic retrograde cholangiopancreatography procedures on 962 patients; 40 patients (12 male, 28 female, with a mean age of 68.1 [SD 4] years) had difficult biliary cannulation and underwent PA-EMR. Technical success was 100%, and none of the patients required a second session. None of the patients had an adverse event, and we encountered no 30-day mortality. The most typical indication was bile duct stones (60%; n = 24), followed by periampullary tumors (15%; n = 6). The total procedure time was 923 (range 392-1224) seconds.PA-EMR was an effective and safe rescue technique in patients with difficult biliary cannulation.

Neurogastroenterology (NGE) refers to a specific sub-specialty of gastroenterology that investigates the pathophysiology, diagnostics and therapeutic approaches to the "disorders of gut-brain interaction" (DGBIs), frequently encountered in clinical practice and often associated with poor quality of life and high healthcare costs. Two recent national surveys, focused on common DGBIs, highlighted two main issues. Despite the high incidence of DGBIs there is a lack of awareness and appropriate training to effectively treat these conditions and a lack of specific referral centers in each region. Indeed, specific training and a multidisciplinary approach are required to properly manage these patients, but these are not always available. As a result, NGE lacks attractiveness for many young gastroenterologists. We believe that NGE has great potential to emerge among the various sub-branches of gastroenterology. However, its growth is limited by lack of specific training, knowledge, accessibility, diagnostic capabilities, multidisciplinary integration, and financial investments in research. To bridge this gap, it would be helpful to overcome these limits through an increase in specific training concerning DGBIs among students, residents, physicians and general practitioners. This, coupled with improved access to advanced diagnostic tests, innovative therapies, and a better multidisciplinary approach, could help expand the knowledge in this still niche area and achieve better treatment outcomes for patients.

Prolonged cannulation during endoscopic retrograde cholangiopancreatography (ERCP) increases risk of complications, particularly post-ERCP pancreatitis (PEP). This study aimed to determine optimal timing to discontinue ERCP when selective biliary cannulation (SBC) cannot be easily achieved.

Patients with naïve papilla who underwent ERCP between January 2021 and December 2021 were analyzed. The primary outcome was to determine optimal timing for discontinuing ERCP based on cannulation success rate and complication rate.

A total of 272 patients with naïve papilla underwent ERCP. Trainees did not participate in any of the procedures. Median age was 71 years, and 152 patients (55.9%) were male. The most common indication for ERCP was choledocholithiasis (60.7%), followed by malignant obstruction (24.3%) and benign stricture (4.8%). SBC was achieved in 249 patients (91.5%). After excluding patients with pre-procedure amylase elevation or preexisting pancreatitis, 232 patients were analyzed for complications. Eighteen patients (6.7%) experienced complications, with PEP occurring in 15 patients (5.5%). SBC success was achieved in 50% of cases at 3.3 minutes and in 90% at 12.1 minutes. In contrast, the PEP rate reached 10% after 7.9 minutes and 14.5% after 12.1 minutes. Multivariate analysis identified distal biliary stricture and age over 70 as significant predictors of difficult SBC.

In cases of difficult SBC, discontinuing attempts at around 8 minutes may minimize risk of PEP. However, extending attempts up to 12 minutes can be justified to achieve higher success rates. Beyond 12 minutes, likelihood of successful SBC diminishes significantly.

E-learning with video content was created to improve trainees' biliary cannulation techniques; this study aimed to evaluate its educational effect prospectively.

E-learning program was conducted using videos demonstrating biliary cannulation for 24 papillae, targeting trainees with 2-6 years of experience in endoscopic retrograde cholangiopancreatography. Ten consecutive cases of biliary cannulation for native papillae performed by trainees were prospectively assessed before and after the e-learning, respectively. The primary outcome was the difficult biliary cannulation rate; the secondary outcomes included a comprehension score assigned by the trainer for each biliary cannulation (maximum of 6 points), trainee failure rate, and adverse events incidence.

Eleven trainees participated in the e-learning program. The overall and per-trainee analyses showed no significant differences in the difficult biliary cannulation rate, trainee failure rate, and adverse event incidence before and after e-learning. However, the overall analysis showed a significant increase in comprehension scores after e-learning (median 4 vs. 5, p < 0.01) and the per-trainee analysis revealed that the rate of comprehension score ≥5 increased significantly after e-learning (p = 0.02). Comprehension score <5 (odds ratio: 4.31, p < 0.01) and endoscopic retrograde cholangiopancreatography experience <3 years (odds ratio: 2.15, p = 0.01) were independent risk factors for difficult biliary cannulation. Additionally, the difficult biliary cannulation incidence showed a negative correlation with the comprehension score (p < 0.01).

E-learning using video content did not result in a reduction in the difficult biliary cannulation rate. However, it significantly enhanced procedural understanding, indicating its potential to support future acquisition of biliary cannulation skills.

Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy.

This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatography at two tertiary care centers between January 2019 and October 2021.

The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01).

Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

A new type of sphincterotome released to the market recently has high rotation performance and a freely bendable blade. It is devised to be singly capable of accommodating not only normal anatomy but also cases with surgically altered anatomy. This study was undertaken for clinical evaluation of the usefulness of this new sphincterotome. Eight cases in a reconstructed intestine for which cannulation or endoscopic sphincterotomy (EST) had been performed were extracted from 32 cases for which endoscopic retrograde cholangiopancreatography-related procedures were performed using the sphincterotome developed during November 2023 through February 2024. The cases were investigated retrospectively. Among these, EST was applied to six cases. Cannulation was performed using the developed sphincterotome in the native papilla in four cases. The primary endpoints were the success rate of cannulation in surgically altered anatomy and the success rate of EST. Secondary endpoints were complications and usability for operators. Usability for operators was evaluated by questionnaire for several items on a 5-point scale. EST was conducted successfully in all six cases subjected to EST. Mild hemorrhage was observed in one case (17%) as an adverse event after EST. Deep cannulation to the native papilla with the developed sphincterotome was conducted successfully in three cases (75.0%). Evaluation results by operators were 4.4 ± 0.55 for rotation performance, 4.00 ± 0.63 for incision performance, 4.29 ± 0.49 for deep cannulation performance, and 4.07 ± 0.19 for overall evaluation. In conclusion, this developed sphincterotome might be very useful for EST and cannulation in cases with surgically altered anatomy.

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.

Periampullary diverticulum (PAD) is a common anatomical variant that can potentially impact the technical difficulty and outcomes of endoscopic retrograde cholangiopancreatography (ERCP), necessitating a comprehensive understanding of its effects on the procedure. To evaluate the effect of PAD subtypes and diameter on ERCP cannulation success and clinical outcomes.

The study included patients with PAD and papilla-naïve patients undergoing ERCP for suspected common bile duct stones or distal benign strictures (due to PAD compression). PAD subtyping was based on Lobo and Li-Tanaka classifications. Diverticulum size was categorized as small (<1 cm), medium (1-2 cm), and giant (≥2 cm).

Of the 907 patients analyzed, 164 (18%) had PAD with a median age of 63 years. PAD patients were significantly older than non-PAD patients and had more comorbidities. The most frequent PAD type was 2B (34.1%) based on the Li-Tanaka classification. Subgroup analysis of PAD types 1, 2, 3, and 4 showed no statistically significant differences in cannulation time, success, total procedure time, or adverse events (AEs). Overall cannulation success rates were similar between PAD and non-PAD groups (99.4% vs 99.6%). Analysis based on diverticulum size revealed higher probabilities of giant stones and procedure-related AEs in giant diverticula. The risk of post-ERCP pancreatitis was notably low at 1.8% in the PAD group.

Diverticulum size, rather than PAD subtype, may be more closely associated with cannulation success and procedure-related AEs in ERCP. Individualized management considering diverticulum size may improve outcomes in PAD patients undergoing ERCP.

The current goal of adapting care structures in the German healthcare system is to increase the provision of interventional treatments in outpatient settings. Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures were traditionally performed in an inpatient setting until 2022. However, with the introduction of a new Ambulatory Surgery Contract (according to Section 115b, Paragraph 1 of the Social Code, Book V) on January 1, 2023, these procedures are now intended to be carried out more strictly on an outpatient basis, meaning that hospitalization will no longer be reimbursed in most cases.Between June 1, 2023, and December 31, 2023 all ERCP procedures performed in an outpatient setting were included in this study. This cohort had standard ERCP indications and a low comorbidity burden according to the §115b specifications. Using propensity score matching (nearest-neighbor), these cases were matched with patients who underwent ERCP procedures in an inpatient setting between June 1, 2022, and December 31, 2022.Propensity-score matching identified a cohort of 166 patients (83 outpatients and 83 inpatients) with similar baseline characteristics. The most common indications for ERCP were choledocholithiasis and biliary strictures. Reported complications comprised pancreatitis, bleeding and cholangitis and were rare in both groups, occurring in 7% of inpatient procedures and in 6% of outpatient procedures. The latter cases required inpatient admission after self-presenting to the emergency department. No serious adverse events were reported.Outpatient ERCP is a safe procedure for selected patients with a low risk profile. Complications occurred rarely and could be adequately managed.

Recent meta-analyses suggested diclofenac may be superior to indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of our study was to compare the efficacy of 100 mg rectal indomethacin versus diclofenac on PEP incidences.

This multicentre, double-blinded, randomised controlled trial was conducted in nine tertiary centres in China. Patients with low and high risk for PEP and native papilla were randomly allocated (1:1) to receive 100 mg diclofenac or 100 mg indomethacin rectally before ERCP. The primary outcome was the occurrence of PEP defined by the Cotton consensus. The intention-to-treat principle was conducted for the analysis.

The trial was terminated early for futility after the predetermined first interim analysis. Between June 2023 and May 2024, 1204 patients were randomised into the diclofenac group (n=600) or indomethacin group (n=604). Baseline characteristics were balanced. The primary outcome occurred in 53 patients (8.8%) of 600 patients allocated to the diclofenac group and 37 patients (6.1%) of 604 patients allocated to the indomethacin group (relative risk 1.44; 95% CI 0.96 to 2.16, p=0.074). PEP occurred in 35 (14.2%) of 247 high-risk patients in the diclofenac group and 26 (9.8%) of 266 high-risk patients in the indomethacin group (p=0.124). PEP incidences were also comparable in low-risk patients between the two groups (18/353 (5.1%) vs 11/338 (3.3%), p=0.227). Other ERCP-related complications did not differ between the two groups.

Pre-procedure 100 mg rectal diclofenac was not superior to the same dose of rectal indomethacin regarding preventing PEP. These findings supported current clinical practice guidelines of 100 mg indomethacin or diclofenac for PEP prophylaxis in patients without contraindications.

ClinicalTrials.gov (NCT05947461).

This review aims to summarize the role of endoscopic therapy in the management and outcomes of recurrent acute pancreatitis (RAP). RAP is a clinical entity characterized by repeated episodes of acute pancreatitis in the setting of a normal gland or chronic pancreatitis (CP). The aetiology of RAP can be identified in about 70% of cases; for the remaining cases, the term "idiopathic" (IRAP) is used. However, advanced diagnostic techniques may reduce the percentage of IRAP to 10%. Recognized causes of RAP are gallstone disease, including microlithiasis and biliary sludge, sphincter of Oddi dysfunction (SOD), pancreatic ductal abnormalities (either congenital or acquired) interfering with pancreatic juice or bile outflow, genetic mutations, and alcohol consumption. SOD, as a clinical entity, was recently revised in the Rome IV consensus, which only recognized type 1 dysfunction as a true pathological condition, while type 2 SOD was defined as a suspected functional biliary sphincter disorder requiring the documentation of elevated basal sphincter pressure to be considered a true clinical entity and type 3 was abandoned as a diagnosis and considered functional pain. Endoscopic therapy by retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) has been proven effective when a mechanical obstruction is found and can be removed. If an obstruction is not documented, few treatment options are available to prevent the recurrence of pancreatitis and progression toward chronic disease. In gallstone disease, endoscopic biliary sphincterotomy (EBS) is effective when a dilated common bile duct or biliary sludge/microlithiasis is documented. In type 1 SOD, biliary or dual sphincterotomy is generally successful, while in type 2 SOD, endotherapy should be reserved for patients with documented sphincter dysfunction. However, in recent years, doubts have been expressed about the real efficacy of sphincterotomy in this setting. When sphincter dysfunction is not confirmed, endotherapy should be discouraged. In pancreas divisum (PD), minor papilla sphincterotomy is effective when there is a dilated dorsal duct, and the success rate is the highest in RAP patients. In the presence of obstructive conditions of the main pancreatic duct, pancreatic endotherapy is generally successful if RAP depends on intraductal hypertension. However, despite the efficacy of endotherapy, progression toward CP has been shown in some of these patients, mainly in the presence of PD, very likely depending on underlying genetic mutations. In patients with IRAP, the real utility of endotherapy still remains unclear; this is because several unknown factors may play a role in the disease, and data on outcomes are few, frequently contradictory or uncontrolled, and, in general, limited to a short period of time.

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Background/Objectives: Pancreatitis is the most frequent and serious complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence between 2 and 10% and a mortality rate of 1 in 500 patients. Etiopathogenesis remains poorly understood. The aim of this study was to analyze the incidence of post-ERCP pancreatitis (PEP) and to identify potential patient- and procedure-related risk factors (RF) in a cohort of patients from a tertiary referral center in Romania. Methods: We conducted a retrospective, observational, single-center study in which we analyzed ERCP procedures performed in the Gastroenterology Department of Colentina Clinical Hospital, Bucharest, Romania, between January 2019 and September 2024. All patients received intrarectal diclofenac before the ERCP and were hydrated with at least 1500 mL of Ringer's solution after the procedure in the absence of contraindications, according to the latest international recommendations. Results: In total, 2743 ERCPs were performed in the given time period, while 2350 procedures were analyzed in the study. PEP occurred in 350 cases (14.9%). Of these, 191 (54.6%) occurred in males with a mean age of 66.5 years. Procedural RF with adjusted odds ratios (OR) were as follows: difficult cannulation of the common bile duct, OR = 3.734, p < 0.001, main pancreatic duct catheterization, OR = 1.454, p = 0.022, and endoscopic papillary balloon dilatation, with an OR of 3.258, p < 0.001. Pancreatic duct stent placement was shown to prevent PEP in this study group (p < 0.001). Conclusions: PEP remains a serious complication of ERCP, associated with significant morbidity and occasional mortality. While some proven risk factors, such as age, gender, or comorbidities, are unmodifiable, avoiding Wirsung duct cannulation and pancreatography, or prophylactic pancreatic duct stent placement, could play a significant role in PEP prevention.

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.

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.

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.

Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS.

EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.

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.

There are few salvage techniques for achieving biliary cannulation when no duct can be accessed.

We retrospectively reviewed 10 consecutive cases in which the mini-forceps traction-assisted cannulation technique (MFTAC) was used after failure of any duct access during endoscopic retrograde cholangiopancreatography (ERCP). Outcomes included technical success, use of adjunct techniques; time to biliary access; and adverse events (AEs).

Most patients had a native papilla (n = 9) of peri-diverticular location (n = 5) and a benign indication (n = 6). Standard cannulation was unsuccessful over 8:23 mm:ss (interquartile range [IQR] 6:04-19:43). MFTAC had 100% technical success, achieved biliary access after 17:38 mm:ss (IQR 8:52-20:31), and had a 10% incidence of AEs (post-ERCP pancreatitis). MFTAC was sufficient to allow biliary cannulation in three cases and allowed pancreatic duct access in seven cases, which then allowed biliary cannulation with double-wire technique (5/10) and transpancreatic septotomy (2/10).

MFTAC is a feasible salvage approach for biliary access when standard cannulation methods fail.

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.

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.

The effectiveness of endoscopic papillary large balloon dilation (EPLBD) alone versus EPLBD combined with endoscopic sphincterotomy (EST) in treating large common bile duct stones (CBDSs; ≥15 mm) remains unclear. This study aimed to evaluate the safety and treatment outcomes of EPLBD combined with limited or large EST versus EPLBD alone in removing large CBDSs.

Between January 2013 and September 2024, total of 408 patients underwent EPLBD, either alone or in combination with EST, to treat large CBDSs (≥15 mm). Patients were divided into 3 groups: EPLBD alone (n = 92), EPLBD with limited EST (n = 124), and EPLBD with large EST (n = 192). The study compared the first-session stone clearance rate, overall stone success rate, mechanical lithotripsy use, and adverse event rate.

Compared with the EPLBD alone group, the EPLBD with limited EST and the EPLBD with large EST groups exhibited higher initial stone clearance rates, required fewer endoscopic procedures for complete stone removal, and had lower rates of mechanical lithotripsy use and CBDS recurrence. Compared with the EPLBD with limited EST group, the EPLBD with large EST group showed a higher initial stone clearance rate, fewer endoscopic procedures required for complete CBDS removal, and no significant differences in adverse events. The multivariate analysis showed that the endoscopic technique and number of endoscopic operations were strongly associated with CBDS recurrence.

EPLBD combined with large EST may represent a more rational endoscopic technique for treating large CBDSs.

To access the common bile duct in endoscopic retrograde cholangiopancreatography (ERCP), needle-knife fistulotomy (NKF) can be associated with a shorter sphincterotomy compared to standard cannulation. We aimed to compare the success and safety of NKF versus standard cannulation in the treatment of choledocholithiasis.

A cohort of 379 naïve patients with choledocholithiasis who underwent ERCP between 2005 and 2022 was retrospectively analyzed. The patients were divided into two groups: group A (179 consecutive patients) underwent NKF, while group B (180 patients) received standard biliary access and were matched for stone characteristics and ERCP year.

Stone removal success rate for group A was significantly lower than that for group B in the initial ERCP (82.0% vs. 92.1%, p = 0.003). In group A, success rates for stone removal were 90.2%, 80%, and 29.4% for stone sizes <10 mm, 10 mm-15 mm, and >15 mm, respectively (p < 0.001). In contrast, group B showed success rates of 99.2%, 81.5%, and 71.4% for the same stone size categories (p < 0.001). Pancreatitis occurred in 3.7% of group A and 5.8% of group B patients (p = 0.340). Regression analysis revealed that NKF cannulation, stone size (>10 mm), and having 4 or more stones were associated with lower stone removal success compared to standard cannulation in the initial ERCP (OR 0.34, p = 0.015; stone size 10-15 mm: OR 0.20, p < 0.001; stone size >15 mm: OR 0.05, p < 0.001; 4 or more stones: OR 0.4, p = 0.040).

The removal of common bile duct stones after NKF access, although safe and effective, is less successful than after a standard cannulation, especially at the baseline ERCP.

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree.

A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes.

65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005).

ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.