Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management

  • Received : 2022.12.12
  • Accepted : 2023.01.11
  • Published : 2023.07.30
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Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

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References

  1. Cappell MS, Friedel DM. Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States. World J Gastroenterol 2019;25:3468-3483. https://doi.org/10.3748/wjg.v25.i27.3468
  2. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020;52:127-149. https://doi.org/10.1055/a-1075-4080
  3. ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, et al. Adverse events associated with ERCP. Gastrointest Endosc 2017;85:32-47. https://doi.org/10.1016/j.gie.2016.06.051
  4. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781-1788. https://doi.org/10.1111/j.1572-0241.2007.01279.x
  5. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-393. https://doi.org/10.1016/S0016-5107(91)70740-2
  6. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111. https://doi.org/10.1136/gutjnl-2012-302779
  7. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001;54:425-434. https://doi.org/10.1067/mge.2001.117550
  8. Inamdar S, Berzin TM, Sejpal DV, et al. Pregnancy is a risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography in a national cohort study. Clin Gastroenterol Hepatol 2016;14:107-114. https://doi.org/10.1016/j.cgh.2015.04.175
  9. Cheng CL, Sherman S, Watkins JL, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006;101:139-147. https://doi.org/10.1111/j.1572-0241.2006.00380.x
  10. Masci E, Mariani A, Curioni S, et al. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 2003;35:830-834. https://doi.org/10.1055/s-2003-42614
  11. Cennamo V, Fuccio L, Zagari RM, et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk?: meta-analysis of randomized controlled trials. Endoscopy 2010;42:381-388. https://doi.org/10.1055/s-0029-1243992
  12. Itoi T, Yasuda I, Doi S, et al. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy 2011;43:369-372. https://doi.org/10.1055/s-0030-1256126
  13. Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline: updated June 2014. Endoscopy 2014; 46:799-815. https://doi.org/10.1055/s-0034-1377875
  14. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62:367-370. https://doi.org/10.1016/j.gie.2005.04.020
  15. Syren EL, Sandblom G, Enochsson L, et al. Outcome of ERCP related to case-volume. Surg Endosc 2022;36:5339-5347. https://doi.org/10.1007/s00464-021-08915-y
  16. Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012;366:1414-1422. https://doi.org/10.1056/NEJMoa1111103
  17. Ishiwatari H, Urata T, Yasuda I, et al. No benefit of oral diclofenac on post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Dis Sci 2016;61:3292-3301. https://doi.org/10.1007/s10620-016-4251-x
  18. Kato K, Shiba M, Kakiya Y, et al. Celecoxib oral administration for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized prospective trial. Pancreas 2017;46:880-886. https://doi.org/10.1097/MPA.0000000000000852
  19. Staritz M, Poralla T, Ewe K, et al. Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure. Gut 1985;26:194-197. https://doi.org/10.1136/gut.26.2.194
  20. Wehrmann T, Schmitt T, Stergiou N, et al. Topical application of nitrates onto the papilla of Vater: manometric and clinical results. Endoscopy 2001;33:323-328. https://doi.org/10.1055/s-2001-13687
  21. Bai Y, Xu C, Yang X, et al. Glyceryl trinitrate for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a meta-analysis of randomized, double-blind, placebo-controlled trials. Endoscopy 2009;41:690-695. https://doi.org/10.1055/s-0029-1214951
  22. Sotoudehmanesh R, Eloubeidi MA, Asgari AA, et al. A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis. Am J Gastroenterol 2014;109:903-909. https://doi.org/10.1038/ajg.2014.9
  23. Tomoda T, Kato H, Ueki T, et al. Combination of diclofenac and sublingual nitrates is superior to diclofenac alone in preventing pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterology 2019;156:1753-1760. https://doi.org/10.1053/j.gastro.2019.01.267
  24. Wu M, Jiang S, Lu X, et al. Aggressive hydration with lactated ringer solution in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis. Medicine (Baltimore) 2021;100:e25598.
  25. Sperna Weiland CJ, Engels MM, et al. Increased use of prophylactic measures in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Dis Sci 2021;66:4457-4466. https://doi.org/10.1007/s10620-020-06796-0
  26. Tarnasky PR, Palesch YY, Cunningham JT, et al. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 1998;115:1518-1524. https://doi.org/10.1016/S0016-5085(98)70031-9
  27. Fan JH, Qian JB, Wang YM, et al. Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2015;21:7577-7583. https://doi.org/10.3748/wjg.v21.i24.7577
  28. Ito K, Fujita N, Noda Y, et al. Can pancreatic duct stenting prevent post-ERCP pancreatitis in patients who undergo pancreatic duct guidewire placement for achieving selective biliary cannulation?: a prospective randomized controlled trial. J Gastroenterol 2010;45:1183-1191. https://doi.org/10.1007/s00535-010-0268-7
  29. Tse F, Yuan Y, Bukhari M, et al. Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2016;(5):CD010571.
  30. Freeman ML, Overby C, Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 2004;59:8-14. https://doi.org/10.1016/S0016-5107(03)02530-6
  31. Tse F, Liu J, Yuan Y, et al. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2022;3(3):CD009662.
  32. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446-454. https://doi.org/10.1016/j.gie.2009.10.027
  33. Cirocchi R, Kelly MD, Griffiths EA, et al. A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system. Surgeon 2017;15:379-387. https://doi.org/10.1016/j.surge.2017.05.004
  34. Enns R, Eloubeidi MA, Mergener K, et al. ERCP-related perforations: risk factors and management. Endoscopy 2002;34:293-298. https://doi.org/10.1055/s-2002-23650
  35. Kumbhari V, Sinha A, Reddy A, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016;83:934-943. https://doi.org/10.1016/j.gie.2015.09.039
  36. Langerth A, Isaksson B, Karlson BM, et al. ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc 2020;34:1939-1947. https://doi.org/10.1007/s00464-019-06966-w
  37. Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000;232:191-198. https://doi.org/10.1097/00000658-200008000-00007
  38. Parlak E, Koksal A, Disibeyaz S, et al. Endoscopic closure of ERCP-related duodenal perforations by using endoclips: a case series. Surg Laparosc Endosc Percutan Tech 2013;23:e225-e228. https://doi.org/10.1097/SLE.0b013e31828b8622
  39. Tyberg A, Zerbo S, Sharaiha RZ, et al. Endoscopic management of a GI perforation. Gastrointest Endosc 2015;82:955.
  40. Khater S, Rahmi G, Perrod G, et al. Over-the-scope clip (OTSC) reduces surgery rate in the management of iatrogenic gastrointestinal perforations. Endosc Int Open 2017;5:E389-E394. https://doi.org/10.1055/s-0043-104862
  41. Hyun JJ, Kozarek RA, Irani SS. Endoscopic suturing of a large type I duodenal perforation. VideoGIE 2018;4:78-80. https://doi.org/10.1016/j.vgie.2018.04.008
  42. Zhang LY, Bejjani M, Ghandour B, et al. Endoscopic through-the-scope suturing. VideoGIE 2021;7:46-51. https://doi.org/10.1016/j.vgie.2021.08.006
  43. Patil NS, Solanki N, Mishra PK, et al. ERCP-related perforation: an analysis of operative outcomes in a large series over 12 years. Surg Endosc 2020;34:77-87. https://doi.org/10.1007/s00464-019-06733-x
  44. Vezakis A, Fragulidis G, Polydorou A. Endoscopic retrograde cholangiopancreatography-related perforations: diagnosis and management. World J Gastrointest Endosc 2015;7:1135-1141. https://doi.org/10.4253/wjge.v7.i14.1135
  45. Odemis B, Oztas E, Kuzu UB, et al. Can a fully covered self-expandable metallic stent be used temporarily for the management of duodenal retroperitoneal perforation during ERCP as a part of conservative therapy? Surg Laparosc Endosc Percutan Tech 2016;26:e9-e17. https://doi.org/10.1097/SLE.0000000000000240
  46. Theopistos V, Theocharis G, Konstantakis C, et al. Non-operative management of type 2 ERCP-related retroperitoneal duodenal perforations: a 9-year experience from a single center. Gastroenterology Res 2018;11:207-212. https://doi.org/10.14740/gr1007w
  47. Arvanitakis M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018;50:524-546. https://doi.org/10.1055/a-0588-5365
  48. Paspatis GA, Arvanitakis M, Dumonceau JM, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) position statement: update 2020. Endoscopy 2020;52:792-810. https://doi.org/10.1055/a-1222-3191
  49. Mashiana HS, Dhaliwal AS, Sayles H, et al. Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events. World J Gastrointest Endosc 2018;10:354-366. https://doi.org/10.4253/wjge.v10.i11.354
  50. Kim JY, Lee HS, Chung MJ, et al. Bleeding complications and clinical safety of endoscopic retrograde cholangiopancreatography in patients with liver cirrhosis. Yonsei Med J 2019;60:440-445. https://doi.org/10.3349/ymj.2019.60.5.440
  51. Oh HC, El Hajj II, Easler JJ, et al. Post-ERCP bleeding in the era of multiple antiplatelet agents. Gut Liver 2018;12:214-218. https://doi.org/10.5009/gnl17204
  52. Veitch AM, Radaelli F, Alikhan R, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021;70:1611-1628. https://doi.org/10.1136/gutjnl-2021-325184
  53. Parras Castanera E, Rodriguez Lopez P, Alvarez A, et al. Predictive factors for post-ERCP bleeding: influence of direct oral anticoagulants. Rev Esp Enferm Dig 2021;113:591-596.
  54. Nakaji S, Hirata N, Matsui H, et al. Hemodialysis is a strong risk factor for post-endoscopic sphincterotomy bleeding in patients with choledocholithiasis. Endosc Int Open 2018;6:E568-E574. https://doi.org/10.1055/a-0587-4470
  55. Bae SS, Lee DW, Han J, et al. Risk factor of bleeding after endoscopic sphincterotomy in average risk patients. Surg Endosc 2019;33:3334-3340. https://doi.org/10.1007/s00464-018-06623-8
  56. Lee HJ, Cho CM, Heo J, et al. Impact of hospital volume and the experience of endoscopist on adverse events related to endoscopic retrograde cholangiopancreatography: a prospective observational study. Gut Liver 2020;14:257-264. https://doi.org/10.5009/gnl18537
  57. ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016;83:3-16. https://doi.org/10.1016/j.gie.2015.09.035
  58. Feng Y, Zhu H, Chen X, et al. Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials. J Gastroenterol 2012;47:655-663. https://doi.org/10.1007/s00535-012-0528-9
  59. Mirjalili SA, Stringer MD. The arterial supply of the major duodenal papilla and its relevance to endoscopic sphincterotomy. Endoscopy 2011;43:307-311. https://doi.org/10.1055/s-0030-1256229
  60. Wilcox CM, Canakis J, Monkemuller KE, et al. Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection. Am J Gastroenterol 2004;99:244-248. https://doi.org/10.1111/j.1572-0241.2004.04058.x
  61. Liu F, Wang GY, Li ZS. Cap-assisted hemoclip application with forward-viewing endoscope for hemorrhage induced by endoscopic sphincterotomy: a prospective case series study. BMC Gastroenterol 2015;15:135.
  62. Aranez JL, Miller J, Hughes M, et al. A novel, duodenoscope-friendly endoscopic clip for treating massive upper-GI bleeding secondary to a Dieulafoy lesion. VideoGIE 2018;3:205-206. https://doi.org/10.1016/j.vgie.2018.02.003
  63. Bilal M, Chandnani M, McDonald NM, et al. Use of fully covered self-expanding metal biliary stents for managing endoscopic biliary sphincterotomy related bleeding. Endosc Int Open 2021;9:E667-E673. https://doi.org/10.1055/a-1380-3268
  64. Dunne R, McCarthy E, Joyce E, et al. Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach. Acta Radiol 2013;54:1159-1164. https://doi.org/10.1177/0284185113491567
  65. ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015;81:81-89. https://doi.org/10.1016/j.gie.2014.08.008
  66. Chen M, Wang L, Wang Y, et al. Risk factor analysis of post-ERCP cholangitis: a single-center experience. Hepatobiliary Pancreat Dis Int 2018;17:55-58. https://doi.org/10.1016/j.hbpd.2018.01.002
  67. Navaneethan U, Jegadeesan R, Nayak S, et al. ERCP-related adverse events in patients with primary sclerosing cholangitis. Gastrointest Endosc 2015;81:410-419. https://doi.org/10.1016/j.gie.2014.06.030
  68. Othman MO, Guerrero R, Elhanafi S, et al. A prospective study of the risk of bacteremia in directed cholangioscopic examination of the common bile duct. Gastrointest Endosc 2016;83:151-157. https://doi.org/10.1016/j.gie.2015.05.018
  69. Sethi A, Chen YK, Austin GL, et al. ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc 2011;73:251-256. https://doi.org/10.1016/j.gie.2010.08.058
  70. Harris A, Chan AC, Torres-Viera C, et al. Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999;31:718-724. https://doi.org/10.1055/s-1999-153
  71. Brand M, Bizos D, O'Farrell P Jr. Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev 2010;(10):CD007345.
  72. Kager LM, Sjouke B, van den Brand M, et al. The role of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography; a retrospective single-center evaluation. Scand J Gastroenterol 2012;47:245-250. https://doi.org/10.3109/00365521.2011.643482
  73. Tonolini M, Pagani A, Bianco R. Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography. Insights Imaging 2015;6:323-338. https://doi.org/10.1007/s13244-015-0393-1
  74. Chandra S, Klair JS, Soota K, et al. Endoscopic retrograde cholangio-pancreatography-obtained bile culture can guide antibiotic therapy in acute cholangitis. Dig Dis 2019;37:155-160. https://doi.org/10.1159/000493579
  75. Negm AA, Schott A, Vonberg RP, et al. Routine bile collection for microbiological analysis during cholangiography and its impact on the management of cholangitis. Gastrointest Endosc 2010;72:284-291. https://doi.org/10.1016/j.gie.2010.02.043