Failed Endoscopic Retrograde Cholangio Pancreatography Predictors
Mohamed Abdel-Rasheed Allam
Assistant professor tropical medicine, Al-Azhar university
Background: – However, there is no solid data regarding value of predictive factors affecting endoscopic retrograde cholangiopancreatography (ERCP) failure, the presence of pre-procedure predictor may facilitate the operator decision and maneuver selection.
The aim of this study was to predict factors increase the ERCP failure.
Patients and methods: – A total of 103 ERCP procedures were done from October 2013 to October 2014 at AL-Hussein university hospital endoscopy unit. Patients were divided according to ERCP procedure into 2 groups; group I consisted of 93 cases of successful ERCP procedure (90.2%) and group II consisted of 10 cases of failed ERCP procedure (9.7%). The basic data regarding age, sex, clinical presentation, laboratory parameters, sonographic data and endoscopic findings were collected and evaluated as predictive factors for ERCP failure.
Results: – Age and sex, clinical presentation, sonographic findings and laboratory parameters did not alter the ERCP success.
History of previous abdominal surgery and common bile duct (CBD) stricture increased the rate of ERCP failure.
Some endoscopic findings as duodenal diverticula, papillary mass and gastric outlet obstruction were significantly raised the rate of ERCP failure.
Conclusion: – Patient with history of previous abdominal surgery, CBD strictures should be investigated before ERCP with non-invasive image as magnetic resonant. Further study for evaluating ERCP complications predictive factors is recommended.
Keyword: – ERCP; endoscopic retrograde cholangiopancreatography, predictive factor, failure rate.
Since its first use in 1968, endoscopic retrograde cholangiopancreatography (ERCP) has become a commonly performed endoscopic procedure. The diagnostic and therapeutic use of ERCP has been well documented for a variety of disorders, including 1.
The success of ERCP depends on many factors including the disease entities being treated, availability of multiple endoscopic accessories, well-trained support staff and the endoscopist’s skill and experience2.
Numerous \studies have detected the expected complications, potential contributing factors for these complications and possibilities of reducing ERCP complications1.
In a large scale, prospective multi-center study performed in 66 hospitals across England, selective deep biliary cannulation was achieved only in 84%. The study included 3209 patients with native papilla3. Differing rates of successful biliary cannulations have been reported from with higher rates (up to 98%) achieved in specialized tertiary centers, which reflects higher workload and experience, greater expertise, and more frequent use of more advanced cannulation techniques4.
Difficulties leading to ERCP failure may involve; blockage of passage ways by tumors, altered anatomy and\or duodenal stenosis5.
The therapeutic options after failed ERCP may include repeat endoscopic attempt, percutaneous cholangiography, Endoscopic ultrasound (EUS)-guided bile duct puncture and drainage or surgical management6.
Patients and methods: –
This prospective study was done during period from October 2013 to October 2014 in the endoscopy unit at AL Hussein university hospital. All patients subjected to ERCP during this period were included, 103 ERCP procedures were done. Patients were divided according to ERCP results into 2 groups; group I consisted of 93 cases of successful ERCP procedure (90.2%) and group II consisted of 10 cases of failed ERCP procedure (9.7%).
For all patient clear written consent, full clinical and routine laboratory assessment and abdominal sonography were done and ERCP was performed in the standard manner using a side-view endoscope (Fujinon ED-250 XT Duodenoscope). After cannulation of the CBD, an initial cholangiogram was taken.
Statistical analysis: –
Data entry and statistical analysis were performed using the statistical package for social sciences, version 20 (SPSS Inc., Chicago, Illinois, USA). Independent-samples t-test of significance was used when comparing between two means. ?2-test of significance was used to compare proportions between two qualitative parameters.
Table 1: Age and sex distribution in the studied groups
Group I Group II P
Age M± SD 56.946±18.188 53.000±10.520 0.672 0.503
Gender Male 49 52.69 7 70.00 1.091 0.296
Female 44 47.31 3 30.00
There is no significant difference regarding age and sex
Table 2: Indications of ERCP in the studied groups.
Group I Group II X2 P-value
N % N %
Calcular 84 90.3 7 70 1.008 0.315
Malignant 9 9.7 2 20 1.7615 0.184
CBD stricture 0 – 1 10 9.391 *0.0021
Patients with CBD stricture had a significant higher rate of ERCP failure.
The commonest indication was calcular obstructive jaundice in 91 cases (88.3%) then malignant obstructive jaundice in 10 cases (9.7%) and CBD stricture in 1 case (0.98%).
Procedure done in group-I was treatment of 86 cases of calcular obstruction; 73 of them by stone extraction, 10 cases with stenting and lithotriptor was used in the remaining 3 cases. Stent was placed in 7 cases; 2 of stricture, 3 of pancreatic mass and 2 of papillary mass.
Table 3: Clinical, sonographic and laboratory findings
Clinical presentation Group I Group II
N (93) % N (10) % X2 \ t P-value
History of previous ERCP 5 5.3 2 20 2.994 0.083
History of abdominal surgery 2 2.2 2 20 7.707 0.0055*
Jaundice 93 100 10 100 0 0 1
Diabetes Mellitus 9 9.7 1 10 0.280 0.597
Hypertension 12 12.9 1 10 0.057 0.812
Ischemic heart disease 3 3.2 0 0 0.171 0.680
Liver cirrhosis 2 2.2 0 0 0.544 0.461
CBD dilatation 89 95.7 10 100 0.037 0.848
IHBR dilatation 90 96.8 8 80 2.468 0.116
pancreatic mass 3 3.2 1 10 0.037 0.848
CBD stone 70 75.27 5 50 1.776 0.183
Total bilirubin 0.8-1 mg 6.933±6.860 4.900±5.749 0.903 0.369
Direct bilirubin0.2 mg 5.631±4.768 3.580±4.122 1.307 0.194