Risk factors for complications of ERCP in primary sclerosing cholangitis

Background and study aims: Endoscopic retrograde cholangiographic pancreatography (ERCP) is the most accurate technique for surveillance of patients with primary sclerosing cholangitis (PSC). Our aim was to evaluate risk factors for complications of ERCP in patients with PSC.

Patients and methods: In 2007 – 2009 we performed 441 ERCPs in patients with PSC. The primary tools for ERCP were a guide wire and papillotomy knife to gain access into the biliary duct. If the primary cannulation failed, and the wire went only into the pancreatic duct, pancreatic sphincterotomy was performed. If necessary, a further oblique cut with a needle knife was done in order to expose the biliary duct.

Results: Primary cannulation was successful in 389 patients (88.2 %). Of these, 147 (37.8 %) had had biliary sphincterotomy performed previously. In the group with failed primary cannulation, access into the biliary duct was achieved after pancreatic sphincterotomy in 52 patients. In 11 of these, a further cut with a needle knife was performed. Post-ERCP pancreatitis (PEP) was diagnosed in 31 patients (7.0 %). Factors predicting PEP were female sex (odds ratio [OR] 2.6, P = 0.015) and a guide wire in the pancreatic duct (OR 8.2, P < 0.01). Previous biliary sphincterotomy was a protective factor (OR 0.28, P = 0.02). The risk of PEP increased with the number of times the wire accidentally passed into the pancreatic duct (P < 0.001). Cholangitis developed in 6 patients (1.4 %).

Conclusions: In patients with PSC the incidence of ERCP complications remained relatively low. The complication risk increased with the complexity of cannulation. In a patient with PSC in whom follow-up ERCP is planned, biliary sphincterotomy should be considered, as it may protect against PEP.

• References

• 1 Chapman R, Fevery J, Kalloo A et al. Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010; 51: 660-678
• 2 Rasmussen HH, Fallingborg JF, Mortensen PB et al. Hepatobiliary dysfunction and primary sclerosing cholangitis in patients with Crohn’s disease. Scand J Gastroenterol 1997; 32: 604-610
• 3 Halme L, Arola J, Numminen K et al. Biliary dysplasia in patients with primary sclerosing cholangitis: additional value of DNA ploidity. Liver Int 2012; 32: 783-789
• 4 Moreno Luna LE, Gores GJ. Advances in the diagnosis of cholangio-carcinoma in patients with primary sclerosing cholangitis. Liver Transpl 2006; 12 (Suppl. 02) 15-19
• 5 Cotton PB, Garrow DA, Gallagher J et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009; 70: 80-88
• 6 Freeman ML, Nelson DB, Sherman S et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 7 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
• 8 Bangarulingam SY, Gossard AA, Petersen BT et al. Complications of endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis. Am J Gastroenterol 2009; 104: 855-860
• 9 Halttunen J, Keränen I, Udd M et al. Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation. Surg Endosc 2009; 23: 745-749
• 10 Ponsioen C, Vrouenraets S, Prawirodirdjo W et al. Natural history of primary sclerosing cholangitis and prognostic value of cholangiography in a Dutch population. Gut 2002; 51: 562-566
• 11 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 12 Etzel JP, Eng SC, Ko CW et al. Complications of ERCP in patients with primary sclerosing cholangitis. Gastrointest Endosc 2008; 67: 643-648
• 13 Lee JG, Schutz SM, England RE et al. Endoscopic therapy of sclerosing cholangitis. Hepatology 1995; 21: 661-667
• 14 Ponsioen CY, Lam K, van Milligen de Wit AW et al. Four years’ experience with short term stenting in primary sclerosing cholangitis. Am J Gastroenterol 1999; 94: 2403-2407
• 15 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
• 16 Wang P, Li ZS, Liu F et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104: 31-40
• 17 Vandervoort J, Soetikno RM, Tham TC et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652-656
• 18 Testoni PA, Mariani A, Giussani A et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: a prospective multicenter study. Am J Gastro-enterol 2010; 105: 1753-1761
• 19 Freeman ML, DiSario JA, Nelson DB et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001; 54: 425-434
• 20 Masci E, Toti G, Mariani A et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96: 417-423
• 21 Lee TH, Park do H, Park JY et al. Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial. Gastrointest Endosc 2009; 69: 444-449
• 22 Loperfido S, Angelini G, Benedetti G et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48: 1-10
• 23 Artifon EL, Sakai P, Cunha JE et al. Guidewire cannulation reduces risk of post-ERCP pancreatitis and facilitates bile duct cannulation. Am J Gastroenterol 2007; 102: 2147-2153
• 24 Lella F, Bagnolo F, Colombo E et al. A simple way of avoiding post-ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834
• 25 Siegel JH, Ben-Zvi JS, Pullano W. The needle-knife: a valuable tool in diagnostic and therapeutic ERCP. Gastrointest Endosc 1989; 35: 499-503
• 26 Bruins Slot W, Schoeman MN, Disario JA. Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications. Endoscopy 1996; 28: 334-339
• 27 Foutch PG. A prospective assessment of results for needle knife papillotomy and standard endoscopic sphincterotomy. Gastrointest Endosc 1995; 41: 25-32
• 28 Rabenstein T, Ruppert T, Muehldorfer S et al. The precut technique is a safe procedure and does not increase the overall complication risk of sphincterotomy [abstract]. Gastrointest Endosc 1995; 41: 412
• 29 Binmoeller KF, Seifert H, Gerke H et al. Papillary roof incision using the Erlangen-type precut papillotome to achieve bile duct cannulation. Gastrointest Endosc 1996; 44: 689-695
• 30 Choudhary A, Bechtold ML, Arif M et al. Pancreatic stent for prophylaxis against post-ERCP pancreatitis: A meta-analysis and systematic review. Gastrointest Endosc 2011; 73: 275-282
• 31 Catalano MF, Linder JD, Chak A et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59: 225-232