Barakat Monique T, Girotra Mohit, Thosani Nirav, Kothari Shivangi, Banerjee Subhas
Divisions of Adult and Pediatric Gastroenterology and Hepatology, Stanford University Medical Center, Cupertino, CA 95014, United States.
Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL 33136, United States.
World J Gastroenterol. 2020 Nov 7;26(41):6391-6401. doi: 10.3748/wjg.v26.i41.6391.
At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.
To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.
Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard" (short position) or "non-standard" ( long, semi-long).
Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years 55.1 ± 14.7, < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 ( < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) ( < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) ( < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques ( < 0.03 for each).
Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.
在我们的学术性三级医疗中心，我们注意到因内镜逆行胰胆管造影术（ERCP）前来就诊的患者越来越需要先进的插管技术。尽管同期内镜医师的经验有所增加且每年的ERCP手术量也有所上升，但这一趋势仍很明显。
评估ERCP插管复杂性明显升级的这一现象，并分析潜在的相关因素。
回顾性分析过去十年开始时（2008年）、中期（2013年）和末期（2018年）ERCP患者的人口统计学/临床变量及记录。插管方法分为“标准”或“先进”，十二指肠镜位置标记为“标准”（短位）或“非标准”（长位、半长位）。
与2008年相比，2018年接受ERCP的患者年龄更大（69.7±15.2岁对55.1±14.7岁，P<0.05）。2018年壶腹变形和壶腹周围憩室增多（P<0.001）。采用非标准十二指肠镜位置进行的ERCP手术比例逐渐增加，从2008年的2.2%增至2013年的5.6%和2018年的16.1%（P<0.001）。对于特定的ERCP手术，使用不止一种先进插管技术的比例从2008年的0.7%增至2013年的0.9%和2018年的6.6%（P<0.001）。原发肿块大小>4cm、胰腺钩突部肿块以及胆红素>10mg/dL预示会使用先进插管技术（每项P<0.03）。
在过去5年中，ERCP插管的复杂性急剧增加，老年患者以及患有恶性肿瘤且需要先进插管方法的患者比例上升。这些数据表明，可根据患者/壶腹特征预测ERCP插管的复杂性。这可能有助于选择经验丰富、手术量大的内镜医师来实施这些复杂手术。
