Han Taek Jeong

Background/Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is the standard treatment for common bile duct (CBD) stones. However, when complete removal is not feasible, the temporary placement of a plastic stent (PS) is commonly used. This study aimed to assess 12-month stent patency in elderly patients with CBD stones. Methods: This prospective study included patients aged 70 years or older who underwent ERCP with PS placement for CBD stones at Daegu Catholic University Medical Center from March to December 2023. Patients were followed every three months with laboratory tests and abdominal radiographs. Stent dysfunction was defined as either cholangitis or cholecystitis due to stent migration or occlusion. Results: Of 12 enrolled patients, 2 were lost to follow-up. The remaining 10 had a median age of 85 years. The median stone diameter and number were 16.5 mm and 3, respectively. Two patients (20%) experienced stent dysfunction at 1.4 and 2.7 months and underwent successful stent exchange. Of the remaining eight, one declined further ERCP, while seven underwent elective ERCP at 12 months. Among them, five achieved successful stone removal and two required stent exchange. Kaplan–Meier analysis showed 90% patency at 1.4 months and 80% at 2.7 months, maintained through 12 months. Conclusions: Plastic stents showed an acceptable 12-month patency in most elderly patients. Early complications suggest the need for close monitoring during the first three months, after which long-term stent maintenance may be feasible in selected cases. Larger studies are needed to validate these findings.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II anastomosis is challenging due to post-surgical anatomical alterations. This study aims to compare the clinical outcomes of using a duodenoscope and a cap-assisted gastroscope in these patients. Seventy-nine patients with Billroth II anastomosis and a naïve papilla were included in the study. ERCP was performed using either a cap-assisted gastroscope (n = 45) or a duodenoscope (n = 34). The primary outcome was the cannulation success rates, while secondary outcomes included clinical success rates, cannulation time, procedure duration, and complications. Afferent limb intubation was successful in 67.1% of patients. Among these, selective biliary cannulation (SBC) was achieved in 73.6%, with no significant difference between the two groups. However, cannulation time was significantly longer in the cap-assisted gastroscope group (7.6 min vs. 5.8 min, p = 0.011). Complications occurred only in the cap-assisted gastroscope group, including one perforation (2.2%) and two cases of pancreatitis (4.4%), though the overall complication rate was not significantly different. Among the 40 patients (50.7%) who failed ERCP, percutaneous transhepatic biliary drainage (PTBD) was the most common rescue intervention (55%), followed by other procedures, including percutaneous gallbladder drainage, repeated ERCP, surgery, and conservative treatment. Both cap-assisted gastroscopes and duodenoscopes are viable options for ERCP in patients with Billroth II anastomosis. However, cannulation time was significantly shorter in the duodenoscope group.

Administering sedation for endoscopic retrograde cholangiopancreatography (ERCP) involves using medications to reduce the patient's level of consciousness during a procedure, which can alleviate patient anxiety and discomfort, and improve clinical outcomes. Due to the complexity of the procedure and physiological changes induced by the prone position, meticulous sedation management is essential during ERCP. Before the procedure, a detailed history taking and physical examination are important. If the Mallampati or American Society of Anesthesiologists classification scores are high, anesthesia provider assistance should be considered. Both standard sedation with a combination of midazolam and opioids and balanced propofol sedation can be used safely. During the procedure, monitoring of vital signs, oxygen saturation, and electrocardiogram is important. For high-risk patients, capnography should also be considered. In particular, personalized approaches, including dosage adjustments and more vigilant monitoring during the procedure, are critical for high-risk patients. To ensure safe ERCP, endoscopists must be familiar with the characteristics of sedatives, as well as the types and dosages of antagonists. To prevent hypoxia during the procedure, preoxygenation and the use of high-flow nasal cannula can be considered, and a laryngeal mask can be useful if intubation is difficult in emergency situations. Above all, care must be taken to avoid excessive doses of sedatives, and it is crucial to continually assess the necessity of ERCP for each patient.

Gwang Hyo Yim, Jimin Han, Jae Hum Yun, Sun-Jae Lee, Chang ho Cho, Joo Dong Kim and Han Taek Jeong. Korean J Gastroenterol 2025;85:216-20. https://doi.org/10.4166/kjg.2024.144

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.

Han Taek Jeong, Jimin Han. Journal of Digestive Cancer Research 2024;12:171-5. https://doi.org/10.52927/jdcr.2024.12.3.171

Bulging of the major duodenal papilla

Background/Aim: This study evaluated the cumulative incidence of pancreatic cancer and worrisome features (WFs) in patients with pancreatic cysts (PCs) clinically considered as branch-duct intrapapillary mucinous neoplasm (BD-IPMN).Methods: Data from 177 patients followed for BD-IPMN were retrospectively analyzed. Suspected BD-IPMN was defined as PCs with confirmed communication with the main pancreatic duct (MPD) via imaging studies, while presumed BD-IPMN referred to PCs lacking clear MPD communication.Results: Among the patients, 30.5% were categorized as suspected BD-IPMN. The median age at diagnosis was 64 years, with a median cyst size of 13 mm. At diagnosis, 19 patients (10.7%) exhibited WFs, and none of the patients had high-risk stigmata. Over a follow-up period of 70.5 months, pancreatic cancer developed in three patients, resulting in a cumulative incidence of 4.0% (95% confidence interval [CI], 0.98 to 10.76%) at 96 months. For the 158 patients without initial WFs, the cumulative incidence of WFs was 5.1% (95% CI, 2.37 to 9.28%) at 24 months and 11.2% (95% CI, 6.34 to 17.53%) at 96 months. The development of WFs was lower in the presumed BD-IPMN group (p=0.102) and among patients aged under 75 (p=0.463), though these differences were not statistically significant. Notably, the incidence of WFs plateaued after two years in the elderly cohort.Conclusions: The cumulative incidence of pancreatic cancer and WFs in patients with low-risk PCs was notably low. Furthermore, discontinuing surveillance may be considered for elderly patients, especially those with no changes within the first two years of observation.

A novel spiral dilator for pancreatic duct drainage: catching two birds with one stone

Jae Hum Yun, June Hwa Bae, Han Taek Jeong, Hyeong Ho Jo, Joong Goo Kwon, Joo-Dong Kim, Dong Lak Choi, and Eun Young Kim. Int J Gastrointest Interv 2024;13:55-9. https://doi.org/10.18528/ijgii240012