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    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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A National Survey on the Environment and Basic Techniques of Endoscopic Retrograde Cholangiopancreatography in Korea

Jae Min Lee1 , Sung Hoon Moon2 , Sang Wook Park3 , Woo Hyun Paik4 , Chang Nyol Paik5 , Byoung Kwan Son6 , Tae Jun Song7 , Dong Won Ahn8 , Eaum Seok Lee9 , Yun Nah Lee10 , Yoon Suk Lee11 , Tae Joo Jeon12 , Hyung Ku Chon13 , Dong Wook Lee14 , Chang Hwan Park15 , and Kwang Bum Cho16 , Committee of Policy-Quality Management, Korean Pancreatobiliary Association

1Department of Internal Medicine, Korea University College of Medicine, Seoul, 2Department of Internal Medicine, Hallym University College of Medicine, Anyang, 3Department of Internal Medicine, Kwangju Christian Hospital, Gwangju, 4Department of Internal Medicine, Seoul National University College of Medicine, 5Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 6Department of Internal Medicine, Eulji University College of Medicine, 7Department of Internal Medicine, University of Ulsan College of Medicine, 8Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, 9Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, 10Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, 11Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, 12Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, 13Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, 14Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 15Department of Internal Medicine, Chonnam National University Medical School, Gwangju, and 16Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Correspondence to:Chang Hwan Park
ORCID https://orcid.org/0000-0002-2995-8779
E-mail p1052ccy@hanmail.net

Kwang Bum Cho
ORCID https://orcid.org/0000-0003-2203-102X
E-mail chokb@dsmc.or.kr

Received: November 7, 2020; Revised: December 23, 2020; Accepted: January 11, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut and Liver 2021; 15(6): 904-911

Published online November 15, 2021 https://doi.org/10.5009/gnl20329

Copyright © Gut and Liver.

Background/Aims: The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea.
Methods: The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP.
Results: Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%.
Conclusions: Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.

Keywords: Endoscopic retrograde cholangiopancreatography, Current status, Survey

Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in the 1968,1 it has been one of the most important procedures to treat biliary and pancreatic diseases. ERCP demands a long procedure time and requires substantial training with the considerable risk of complications.2 The total volume of its practice has increased significantly the recent years in Korea.3 According to a previous study with a Health Insurance Review and Assessment data in Korea, the number of patients who underwent ERCP was 47,027 in 2017, and the annual ERCP rate was reported to be approximately 91 per 100,000 in 2017.4 However, the number of studies about the current status and trend of ERCP at a national scale in Korea are lacking.

The environment of endoscopy includes the factors such as endoscopy room, medical professionals, and preparation for endoscopic procedure. Although the overall environment of ERCP is similar to that of esophagogastroduodenoscopy or colonoscopy, it differs with regard to the number of required additional assistants and the need for a radiology technician. The dedicated room and medical professionals for ERCP are important factors that may affect the results. The patient’s position and mode of anesthesia or sedation can ensure an easier and better outcome. Moreover, the ERCP procedure and the techniques associated with the cannulation and stone removal must considerably influence the outcomes.5 Since technical variations must be associated with differences in quality and safety, it is important to consider these parameters in practice.

Current status of ERCP related with specific issues had been published in Japan.6,7 There was a study regarding the Korean trend of ERCP based on publicly open Health Insurance Review and Assessment data.4 Recently, a national survey by Korean investigators had been conducted to investigate the ERCP practices and outcomes.8 However, it did not identify the current trends of basic ERCP procedures or present a detailed information on its operational setup in Korea.

We conducted a national survey about ERCP, which focused on basic techniques and the associated operational setups. This study is aimed to assess the current trend of ERCP in Korea.

1. Conduct of the survey

This study was designed as a national survey. It was organized by the committee of policy and quality management in Korean Pancreatobiliary Association. The committee members accumulated the important issues associated with ERCP and constructed key questions about the basic techniques for the same. The questionnaires were prepared and revised by the committee of policy and quality management, and finally constructed in 2019. The survey was performed through a papered questionnaire (Supplementary Material) for participants in Annual Congress of Korean Pancreatobiliary Association 2019 in Korea. Additionally, an online survey with same questions was released for Korean Pancreatobiliary Association members who were unable to attend the congress. It consisted of 36 questions and the contents were classified into three categories: (1) the current environment of ERCP; (2) the preparation for ERCP; and (3) the current trend of basic techniques for ERCP in Korea. The questionnaire was considered valid if all of the required information was provided.

2. Statistical analysis

All continuous variables were presented as mean± standard deviations. Categorical variables were presented as numbers or proportions. Data were analyzed using the Statistical Package for the Social Sciences version 24.0 (IBM Corp., Armonk, NY, USA).

A total of 84 completed questionnaires were collected. The mean age of answered ERCP doctors was 46.9±7.7 years. There were 80 male doctors and four female doctors. In total, 59% of doctors had an experience of over 11 years and 41% of doctors had performed ERCP for more than 5,000 cases.

1. The environment for ERCP procedure

Fig. 1 shows the results pertaining to the doctors’ experience and ERCP volume. With regard to the number of ERCP procedures performed per week, 41% of doctors performed the procedure for 5 to 10 cases, and 30% performed for 11 to 20 cases. In total, 16% of doctors performed over 20 cases per week. However, 60% of doctors answered that they had a dedicated ERCP team with experienced nurses, and 40% of doctors performed ERCP with endoscopy nurses (Fig. 2A). In total, 68% of doctors reported the presence of a fluoroscopy room dedicated for ERCP in the endoscopy or radiology intervention unit (Fig. 2B). Emergency ERCP was available in 69%, regardless of a weekend or a holiday.

Figure 1.Endoscopic retrograde cholangiopancreatography (ERCP) experience of Korean doctors and their current ERCP volume. (A) Age, (B) ERCP experience, (C) total number of ERCP, (D) current ERCP volume.

Figure 2.Specialized nurse staff (A) and designated unit for endoscopic retrograde cholangiopancreatography (ERCP) (B).

2. The preparation of ERCP

Whereas 50% of ERCP doctors used a balanced propofol sedation for procedural sedation for ERCP, 47% of ERCP doctors preferred to use midazolam only for procedural sedation (Fig. 3). Only 1% of the doctors performed the procedure using general anesthesia in Korea. Table 1 presents the preference of patient position and premedication. Most doctors preferred the prone position. The number of positive answers was 80 (95%) for prophylactic use of opioid drug, 68 (80%) for prophylactic use of antiperistaltic agent, and 50 (60%) regarding the use of prophylactic antibiotics before diagnostic ERCP. While 51% of the doctors routinely use a restriction device for patient’s position in ERCP, 49% did not use it. Sixteen percent of ERCP doctors answered that they routinely conducted endoscopic ultrasonography before therapeutic ERCP. In the questionnaire about prevention methods against post-ERCP pancreatitis (multiple choices are available), most ERCP doctors answered that they usually used the combination of techniques by intravenous hydration, intravenous protease inhibitor and pancreatic stenting against post-ERCP pancreatitis (Table 2). Table 2 shows data about preparation for ERCP and management after procedure.

Table 1. Patient’s Position and Prophylactic Treatment for ERCP

VariableNo. (%)
No. of ERCP doctor84
Patient’s position for ERCP
Prone position77 (92)
Left lateral position4 (5)
Position change as prone after duodenal approach3 (3)
Use of restriction device
Yes43 (51)
No41 (49)
Use of opioid analgesics
Meperidine72 (86)
Fentanyl8 (9)
None4 (5)
Use of antiperistaltic agent
Yes67 (80)
No17 (20)
Use of prophylactic antibiotics
Yes50 (60)
No34 (40)

ERCP, endoscopic retrograde cholangiopancreatography.



Table 2. Preparation for ERCP and Management after Procedure

VariableValue
No. of ERCP doctor84
Routine diagnostic EUS before therapeutic ERCP
Yes13
No70
No answer1
Routine follow-up ERCP after successful ERCP
Yes3
No80
No answer1
Performing urgent ERCP*
Yes58
No24
No answer2
Prevention against post-ERCP pancreatitis
Intravenous hydration over 1 L fluid52
Intravenous protease inhibitor64
Oral protease inhibitor5
Pancreatic stenting53
Others2
Timing to permit a diet after ERCP
4–6 Hours14
6–12 Hours22
>12 Hours47
No answer1
First diet on the day after ERCP
Water only27
Liquid diet17
Soft diet12
Regular diet5
NPO on the day23

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; NPO, nil per os.

*ERCP as urgent treatment at night or over the weekend; Multiple choices are available.



Figure 3.(A, B) Preferred method of procedural sedation for ERCP in Korea.
ERCP, endoscopic retrograde cholangiopancreatography; G/A, general anesthesia.

3. The preferred basic technique of ERCP

Table 3 presents the current trend of prepared device and technique for ERCP in Korea. Regarding selective deep cannulation, 46% of doctors preferred to use sphincterotome and guidewire, but 35% preferred using a cannulation catheter. Additionally, 19% preferred to use a contrast agent than a guidewire. There were differences with regard to the basic accessories used in the procedure. A 0.035-inch guidewire with a straight tip was used by 42%. But 28% chose a 0.025-inch angled guidewire, and 23% preferred a thin straight guidewire. The device used to crush a large stone were as follows; TrapezoidTM basket (Boston Scientific, Marlborough, MA, USA), 55%; Power-Catch basket (MTW, Wesel, Germany), 24%; BML lithotripsy basket (Olympus, Tokyo, Japan), 16%; and Fusion® lithotripsy extraction basket (Cook Medical, Bloomington, IN, USA), 3%. Endoscopic sphincterotomy was more dominantly used than the endoscopic papillary balloon dilation for papilla dilatation in patients with naïve ampulla (Fig. 4A). The preferred methods for biliary drainage included endoscopic retrograde biliary drainage in 60%, endoscopic retrograde nasobiliary drainage in 22%, and both methods at simultaneously in 18% (Fig. 4B). The mostly preferred salvage technique was wire assisted technique and double guidewire technique.

Table 3. Current Status of Prepared Devices and Techniques Used in ERCP

VariableNo. (%)
No. of ERCP doctor84
Device for selective cannulation
Sphincterotome44 (52)
Cannulation catheter40 (48)
Initial check-up for bile duct cannulation
Guidewire68 (81)
Contrast16 (19)
Favorite cannulation technique
Sphincterotome+guidewire39 (46)
Cannulation catheter+guidewire29 (35)
Sphincterotome+contrast5 (6)
Cannulation catheter+contrast11 (13)
Type of guidewire
Straight tip with 0.035-inch diameter35 (42)
Angled tip with 0.035-inch diameter4 (5)
Straight tip with 0.025-inch diameter19 (23)
Angled tip with 0.025-inch diameter24 (28)
Others2 (2)
Product for mechanical lithotripsy in ERCP
BML lithotripsy basket (Olympus)14
FusionⓇ Lithotripsy basket (Cook Medical)2
TrapezoidTM (Boston Scientific)46
MTW Basket (MTW)20
Others2

ERCP, endoscopic retrograde cholangiopancreatography.



Figure 4.Preferred basic technique for ERCP. (A) Basic procedure for opening of the naïve ampulla. (B) Basic procedure for bile drainage.
ERCP, endoscopic retrograde cholangiopancreatography; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; EST, endoscopic sphincterotomy; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage.

4. The difference of ERCP procedure between groups by experience

Table 4 shows the difference of preparation, basic procedure and preferred device for ERCP between three groups by doctor’s experience in Korea. There were no significant differences in each group by their experiences.

Table 4. Comparison of ERCP Procedure by Experience

Variable<5 Years5–10 Years>10 Years
No. of ERCP doctor231150
Preparation for ERCP, No. (%)
Patient’s position
Prone position22 (96)11 (100)44 (88)
Left lateral or changing position1 (4)06 (12)
Use of antiperistaltic agent
Yes20 (87)10 (91)37 (74)
No3 (13)1 (9)13 (26)
Use of prophylactic antibiotics
Yes13 (57)8 (73)29 (58)
No10 (43)3 (27)21 (42)
Preferred technique & device for ERCP, No. (%)
Cannulation technique
Sphincterotome+guidewire9 (39)8 (73)22 (44)
Cannulation catheter+guidewire10 (43)3 (27)16 (32)
Sphincterotome+contrast005 (10)
Cannulation catheter+contrast4 (17)07 (14)
Type of guidewire
Straight tip/0.035-inch diameter7 (30)1 (9)11 (22)
Angled tip/0.035-inch diameter8 (35)6 (55)22 (44)
Straight tip/0.025-inch diameter7 (30)4 (36)12 (24)
Angled tip/0.025-inch diameter1 (4)03 (6)
Others2 (4)
Opening of naïve ampulla
EST20 (87)10 (91)37 (74)
EPBD (or EPLBD)003 (6)
EST+EPBD (or EPLBD)3 (13)1 (9)10 (20)
Biliary drainage therapy
ERBD14 (61)10 (91)26 (52)
ENBD6 (26)012 (24)
ERBD+ENBD3 (13)1 (9)11 (22)
Device for small CBD stone
4-Wired basket11 (48)2 (18)26 (52)
8-Wired basket7 (30)5 (45)13 (26)
Retrieval balloon5 (22)4 (36)11 (22)

ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage; CBD, common bile duct.


This study is a national survey regarding ERCP operational environment and basic ERCP technique trends in Korea. The result was primarily collected from well-experienced ERCP doctors. Most Korean ERCP doctors in this survey perform over five cases requiring ERCP procedures per week, with an overall experience of more than 10 years. Therefore, the trend in the survey represents highly active endoscopists. Notably, the status of ERCP in Korea showed that it somewhat differed from that in other countries.

The staff required for the ERCP procedure typically include minimum of one physician, two assistants, and a radiology technician.9 It is recommended to have a fluoroscopy room for endoscopic procedure, specifically in medical centers that perform over 600 ERCP annually.10 The quality of Korean ERCP doctors showed to be in a well-controlled state. However, the lack of specialized ERCP nurses and appropriate systems for emergency ERCP are often noted. In other countries, 40% of endoscopists perform fewer than 50 sphincterotomies in Canada,11 and a large number of ERCPs tend to be performed in low volume centers in America and United Kingdom.12,13 According to the national data obtained from Health Insurance Review and Assessment Service, ERCP is mostly performed in university hospitals or tertiary care institutions.8 Our survey in Korea revealed that a large number of ERCPs were performed by small number of well-experienced ERCP doctors. We found that ERCP procedures in Korea had a tendency to be concentrated on doctors in university hospitals or tertiary referral centers.

There are some differences of ERCP preparation in Korea compared with other Western countries. Sedation is one of the important issues in therapeutic endoscopy and related with reducing the failure rate.14,15 Anesthesia-administered sedation can improve the success of advanced endoscopic procedures.16 In most Western countries, ERCP is usually performed with deep sedation or general endotracheal anesthesia. In Asian countries such as Korea, ERCP is often performed under sedation by an endoscopist. A previous survey in Korea suggested that ERCP procedures were usually performed under sedation rather than general anesthesia and the most preferred agent for sedation was propofol and/or midazolam.8 Agents such as propofol, midazolam or dexmedetomidine can be used to achieve moderate sedation for the procedure.17 Previously, propofol alone provided identical or superior sedation quality than combination with midazolam in regard of both the recovery time and patient tolerance.18-21 In this survey, half of ERCP doctors in Korea preferred to use a balanced propofol sedation technique for ERCP preparation.

Post-ERCP pancreatitis is the most common complication with incidence up to 15%.22 It is sometimes severe and potentially fatal, with a mortality rate of 0.1% to 0.5%. A number of agents or techniques have been investigated previously to prevent post-ERCP-pancreatitis. Previous meta-analyses suggested that the use of rectal nonsteroidal anti-inflammatory drug,23-25 aggressive hydration with lactated Ringer’s solution and prophylactic pancreatic stent placement are effective in reducing the incidence and severity of post-ERCP pancreatitis.26,27 Since rectal nonsteroidal anti-inflammatory drug is not commercially available in Korea, it cannot be used for ERCP premedication as prophylaxis. In the future, more research will be needed to develop the optimal prophylactic treatment for ERCP. Since prone position ERCP is favorable with a higher technical success rate and easy to visualize an abdominal image than lateral position,28 prone position is dominantly used for patient’s position during ERCP in Korea.

Among the ERCP techniques, there are important basic techniques such as selective cannulation, biliary sphincterotomy, and stone extraction. In practice, most ERCP doctors opt to cannulate the naïve papilla a sphincterotome rather than catheter.9 Generally, guidewire with a hydrophilic tip is used commonly and the use of an angled or J-tip guidewire is recommended as a standard technique.29 When performing ERCP, doctors often encounter some difficult cases such as repeated failure of selective cannulation or impacted large stones. In cases of a failed initial cannulation attempt, a salvage technique should be selected to approach the common bile duct. European Society of Gastrointestinal Endoscopy and Japan Gastroenterological Endoscopy Society recommend needle-knife fistulotomy as the salvage technique.30,31 For large common bile duct stones over 2 cm or impacted stones, fragmentation of the stones within the bile duct is frequently required before removal. In Korea, TrapezoidTM basket was dominantly preferred as lithotripsy device during ERCP. Most ERCP doctors choose endoscopic retrograde biliary drainage rather than endoscopic retrograde nasobiliary drainage for biliary drainage therapy. However, the advantage and effectiveness are still unclear. Thus, comparative study would be required to establish a standard biliary drainage therapy.

We found no significant differences for preferred devices or techniques between groups by doctor’s experiences. The doctor’s preference of basic techniques and accessories might be more closely related with the mentor’s taste than the individual taste in Korea. However, this national survey in Korea has some limitations. The accuracy of the answers depended on the participants’ memory, due to which recall bias could not be avoided. The lack of opinion from young doctors is another limitation of this study. The answers about ERCP environment might be inaccurate among individual doctors. National survey for all hospitals and medical centers could guarantee accurate results for ERCP environment. Furthermore, multinational survey or prospective registry will be required to subsequent study for current trend of ERCP. Some important factors about safety such as radiation exposure, medical outcomes and complication rates are missing from the content of survey.

In conclusion, data from this survey involving ERCP doctors in Korea showed a diversity of preferences in the basic techniques and ERCP environment. More studies are required to develop ERCP standards in Korea.

We thank all respondents and members of the Korean Pancreatobiliary Association for their contribution to the study.


Analysis and interpretation of data: J.M.L., H.K.C., T.J.S., D.W.A., Y.S.L., D.W.L. Drafting of the manuscript, statistical analysis: J.M.L. Study design, administrative, technical and material support: C.H.P., K.B.C. Critical revision of the manuscript: C.H.P., K.B.C., E.S.L., Y.N.L., H.K.C. Acquisition of data, study supervision: S.H.M., S.W.P., W.H.P., C.N.P., B.K.S., T.J.J. All authors read and approved the final manuscript.

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Article

Original Article

Gut and Liver 2021; 15(6): 904-911

Published online November 15, 2021 https://doi.org/10.5009/gnl20329

Copyright © Gut and Liver.

A National Survey on the Environment and Basic Techniques of Endoscopic Retrograde Cholangiopancreatography in Korea

Jae Min Lee1 , Sung Hoon Moon2 , Sang Wook Park3 , Woo Hyun Paik4 , Chang Nyol Paik5 , Byoung Kwan Son6 , Tae Jun Song7 , Dong Won Ahn8 , Eaum Seok Lee9 , Yun Nah Lee10 , Yoon Suk Lee11 , Tae Joo Jeon12 , Hyung Ku Chon13 , Dong Wook Lee14 , Chang Hwan Park15 , and Kwang Bum Cho16 , Committee of Policy-Quality Management, Korean Pancreatobiliary Association

1Department of Internal Medicine, Korea University College of Medicine, Seoul, 2Department of Internal Medicine, Hallym University College of Medicine, Anyang, 3Department of Internal Medicine, Kwangju Christian Hospital, Gwangju, 4Department of Internal Medicine, Seoul National University College of Medicine, 5Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 6Department of Internal Medicine, Eulji University College of Medicine, 7Department of Internal Medicine, University of Ulsan College of Medicine, 8Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, 9Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, 10Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, 11Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, 12Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, 13Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, 14Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, 15Department of Internal Medicine, Chonnam National University Medical School, Gwangju, and 16Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Correspondence to:Chang Hwan Park
ORCID https://orcid.org/0000-0002-2995-8779
E-mail p1052ccy@hanmail.net

Kwang Bum Cho
ORCID https://orcid.org/0000-0003-2203-102X
E-mail chokb@dsmc.or.kr

Received: November 7, 2020; Revised: December 23, 2020; Accepted: January 11, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims: The work environment in which endoscopic retrograde cholangiopancreatography (ERCP) is conducted has influence on its efficacy and safety. We aimed to assess the current status of ERCP work environments and to investigate the trends associated with the basic techniques of ERCP in Korea.
Methods: The work environment and information on the basic techniques of ERCP were acquired by the Korean Pancreatobiliary Association (KPBA) through a national survey in 2019. The survey was performed at the KPBA conference in 2019. The contents of survey comprised of the current environment of ERCP, preparation before ERCP, and the preferred basic techniques used in ERCP.
Results: Completed questionnaires were returned from 84 KPBA members. The mean ERCP volume per year was approximately 500. About 60% (50/84) reported that they worked with a dedicated ERCP team with experienced nurses. Two-thirds (57/84, 68%) answered that they had a fluoroscopy room used solely for ERCP procedures. All respondents intravenously hydrated the patient to prevent post-ERCP pancreatitis (84/84, 100%). The preferred procedural sedations were balanced propofol sedation (50%) and midazolam-only sedation (47%). Wire-guided cannulation was most commonly used for selective cannulation (81%). Endoscopic retrograde biliary drainage was preferred over endoscopic nasobiliary drainage (60% vs 22%). The initial method of ampullary intervention was endoscopic sphincterotomy in 60%.
Conclusions: Data from the survey involving a large number of Korean ERCP doctors revealed considerable variabilities with regard to the work environment and basic techniques of ERCP in Korea. The study provides information regarding the current trends of ERCP that can be used to establish ERCP standards in Korea.

Keywords: Endoscopic retrograde cholangiopancreatography, Current status, Survey

INTRODUCTION

Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in the 1968,1 it has been one of the most important procedures to treat biliary and pancreatic diseases. ERCP demands a long procedure time and requires substantial training with the considerable risk of complications.2 The total volume of its practice has increased significantly the recent years in Korea.3 According to a previous study with a Health Insurance Review and Assessment data in Korea, the number of patients who underwent ERCP was 47,027 in 2017, and the annual ERCP rate was reported to be approximately 91 per 100,000 in 2017.4 However, the number of studies about the current status and trend of ERCP at a national scale in Korea are lacking.

The environment of endoscopy includes the factors such as endoscopy room, medical professionals, and preparation for endoscopic procedure. Although the overall environment of ERCP is similar to that of esophagogastroduodenoscopy or colonoscopy, it differs with regard to the number of required additional assistants and the need for a radiology technician. The dedicated room and medical professionals for ERCP are important factors that may affect the results. The patient’s position and mode of anesthesia or sedation can ensure an easier and better outcome. Moreover, the ERCP procedure and the techniques associated with the cannulation and stone removal must considerably influence the outcomes.5 Since technical variations must be associated with differences in quality and safety, it is important to consider these parameters in practice.

Current status of ERCP related with specific issues had been published in Japan.6,7 There was a study regarding the Korean trend of ERCP based on publicly open Health Insurance Review and Assessment data.4 Recently, a national survey by Korean investigators had been conducted to investigate the ERCP practices and outcomes.8 However, it did not identify the current trends of basic ERCP procedures or present a detailed information on its operational setup in Korea.

We conducted a national survey about ERCP, which focused on basic techniques and the associated operational setups. This study is aimed to assess the current trend of ERCP in Korea.

MATERIALS AND METHODS

1. Conduct of the survey

This study was designed as a national survey. It was organized by the committee of policy and quality management in Korean Pancreatobiliary Association. The committee members accumulated the important issues associated with ERCP and constructed key questions about the basic techniques for the same. The questionnaires were prepared and revised by the committee of policy and quality management, and finally constructed in 2019. The survey was performed through a papered questionnaire (Supplementary Material) for participants in Annual Congress of Korean Pancreatobiliary Association 2019 in Korea. Additionally, an online survey with same questions was released for Korean Pancreatobiliary Association members who were unable to attend the congress. It consisted of 36 questions and the contents were classified into three categories: (1) the current environment of ERCP; (2) the preparation for ERCP; and (3) the current trend of basic techniques for ERCP in Korea. The questionnaire was considered valid if all of the required information was provided.

2. Statistical analysis

All continuous variables were presented as mean± standard deviations. Categorical variables were presented as numbers or proportions. Data were analyzed using the Statistical Package for the Social Sciences version 24.0 (IBM Corp., Armonk, NY, USA).

RESULTS

A total of 84 completed questionnaires were collected. The mean age of answered ERCP doctors was 46.9±7.7 years. There were 80 male doctors and four female doctors. In total, 59% of doctors had an experience of over 11 years and 41% of doctors had performed ERCP for more than 5,000 cases.

1. The environment for ERCP procedure

Fig. 1 shows the results pertaining to the doctors’ experience and ERCP volume. With regard to the number of ERCP procedures performed per week, 41% of doctors performed the procedure for 5 to 10 cases, and 30% performed for 11 to 20 cases. In total, 16% of doctors performed over 20 cases per week. However, 60% of doctors answered that they had a dedicated ERCP team with experienced nurses, and 40% of doctors performed ERCP with endoscopy nurses (Fig. 2A). In total, 68% of doctors reported the presence of a fluoroscopy room dedicated for ERCP in the endoscopy or radiology intervention unit (Fig. 2B). Emergency ERCP was available in 69%, regardless of a weekend or a holiday.

Figure 1. Endoscopic retrograde cholangiopancreatography (ERCP) experience of Korean doctors and their current ERCP volume. (A) Age, (B) ERCP experience, (C) total number of ERCP, (D) current ERCP volume.

Figure 2. Specialized nurse staff (A) and designated unit for endoscopic retrograde cholangiopancreatography (ERCP) (B).

2. The preparation of ERCP

Whereas 50% of ERCP doctors used a balanced propofol sedation for procedural sedation for ERCP, 47% of ERCP doctors preferred to use midazolam only for procedural sedation (Fig. 3). Only 1% of the doctors performed the procedure using general anesthesia in Korea. Table 1 presents the preference of patient position and premedication. Most doctors preferred the prone position. The number of positive answers was 80 (95%) for prophylactic use of opioid drug, 68 (80%) for prophylactic use of antiperistaltic agent, and 50 (60%) regarding the use of prophylactic antibiotics before diagnostic ERCP. While 51% of the doctors routinely use a restriction device for patient’s position in ERCP, 49% did not use it. Sixteen percent of ERCP doctors answered that they routinely conducted endoscopic ultrasonography before therapeutic ERCP. In the questionnaire about prevention methods against post-ERCP pancreatitis (multiple choices are available), most ERCP doctors answered that they usually used the combination of techniques by intravenous hydration, intravenous protease inhibitor and pancreatic stenting against post-ERCP pancreatitis (Table 2). Table 2 shows data about preparation for ERCP and management after procedure.

Table 1 . Patient’s Position and Prophylactic Treatment for ERCP.

VariableNo. (%)
No. of ERCP doctor84
Patient’s position for ERCP
Prone position77 (92)
Left lateral position4 (5)
Position change as prone after duodenal approach3 (3)
Use of restriction device
Yes43 (51)
No41 (49)
Use of opioid analgesics
Meperidine72 (86)
Fentanyl8 (9)
None4 (5)
Use of antiperistaltic agent
Yes67 (80)
No17 (20)
Use of prophylactic antibiotics
Yes50 (60)
No34 (40)

ERCP, endoscopic retrograde cholangiopancreatography..



Table 2 . Preparation for ERCP and Management after Procedure.

VariableValue
No. of ERCP doctor84
Routine diagnostic EUS before therapeutic ERCP
Yes13
No70
No answer1
Routine follow-up ERCP after successful ERCP
Yes3
No80
No answer1
Performing urgent ERCP*
Yes58
No24
No answer2
Prevention against post-ERCP pancreatitis
Intravenous hydration over 1 L fluid52
Intravenous protease inhibitor64
Oral protease inhibitor5
Pancreatic stenting53
Others2
Timing to permit a diet after ERCP
4–6 Hours14
6–12 Hours22
>12 Hours47
No answer1
First diet on the day after ERCP
Water only27
Liquid diet17
Soft diet12
Regular diet5
NPO on the day23

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; NPO, nil per os..

*ERCP as urgent treatment at night or over the weekend; Multiple choices are available..



Figure 3. (A, B) Preferred method of procedural sedation for ERCP in Korea.
ERCP, endoscopic retrograde cholangiopancreatography; G/A, general anesthesia.

3. The preferred basic technique of ERCP

Table 3 presents the current trend of prepared device and technique for ERCP in Korea. Regarding selective deep cannulation, 46% of doctors preferred to use sphincterotome and guidewire, but 35% preferred using a cannulation catheter. Additionally, 19% preferred to use a contrast agent than a guidewire. There were differences with regard to the basic accessories used in the procedure. A 0.035-inch guidewire with a straight tip was used by 42%. But 28% chose a 0.025-inch angled guidewire, and 23% preferred a thin straight guidewire. The device used to crush a large stone were as follows; TrapezoidTM basket (Boston Scientific, Marlborough, MA, USA), 55%; Power-Catch basket (MTW, Wesel, Germany), 24%; BML lithotripsy basket (Olympus, Tokyo, Japan), 16%; and Fusion® lithotripsy extraction basket (Cook Medical, Bloomington, IN, USA), 3%. Endoscopic sphincterotomy was more dominantly used than the endoscopic papillary balloon dilation for papilla dilatation in patients with naïve ampulla (Fig. 4A). The preferred methods for biliary drainage included endoscopic retrograde biliary drainage in 60%, endoscopic retrograde nasobiliary drainage in 22%, and both methods at simultaneously in 18% (Fig. 4B). The mostly preferred salvage technique was wire assisted technique and double guidewire technique.

Table 3 . Current Status of Prepared Devices and Techniques Used in ERCP.

VariableNo. (%)
No. of ERCP doctor84
Device for selective cannulation
Sphincterotome44 (52)
Cannulation catheter40 (48)
Initial check-up for bile duct cannulation
Guidewire68 (81)
Contrast16 (19)
Favorite cannulation technique
Sphincterotome+guidewire39 (46)
Cannulation catheter+guidewire29 (35)
Sphincterotome+contrast5 (6)
Cannulation catheter+contrast11 (13)
Type of guidewire
Straight tip with 0.035-inch diameter35 (42)
Angled tip with 0.035-inch diameter4 (5)
Straight tip with 0.025-inch diameter19 (23)
Angled tip with 0.025-inch diameter24 (28)
Others2 (2)
Product for mechanical lithotripsy in ERCP
BML lithotripsy basket (Olympus)14
FusionⓇ Lithotripsy basket (Cook Medical)2
TrapezoidTM (Boston Scientific)46
MTW Basket (MTW)20
Others2

ERCP, endoscopic retrograde cholangiopancreatography..



Figure 4. Preferred basic technique for ERCP. (A) Basic procedure for opening of the naïve ampulla. (B) Basic procedure for bile drainage.
ERCP, endoscopic retrograde cholangiopancreatography; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; EST, endoscopic sphincterotomy; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage.

4. The difference of ERCP procedure between groups by experience

Table 4 shows the difference of preparation, basic procedure and preferred device for ERCP between three groups by doctor’s experience in Korea. There were no significant differences in each group by their experiences.

Table 4 . Comparison of ERCP Procedure by Experience.

Variable<5 Years5–10 Years>10 Years
No. of ERCP doctor231150
Preparation for ERCP, No. (%)
Patient’s position
Prone position22 (96)11 (100)44 (88)
Left lateral or changing position1 (4)06 (12)
Use of antiperistaltic agent
Yes20 (87)10 (91)37 (74)
No3 (13)1 (9)13 (26)
Use of prophylactic antibiotics
Yes13 (57)8 (73)29 (58)
No10 (43)3 (27)21 (42)
Preferred technique & device for ERCP, No. (%)
Cannulation technique
Sphincterotome+guidewire9 (39)8 (73)22 (44)
Cannulation catheter+guidewire10 (43)3 (27)16 (32)
Sphincterotome+contrast005 (10)
Cannulation catheter+contrast4 (17)07 (14)
Type of guidewire
Straight tip/0.035-inch diameter7 (30)1 (9)11 (22)
Angled tip/0.035-inch diameter8 (35)6 (55)22 (44)
Straight tip/0.025-inch diameter7 (30)4 (36)12 (24)
Angled tip/0.025-inch diameter1 (4)03 (6)
Others2 (4)
Opening of naïve ampulla
EST20 (87)10 (91)37 (74)
EPBD (or EPLBD)003 (6)
EST+EPBD (or EPLBD)3 (13)1 (9)10 (20)
Biliary drainage therapy
ERBD14 (61)10 (91)26 (52)
ENBD6 (26)012 (24)
ERBD+ENBD3 (13)1 (9)11 (22)
Device for small CBD stone
4-Wired basket11 (48)2 (18)26 (52)
8-Wired basket7 (30)5 (45)13 (26)
Retrieval balloon5 (22)4 (36)11 (22)

ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage; CBD, common bile duct..


DISCUSSION

This study is a national survey regarding ERCP operational environment and basic ERCP technique trends in Korea. The result was primarily collected from well-experienced ERCP doctors. Most Korean ERCP doctors in this survey perform over five cases requiring ERCP procedures per week, with an overall experience of more than 10 years. Therefore, the trend in the survey represents highly active endoscopists. Notably, the status of ERCP in Korea showed that it somewhat differed from that in other countries.

The staff required for the ERCP procedure typically include minimum of one physician, two assistants, and a radiology technician.9 It is recommended to have a fluoroscopy room for endoscopic procedure, specifically in medical centers that perform over 600 ERCP annually.10 The quality of Korean ERCP doctors showed to be in a well-controlled state. However, the lack of specialized ERCP nurses and appropriate systems for emergency ERCP are often noted. In other countries, 40% of endoscopists perform fewer than 50 sphincterotomies in Canada,11 and a large number of ERCPs tend to be performed in low volume centers in America and United Kingdom.12,13 According to the national data obtained from Health Insurance Review and Assessment Service, ERCP is mostly performed in university hospitals or tertiary care institutions.8 Our survey in Korea revealed that a large number of ERCPs were performed by small number of well-experienced ERCP doctors. We found that ERCP procedures in Korea had a tendency to be concentrated on doctors in university hospitals or tertiary referral centers.

There are some differences of ERCP preparation in Korea compared with other Western countries. Sedation is one of the important issues in therapeutic endoscopy and related with reducing the failure rate.14,15 Anesthesia-administered sedation can improve the success of advanced endoscopic procedures.16 In most Western countries, ERCP is usually performed with deep sedation or general endotracheal anesthesia. In Asian countries such as Korea, ERCP is often performed under sedation by an endoscopist. A previous survey in Korea suggested that ERCP procedures were usually performed under sedation rather than general anesthesia and the most preferred agent for sedation was propofol and/or midazolam.8 Agents such as propofol, midazolam or dexmedetomidine can be used to achieve moderate sedation for the procedure.17 Previously, propofol alone provided identical or superior sedation quality than combination with midazolam in regard of both the recovery time and patient tolerance.18-21 In this survey, half of ERCP doctors in Korea preferred to use a balanced propofol sedation technique for ERCP preparation.

Post-ERCP pancreatitis is the most common complication with incidence up to 15%.22 It is sometimes severe and potentially fatal, with a mortality rate of 0.1% to 0.5%. A number of agents or techniques have been investigated previously to prevent post-ERCP-pancreatitis. Previous meta-analyses suggested that the use of rectal nonsteroidal anti-inflammatory drug,23-25 aggressive hydration with lactated Ringer’s solution and prophylactic pancreatic stent placement are effective in reducing the incidence and severity of post-ERCP pancreatitis.26,27 Since rectal nonsteroidal anti-inflammatory drug is not commercially available in Korea, it cannot be used for ERCP premedication as prophylaxis. In the future, more research will be needed to develop the optimal prophylactic treatment for ERCP. Since prone position ERCP is favorable with a higher technical success rate and easy to visualize an abdominal image than lateral position,28 prone position is dominantly used for patient’s position during ERCP in Korea.

Among the ERCP techniques, there are important basic techniques such as selective cannulation, biliary sphincterotomy, and stone extraction. In practice, most ERCP doctors opt to cannulate the naïve papilla a sphincterotome rather than catheter.9 Generally, guidewire with a hydrophilic tip is used commonly and the use of an angled or J-tip guidewire is recommended as a standard technique.29 When performing ERCP, doctors often encounter some difficult cases such as repeated failure of selective cannulation or impacted large stones. In cases of a failed initial cannulation attempt, a salvage technique should be selected to approach the common bile duct. European Society of Gastrointestinal Endoscopy and Japan Gastroenterological Endoscopy Society recommend needle-knife fistulotomy as the salvage technique.30,31 For large common bile duct stones over 2 cm or impacted stones, fragmentation of the stones within the bile duct is frequently required before removal. In Korea, TrapezoidTM basket was dominantly preferred as lithotripsy device during ERCP. Most ERCP doctors choose endoscopic retrograde biliary drainage rather than endoscopic retrograde nasobiliary drainage for biliary drainage therapy. However, the advantage and effectiveness are still unclear. Thus, comparative study would be required to establish a standard biliary drainage therapy.

We found no significant differences for preferred devices or techniques between groups by doctor’s experiences. The doctor’s preference of basic techniques and accessories might be more closely related with the mentor’s taste than the individual taste in Korea. However, this national survey in Korea has some limitations. The accuracy of the answers depended on the participants’ memory, due to which recall bias could not be avoided. The lack of opinion from young doctors is another limitation of this study. The answers about ERCP environment might be inaccurate among individual doctors. National survey for all hospitals and medical centers could guarantee accurate results for ERCP environment. Furthermore, multinational survey or prospective registry will be required to subsequent study for current trend of ERCP. Some important factors about safety such as radiation exposure, medical outcomes and complication rates are missing from the content of survey.

In conclusion, data from this survey involving ERCP doctors in Korea showed a diversity of preferences in the basic techniques and ERCP environment. More studies are required to develop ERCP standards in Korea.

Supplemental Materials

ACKNOWLEDGEMENTS

We thank all respondents and members of the Korean Pancreatobiliary Association for their contribution to the study.

Footnote


See editorial on page 795.

CONFLICTS OF INTEREST


No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS


Analysis and interpretation of data: J.M.L., H.K.C., T.J.S., D.W.A., Y.S.L., D.W.L. Drafting of the manuscript, statistical analysis: J.M.L. Study design, administrative, technical and material support: C.H.P., K.B.C. Critical revision of the manuscript: C.H.P., K.B.C., E.S.L., Y.N.L., H.K.C. Acquisition of data, study supervision: S.H.M., S.W.P., W.H.P., C.N.P., B.K.S., T.J.J. All authors read and approved the final manuscript.

Fig 1.

Figure 1.Endoscopic retrograde cholangiopancreatography (ERCP) experience of Korean doctors and their current ERCP volume. (A) Age, (B) ERCP experience, (C) total number of ERCP, (D) current ERCP volume.
Gut and Liver 2021; 15: 904-911https://doi.org/10.5009/gnl20329

Fig 2.

Figure 2.Specialized nurse staff (A) and designated unit for endoscopic retrograde cholangiopancreatography (ERCP) (B).
Gut and Liver 2021; 15: 904-911https://doi.org/10.5009/gnl20329

Fig 3.

Figure 3.(A, B) Preferred method of procedural sedation for ERCP in Korea.
ERCP, endoscopic retrograde cholangiopancreatography; G/A, general anesthesia.
Gut and Liver 2021; 15: 904-911https://doi.org/10.5009/gnl20329

Fig 4.

Figure 4.Preferred basic technique for ERCP. (A) Basic procedure for opening of the naïve ampulla. (B) Basic procedure for bile drainage.
ERCP, endoscopic retrograde cholangiopancreatography; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; EST, endoscopic sphincterotomy; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage.
Gut and Liver 2021; 15: 904-911https://doi.org/10.5009/gnl20329

Table 1 Patient’s Position and Prophylactic Treatment for ERCP

VariableNo. (%)
No. of ERCP doctor84
Patient’s position for ERCP
Prone position77 (92)
Left lateral position4 (5)
Position change as prone after duodenal approach3 (3)
Use of restriction device
Yes43 (51)
No41 (49)
Use of opioid analgesics
Meperidine72 (86)
Fentanyl8 (9)
None4 (5)
Use of antiperistaltic agent
Yes67 (80)
No17 (20)
Use of prophylactic antibiotics
Yes50 (60)
No34 (40)

ERCP, endoscopic retrograde cholangiopancreatography.


Table 2 Preparation for ERCP and Management after Procedure

VariableValue
No. of ERCP doctor84
Routine diagnostic EUS before therapeutic ERCP
Yes13
No70
No answer1
Routine follow-up ERCP after successful ERCP
Yes3
No80
No answer1
Performing urgent ERCP*
Yes58
No24
No answer2
Prevention against post-ERCP pancreatitis
Intravenous hydration over 1 L fluid52
Intravenous protease inhibitor64
Oral protease inhibitor5
Pancreatic stenting53
Others2
Timing to permit a diet after ERCP
4–6 Hours14
6–12 Hours22
>12 Hours47
No answer1
First diet on the day after ERCP
Water only27
Liquid diet17
Soft diet12
Regular diet5
NPO on the day23

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; NPO, nil per os.

*ERCP as urgent treatment at night or over the weekend; Multiple choices are available.


Table 3 Current Status of Prepared Devices and Techniques Used in ERCP

VariableNo. (%)
No. of ERCP doctor84
Device for selective cannulation
Sphincterotome44 (52)
Cannulation catheter40 (48)
Initial check-up for bile duct cannulation
Guidewire68 (81)
Contrast16 (19)
Favorite cannulation technique
Sphincterotome+guidewire39 (46)
Cannulation catheter+guidewire29 (35)
Sphincterotome+contrast5 (6)
Cannulation catheter+contrast11 (13)
Type of guidewire
Straight tip with 0.035-inch diameter35 (42)
Angled tip with 0.035-inch diameter4 (5)
Straight tip with 0.025-inch diameter19 (23)
Angled tip with 0.025-inch diameter24 (28)
Others2 (2)
Product for mechanical lithotripsy in ERCP
BML lithotripsy basket (Olympus)14
FusionⓇ Lithotripsy basket (Cook Medical)2
TrapezoidTM (Boston Scientific)46
MTW Basket (MTW)20
Others2

ERCP, endoscopic retrograde cholangiopancreatography.


Table 4 Comparison of ERCP Procedure by Experience

Variable<5 Years5–10 Years>10 Years
No. of ERCP doctor231150
Preparation for ERCP, No. (%)
Patient’s position
Prone position22 (96)11 (100)44 (88)
Left lateral or changing position1 (4)06 (12)
Use of antiperistaltic agent
Yes20 (87)10 (91)37 (74)
No3 (13)1 (9)13 (26)
Use of prophylactic antibiotics
Yes13 (57)8 (73)29 (58)
No10 (43)3 (27)21 (42)
Preferred technique & device for ERCP, No. (%)
Cannulation technique
Sphincterotome+guidewire9 (39)8 (73)22 (44)
Cannulation catheter+guidewire10 (43)3 (27)16 (32)
Sphincterotome+contrast005 (10)
Cannulation catheter+contrast4 (17)07 (14)
Type of guidewire
Straight tip/0.035-inch diameter7 (30)1 (9)11 (22)
Angled tip/0.035-inch diameter8 (35)6 (55)22 (44)
Straight tip/0.025-inch diameter7 (30)4 (36)12 (24)
Angled tip/0.025-inch diameter1 (4)03 (6)
Others2 (4)
Opening of naïve ampulla
EST20 (87)10 (91)37 (74)
EPBD (or EPLBD)003 (6)
EST+EPBD (or EPLBD)3 (13)1 (9)10 (20)
Biliary drainage therapy
ERBD14 (61)10 (91)26 (52)
ENBD6 (26)012 (24)
ERBD+ENBD3 (13)1 (9)11 (22)
Device for small CBD stone
4-Wired basket11 (48)2 (18)26 (52)
8-Wired basket7 (30)5 (45)13 (26)
Retrieval balloon5 (22)4 (36)11 (22)

ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; EPBD, endoscopic papillary balloon dilatation; EPLBD, endoscopic papillary large balloon dilatation; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage; CBD, common bile duct.


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Gut and Liver

Vol.15 No.6
November, 2021

pISSN 1976-2283
eISSN 2005-1212

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