Advertisement

Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis

  • Mahendran Jayaraj
  • Babu P. Mohan
  • Banreet S. Dhindsa
  • Harmeet S. Mashiana
  • Gowri Radhakrishnan
  • Vinay Dhir
  • Arvind J. Trindade
  • Douglas G. Adler
Original Article
  • 101 Downloads

Abstract

Introduction

Periampullary diverticulum (PAD) is most often asymptomatically found in elderly population. ERCP in the presence of PAD is technically challenging since the location and orientation of the ampulla could be altered. Various studies have reported differing results on the technical success and safety outcomes of ERCP in the presence of PAD. We aimed at a meta-analysis of such studies to assess the technical success and the occurrence of complications during ERCP in patients with PAD.

Methods

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2017). The search was done in accordance with PRISMA guidelines to identify studies. Studies that reported on the ERCP outcomes based on the presence of PAD were included. Both prospective and retrospective studies, manuscripts and abstracts were included. Only articles in English literature were included. The primary analysis focused on the overall technical success of ERCP in the presence of PAD, and the secondary analysis was to estimate the risk of occurrence of complications.

Results

Our search resulted in 16 studies that were included for final analysis. These 16 studies reported on 2794 patients, who had PAD, and the control group included 13,032 patients, who did not have a PAD during ERCP. Our meta-analysis of this data showed an Odd’s ratio estimate of having a successful ERCP procedure in patients with PAD to be 0.51 [95% C.I. (0.35–0.72)] when compared to patients without it. This was statistically significant, with a p value 0.00. Considerable heterogeneity was noted among the studies. The heterogeneity proportion was quantified at 74.6% based on I2 statistic. The secondary outcomes measured were complications. We analyzed the pooled Post-ERCP Pancreatitis (PEP), cholangitis, perforation, and bleeding. Only those studies that had the data for these complications in both the study and the control groups were selected. PEP: The pooled Odd’s estimate of having PEP was 1.28, [95% C.I (0.88–1.87)] from 12 studies reporting on 1863 patients with PAD in comparison with 7803 patients without it. The risk of PEP occurrence tended to be more in the group without PAD, though it was not statistically significant, with a p value 0.20. There was some heterogeneity observed between the studies, with the quantification I2 statistic being 28.6%. Our analysis shows that having PAD does not put a patient at increased risk for PEP. Bleeding: The pooled Odds estimate was 1.69, 95% C.I. 0.88–3.25 from nine studies reporting on 1816 patients with PAD in comparison with 5327 patients without it. This was not statistically significant, p value 0.11. Considerable heterogeneity was noted, with I2 being 55.7%. The risk of having a bleed was noted to be more in control group, and having PAD did not put patients at increased risk for bleeding during an ERCP procedure. Perforation: Patients with PAD undergoing ERCP were not at increased risk for perforation. Seven studies reported on this complication. This was noted in seven patients out of 1245 in study group, and 19 patients out of 4912 in control group. The pooled Odd’s estimate was 1.24, 95% C.I. 0.54–2.87. There was no statistical significance, p value 0.61. No heterogeneity was noted among the studies included in this analysis. Cholangitis: Only four studies reported on this complication. In a total of 778 patients in study group, four had cholangitis and eight had this complication out of 3886 patients in the control group. The pooled Odd’s was 2.12, 95% C.I. 0.61–7.33. There was no statistical significance, p value 0.24. No heterogeneity was noted.

Conclusion

ERCP is technically feasible and increasingly successful when performed by experts in the presence of PAD. The risk of complications such as PEP, bleeding, perforation and cholangitis does not differ between ERCP done in patients with and without PAD.

Keywords

Periampullary diverticulum (PAD) ERCP Duodenal diverticula Ampulla 

Notes

Compliance with ethical standards

Conflict of Interest

The authors declare no conflict of interest.

References

  1. 1.
    Wu SD, Su Y, Fan Y, et al. Relationship between intraduodenal peri-ampullary diverticulum and biliary disease in 178 patients undergoing ERCP. Hepatobiliary Pancreat Dis Int.. 2007;6:299–302.PubMedGoogle Scholar
  2. 2.
    Ackermann W. Diverticula and variations of the duodenum. Ann Surg. 1943;117:403–413.CrossRefGoogle Scholar
  3. 3.
    Mizuguchi K, Matsumoto M. A histopathological study on the etiology of duodenal diverticulum related to the fusion of the pancreatic anlage. Am J Gastroenterol. 1983;78:335–338.PubMedGoogle Scholar
  4. 4.
    Rajnakova A, Goh PM, Ngoi SS, Lim SG. ERCP in patients with periampullary diverticulum. Hepatogastroenterology. 2003;50:625–628.PubMedGoogle Scholar
  5. 5.
    Tham T, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy. 2004;36:1050–1053.CrossRefGoogle Scholar
  6. 6.
    Yildirgan MI, Basoglu M, Yimaz I, et al. Periampullary diverticula causing pancreaticobiliary disease. Dig Dis Sci. 2004;49:1943–1945.CrossRefGoogle Scholar
  7. 7.
    Zoepf T, Zoepf DS; Arnold JC, Benz C, Riemann JF. The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc. 2001;54:56–61.CrossRefGoogle Scholar
  8. 8.
    Dennison AR, Watkins RM, Sarr MJ, Lee EC. Adenocarcinoma complicating a duodenal diverticulum. J R Coll Surg Edinb. 1987;32:44.PubMedGoogle Scholar
  9. 9.
    Oddo F, Chevallier P, Souci J, et al. Aspects radiologiques des complications des diverticules duodenaux. J Radiol. 1999;80:134–140.PubMedGoogle Scholar
  10. 10.
    Panteris V, Vezakis A, Filippou G, Fillipou D, Karamanolis D, Rizos S. Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate. Gastrointest Endosc. 2008;68:903–910.CrossRefGoogle Scholar
  11. 11.
    Tyagi P, Sharma P, Sharma BC, Puri AS. Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography. Surg Endosc. 2009;23:1342.CrossRefGoogle Scholar
  12. 12.
    Yoneyama F, Miyata K, Ohta H, Takeuchi E, Yamada T, Kobayashi Y. Excision of a juxtapapillary duodenal diverticulum causing biliary obstruction: report of three cases. J Hepato-Biliary-Pancreatic Sci. 2004;11:69–72.CrossRefGoogle Scholar
  13. 13.
    Lobo D, Balfour T, Iftikhar S. Periampullary diverticula: consequences of failed ERCP. Ann R Coll Surg Engl. 1998;80:326.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Mohammad Alizadeh AH, Afzali ES, Shahnazi A, Mousavi M, Mirsattari D, Zali MR. ERCP features and outcome in patients with periampullary duodenal diverticulum. ISRN gastroenterology, 2013.Google Scholar
  15. 15.
    Testoni PA, Mariani A, Aabakken L, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48:657–683.  https://doi.org/10.1055/s-0042-108641.CrossRefPubMedGoogle Scholar
  16. 16.
    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: The prisma statement. Ann Intern Med. 2009;151:264–269.CrossRefGoogle Scholar
  17. 17.
    Stang A. Critical evaluation of the Newcastle–Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25:603–605.CrossRefGoogle Scholar
  18. 18.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Controll Clin Trials. 1986;7:177–188.CrossRefGoogle Scholar
  19. 19.
    Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F. Methods for meta-analysis in medical research. 2000.Google Scholar
  20. 20.
    Kanwal F, White D. “Systematic Reviews and Meta-analyses” in clinical gastroenterology and hepatology. Clin Gastroenterol Hepatol. 2012;10:1184–1186.CrossRefGoogle Scholar
  21. 21.
    Higgins JPT, Thompson SG, Deeks, JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ: Br Med J. 2003;327:557.CrossRefGoogle Scholar
  22. 22.
    Thompson SG, Pocock SJ. Can meta-analyses be trusted? Lancet. 1991;338:1127–1130.CrossRefGoogle Scholar
  23. 23.
    Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 7. Rating the quality of evidenceinconsistency. J Clin Epidemiol. 2011;64:1294–1302.CrossRefGoogle Scholar
  24. 24.
    Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. Bmj. 2011;342:d549.CrossRefGoogle Scholar
  25. 25.
    Easterbrook PJ, Gopalan R, Berlin JA, Matthews DR. Publication bias in clinical research. Lancet. 1991;337:867–872.CrossRefGoogle Scholar
  26. 26.
    Boix J, Lorenzo-Zuniga V, Ananos F, Domenech E, Morillas RM, Gassuli MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutaneous Tech. 2006;16:208–211.CrossRefGoogle Scholar
  27. 27.
    Chang-Chien C-S. Do juxtapapillary diverticula of the duodenum interfere with cannulation at endoscopic retrograde cholangiopancreatography?: A prospective study. Gastrointest Endosc. 1987;33:298–300.CrossRefGoogle Scholar
  28. 28.
    Katsinelos P, Paroutoglou G, Kountouras J, Zavos C, Beltsis A, Tzovaras G. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointestinal endoscopy. 2006;63:417–423.CrossRefGoogle Scholar
  29. 29.
    Kim KH, Kim TN. Endoscopic papillary large balloon dilation in patients with periampullary diverticula. World J Gastroenterol: WJG. 2013;19:7168.CrossRefGoogle Scholar
  30. 30.
    Kirk A, Summerfield J. Incidence and significance of juxtapapillary diverticula at endoscopic retrograde cholangiopancreatography. Digestion. 1980;20:31–35.CrossRefGoogle Scholar
  31. 31.
    Leivonen M, Halttunen J, Kivilaakso E. Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients. Hepato-Gastroenterol. 1996;43:961–966.Google Scholar
  32. 32.
    Loffeld, R, Dekkers, P. The Impact of Duodenal Diverticuli and the Execution of Endoscopic Retrograde Cholangiopancreaticography. International scholarly research notices, 2016.Google Scholar
  33. 33.
    Parlak E, Suna N, Kuzu UB, et al. Diverticulum with papillae: does position of papilla affect technical success? Surg Laparosc Endosc Percutaneous Tech. 2015;25:395–398.CrossRefGoogle Scholar
  34. 34.
    Vaira D, Dowsett JF, Hatfield AR, et al. Is duodenal diverticulum a risk factor for sphincterotomy? Gut. 1989;30:939–942.CrossRefGoogle Scholar
  35. 35.
    Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–919.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Mahendran Jayaraj
    • 1
  • Babu P. Mohan
    • 2
  • Banreet S. Dhindsa
    • 3
  • Harmeet S. Mashiana
    • 3
  • Gowri Radhakrishnan
    • 4
  • Vinay Dhir
    • 5
  • Arvind J. Trindade
    • 6
  • Douglas G. Adler
    • 7
  1. 1.Division of GastroenterologyUniversity of Nevada Las Vegas (UNLV) School of MedicineLas VegasUSA
  2. 2.University of AlabamaTuscaloosaUSA
  3. 3.Department of Internal MedicineUniversity of Nevada Las Vegas (UNLV) School of MedicineLas VegasUSA
  4. 4.Sound PhysiciansLas VegasUSA
  5. 5.Department of Gastroenterology and EndoscopyS L Raheja Hospital- A Fortis AssociateMahim, MumbaiIndia
  6. 6.Long Island Jewish Medical CenterNorthwell Hofstra UniversityHempsteadUSA
  7. 7.Division of Gastroenterology and HepatologyUniversity of Utah School of Medicine, Huntsman Cancer CenterSalt Lake CityUSA

Personalised recommendations