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Gastroenterology Expert Witness

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Gastroenterology is a medical branch that focuses on the digestive system and the disorders associated with it. Gastroenterologists study diseases spanning all of the organs of the gastrointestinal tract and alimentary canal. General practioners in this field do not typically perform surgery (gastroenterology surgery is a more specialized field).

 

One of AME's gastroenterology expert witnesses has written an exclusive medical malpractice article that we have provided, for your interest, below.

Pancreatitis associated with ERCP, medical malpractice case

 

Endoscopic retrograde cholangiopancreatography (ERCP) remains the most common cause of iatrogenic pancreatitis [1]. Studies have shown post-ERCP complications were responsible for greater than 65 percent of malpractice claims [2, 3].

A recent autopsy study showed that more than half the deaths associated with ERCP were due to iatrogenic pancreatitis [4]. Historically the rates of pancreatitis associated with ERCP have ranged from 1.6-15.1 percent. Most cases of pancreatitis are mild however approximately 1 percent of cases may result in severe complications including death. There are many risk factors which have been identified which are predictive of an individual having an increased likelihood of developing post ERCP pancreatitis. The most common patient risk factors associated with an increased risk of pancreatitis after ERCP include female gender, younger age, sphincter of Oddi dysfunction and recurrent unexplained pancreatitis [5]. Procedure related factors include performance of Sphincter of Oddi manometry, performance of a sphincterotomy, difficult cannulation and balloon sphincteroplasty [5].

The presence of one or more of these factors significantly increases the likelihood that an individual will develop pancreatitis and should prompt appropriate caution in the operator.

In an attempt to reduce the incidence of pancreatitis after ERCP the National Institutes of Health held a consensus in 2002 [6]. The recommendation of the NIH panel was that there was no longer a need for diagnostic ERCP except in few special circumstances. As a result of these recommendations diagnostic ERCP has been replaced by the performance of MRCP. . At our institution the need for performance of diagnostic pancreatography via ERCP has been replaced by MRCP with secretin. Secretin MRCP provides a method for evaluating the pancreatic ductal anatomy which is not dependent on the skill of an ERCP operator. This advantage makes it the procedure of choice for evaluating the pancreatic ductal anatomy in subjects with complex biliary anatomy such as Bilroth II anastomoses. Sphincter of Oddi manometry remains one of the only procedures in which diagnostic ERCP is recommended. Sphincter of Oddi manometry has the highest risk of causing pancreatitis of any procedure performed during ERCP. The indications for performing this intervention must be clearly defined and explicit because most individuals will have approximately a 1 in 5 chance of developing pancreatitis after this procedure. It is extremely important to characterize the type of sphincter of Oddi dysfunction being investigated because only type I and some type II SOD patients should undergo diagnostic ERCP.

In summary, the risk of pancreatitis after ERCP is a common but highly preventable complication of the procedure. Factors which may reduce the risk include the experience of the operators and careful screening of patients prior to the procedure. High risk patients should also be evaluated by an experienced clinical pancreatologist who can assist in pre-procedural risk stratification.

1. Cotton P et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointestinal Endoscopy 1991; 37:383.

2. Rabenstein T et al. 25 years of endoscopic sphincterotomy complications in Erlangen: assessment of the experience in 3,498 patients. Endoscopy 1998;30:A194.

3. Trap R et al. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals. Endoscopy 1999; 31:125.

4. Cotton, PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointestinal Endoscopy 2006; 63:378.

5. Freeman, ML et al. Risk factors associated for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointestinal Endoscopy 2001; 54: 425.

6. http://consensus.nih.gov/2002/2002ERCPsos020html.htm

Author bio:

This Gastroenterology Expert is co-director of the Pancreas Center in Boston, a Harvard teaching hospital. He is an Assistant Professor of Medicine at Harvard Medical School and also sees patients at a local community hospital in MA. He is a national and international expert in the fields of acute and chronic pancreatitis. His duties include evaluation and management of complex pancreatitis, pancreatic cystic disease and pancreatic cancer. He has won numerous awards including the American College of Gastroenterology Governors for excellence in clinic research. He is available for expert clinical case review, expert witness reports and consultation starting at our greatly reduced rates found on our Web site.

 

 

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