Peter Cotton

• MD FRCS FRCP
• Professor at Medical University of South Carolina

Objective Sphincter of Oddi disorders (SOD) are contentious conditions in patients whose abdominal pain, idiopathic acute pancreatitis (iAP) might arise from pressurisation at the sphincter of Oddi. The present study aimed to measure the benefit of sphincterotomy for suspected SOD. Design Prospective cohort conducted at 14 US centres with 12 month...

Objective: Sphincter of Oddi Disorders (SOD) are contentious conditions in patients whose abdominal pain, idiopathic acute pancreatitis (iAP) might arise from pressurization at the sphincter of Oddi. The present study aimed to measure the benefit of sphincterotomy for suspected SOD. Design: Prospective cohort conducted at 14 U.S. centers with 12 mo...

The concept that sphincter of Oddi dysfunction (SOD) can cause attacks of biliary-type pain in postcholecystectomy patients and those with unexplained recurrent acute pancreatitis, and that endoscopic sphincterotomy can ameliorate symptoms, remains unproven. The Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) study...

Background and aims : Measuring adherence to ERCP quality indicators (QIs) is confounded by variability in indications, maneuvers, and documentation styles. We hypothesized that incorporation of mandatory, structured data fields within reporting software would permit accurate measurement of QI adherence rates and facilitate generation of a provider...

Background & Aims Extracorporeal shock wave lithotripsy (ESWL) for pancreaticolithiasis is most commonly performed by urologists. We investigated the effects of transitioning from urologist- to gastroenterologist-directed ESWL on case complexity, process measures, and duct clearance. Methods We performed a retrospective study of patients who under...

Background and Aims Accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool. Methods Based on review of procedural...

ERCP is the most complex common endoscopic (digestive) procedure. It has great potential for benefit, but it also carries significant risk of failure, adverse events, and medicolegal jeopardy. ERCP training is usually a part of the postgraduate training of selected gastroenterologists and a few surgeons. This chapter focuses mainly on the difficult...

This chapter describes adverse events and avoiding and managing them when they occur. Endoscopist's experience, preprocedural risk assessment, early detection, and appropriate management of the adverse events of ERCP are keys to minimize the risks. Several studies indicate that standard biliary sphincterotomy does not markedly increase the overall...

Endoscopic retrograde cholangiopancreatography (ERCP) has become enormously popular throughout the world because of its tremendous clinical value. The problem is that the benefits are maximized only when procedures are performed at an optimal level of quality, which is not always the case. The ERCP quality project confirmed the obvious fact that en...

Modern imaging methods (computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP], and endoscopic ultrasound [EUS]) have replaced diagnostic ERCP for investigation of suspected biliary and pancreatic pain. The only potential remaining indication for ERCP in patients with negative imaging studies is suspected sphincter of Oddi dys...

Endoscopic retrograde cholangiopancreatography (ERCP) can be beneficial but can also result in serious injury. Patient education is primarily the responsibility of the endoscopist offering ERCP. The education process should involve a face‐to‐face, sit‐down, fully clothed consultation with the endoscopist concerned and include a family member if pos...

Objective and study aims This study was designed to demonstrate the techniques used and the effectiveness of blinding in the EPISOD study (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction). This was a large sham-controlled trial evaluating the efficacy of endoscopic sphincterotomy treatment for patients with suspected sphinc...

The concept that motor disorders of the sphincter of Oddi (SOD) can cause biliary pain and pancreatitis is attractive, and popular, at least in the United States, leading to the widespread use of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. However, the results are not uniformly good, and there are substantial risks. T...

Objectives: Pancreatic endoscopic sphincterotomy (PES) is an independent risk factor for short- and long-term adverse events (AEs) of endoscopic retrograde cholangiopancreatography. We sought to measure PES-specific AEs and trends in the use of PES. Methods: This was a retrospective cohort of consecutive patients who underwent first-time PES bet...

Background and aims: ERCP has largely replaced common bile duct exploration for therapy of common bile duct pathology, yet its use as a purely diagnostic test has declined. Among inpatients, we hypothesized that timing between ERCP and cholecystectomy (CCY) have changed. The objectives were to measure temporal trends in the timing between inpatien...

Background: Cholecystectomy is a common operation, increasingly performed, in the USA, for "functional gall bladder disorder" (FGBD). Outcomes of these surgeries are uncertain. In planning a study of FGBD, we needed to define the best outcome measures. Methods: We sought the opinions of patients (52 with FGBD and 100 with stones for comparison)...

Background and aims: The EPISOD (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction) study randomized subjects with post-cholecystectomy pain, and little or no objective evidence for biliary obstruction, to sphincterotomy or sham intervention. Results at 1 year showed no benefit for the active treatment. We now report the out...

Background and aims: There are limited data measuring the variability in standards used by hospitals for credentialing physicians to ERCP in the United States. Methods: We performed an electronic survey of U.S. gastroenterologists. Results: Among 1,126 respondents, 21% and 59% reported that their hospitals had no written guidelines for initial...

Background: Prior studies have demonstrated that existing risk stratification guidelines for the evaluation of suspected choledocholithiasis lack accuracy, leading to the overutilization of endoscopic retrograde cholangiopancreatography (ERCP). The aim of our study was to evaluate the performance characteristics of published guidelines in predicti...

Objective To examine the tolerability and efficacy of duloxetine in patients with suspected sphincter of Oddi dysfunction (SOD). Methods An open-label, single-center, 12-week trial of duloxetine 60 mg once daily was conducted in 20 patients with suspected SOD. All patients were evaluated by expert pancreato-biliary specialists. The primary outcome...

The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose d...

. Pancreatic enzyme supplementation is widely used to treat pain in patients with chronic pancreatitis, despite little evidence for efficacy. We performed a systematic review of the literature and a meta-analysis to investigate its effectiveness. Methods . All randomized controlled parallel or crossover trials in patients with chronic pancreatitis...

Background/aims: The reproducibility of sphincter of oddi manometry (SOM) measurements and results of SOM after sphincterotomy have not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. Methods: The recently published EPISOD (Evaluating Predictors and Interventions i...

Background and study aim: Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a significant and potentially life-threatening adverse event and is common in patients with suspected sphincter of Oddi dysfunction (SOD). Here we aimed to identify predictors of the risk in this population. Patients and methods: The Evaluating...

Endoscopic Retrograde Cholangio Pancreatography (ERCP) is the most dangerous procedure performed regularly by gastroenterologists. While serious adverse events cannot all be avoided, there are many ways to reduce the risk of their resulting in a lawsuit. The most important is for the endoscopist to communicate carefully and fully with patients and...

The significant potential for failure and for severe complications means that patients must be advised carefully so that they can make an informed decision to give consent. This is primarily the responsibility of the involved endoscopist, but staff and written materials can assist. Except in emergencies, this education process should take place in...

The results of endoscopic retrograde cholangiopancreatography (ERCP) procedures are dependent on the expertise of the involved endoscopist, and the quality of the facility and assisting team. Metrics of these quality issues are now available and should be used to provide information on individuals (report cards) and how they compare with peers (ben...

Patients with biliary and/or pancreatic pain are best investigated based on laboratory studies and cross-sectional imaging, such as computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is valuable if these are unrevealing when clinical suspicion remains. The only indication for endoscopic retr...

Endoscopic retrograde cholangiopancreatography (ERCP) has become popular worldwide because it can provide significant benefit in many clinical contexts. Sadly, it has also caused considerable harm in a small number of patients. This chapter describes the range of adverse events, risk factors, and ways to reduce them, and provides guidance about man...

Endoscopic retrograde cholangiopancreatography (ERCP) procedures are complex and potentially hazardous. It is essential for clinical and technical aspects to be taught effectively, and for the outcomes to be assessed objectively. Whilst apprenticeship training remains dominant, there is room for more structured training, and for using more simulati...

Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as lo...

Importance Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy.Objective To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predi...

Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown. To assess which clinical factors are associated w...

Objectives: Patients with several painful functional gastrointestinal disorders (FGIDs) are reported to have a high prevalence of psychosocial disturbance. These aspects have not been studied extensively in patients with suspected Sphincter of Oddi dysfunction (SOD). Methods: A total of 214 patients with post-cholecystectomy pain and suspected S...

Translated into seven languages, Cotton and Williams' Practical Gastrointestinal Endoscopy has for the last 25 years been the basic primer for endoscopy around the world, providing clear, clinical and practical guidance on the fundamentals of endoscopy practice, from patient positioning and safety, how to perform different endoscopic procedures, an...

The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken...

Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy. The ERCP Qualit...

We aimed to establish benchmarks for fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) and assess the effect of physician practice networking on time trends. Data from the ERCP Quality Network were used to assess practice variability in FT and establish case- and provider-level benchmarks of the first 200 cases for prov...

Pancreatitis is a complex, progressively destructive inflammatory disorder. Alcohol was long thought to be the primary causative agent, but genetic contributions have been of interest since the discovery that rare PRSS1, CFTR and SPINK1 variants were associated with pancreatitis risk. We now report two associations at genome-wide significance ident...

There is increasing interest in the quality of endoscopic practice and in documenting it. Endoscopic retrograde cholangiopancreatography (ERCP) is the most complex and risky procedure performed regularly by gastroenterologists. The goal was to test the acceptability and functioning of a voluntary system for individual endoscopists to report details...

Endoscopic retrograde cholangiopancreatography (ERCP) has become enormously popular throughout the world because of its proven value in the management of patients with known and suspected biliary and pancreatic disease. The results of ERCP are operator dependent, and there are significant risks. Adverse events are more likely when procedures are pe...

Objective The Endoscopic retrograde cholangiopancreatography (ERCP) Quality Network is a voluntary system for submission of data to generate individual report cards and benchmarking. The aim of this study was to compare aspects of ERCP practice between USA and UK participants. Design Analysis was limited to USA and UK based endoscopists who had eac...

The growth in the use of endoscopy to diagnose and treat many gastointestinal disorders, and its central role in cancer screening programs, has led to a significant increase in the number of procedures performed. This growth, however, has also led to many variations in, among others, the provision of services, the choice of sedative medications and...

Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The conse...

The beneficial role of GI endoscopy for the prevention, diagnosis, and treatment of many digestive diseases and cancer is well established. Like many sophisticated medical devices, the endoscope is a complex, reusable instrument that requires reprocessing before being used on subsequent patients. The most commonly used methods for reprocessing endo...

Careful documentation of performance is a crucial part of assessing progress in endoscopy training, and is increasingly recognized as important also in practice. In turn, results in practice can drive improvements in training.

Endoscopy plays an important role in the diagnosis and treatment of digestive diseases. The benefits are maximized when procedures are performed at an optimal level of quality. Technical failures and adverse events are more likely to occur when procedures are performed by inexperienced endoscopists. Professional organizations and manufacturing indu...

IntroductionThere is increasing interest in documenting the performance of individual Endoscopists, for their own education and to ensure quality standards. What has been lacking hitherto is an infrastructure to facilitate collection and analyses of data to allow practitioners to easily compile a ‘report card’ of their own practice or benchmark the...

Introduction Working parties of the ASGE Quality Committee recently published a proposed new lexicon for adverse events (complications), and a separate extensive review of risk factors. The complexity of procedures also affects outcomes. A scale of complexity for ERCP was developed in 20001 and has been used in a modified form.2 Our goal was to upd...

Our goal was to identify or develop a relatively small data set that would be useful in predicting the risk of endoscopic procedures. This review shows that this is not an easy task because there are a wide range of factors and a variety of risks. Risk assessment may also be complex when more than 1 risk factor is present because the way in which d...

Working parties of the American Society for Gastrointestinal Endoscopy (ASGE) Quality Committee recently published a proposed new lexicon for adverse events and a separate extensive review of risk factors. The complexity of procedures also affects outcomes. To establish a system for grading the complexity of endoscopic procedures. Voting on levels...

Sphincter of Oddi dysfunction (SOD) is a controversial topic, especially in patients with no objective findings on laboratory or imaging studies (SOD type III). The value of ERCP manometry with sphincterotomy is unproven and carries significant risks. To describe the process of planning and initiating a randomized sham-controlled study to establish...

Idiopathic chronic pancreatitis (ICP) is a complex inflammatory disorder associated with multiple genetic and environmental factors. In individuals without cystic fibrosis (CF), variants of CFTR that inhibit bicarbonate conductance but maintain chloride conductance might selectively impair secretion of pancreatic juice, leading to trypsin activatio...