A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis

Impact of pancreatic stent caliber on post-endoscopic retrograde cholangiopancreatogram pancreatitis rates in patients with confirmed sphincter of Oddi dysfunction

BACKGROUND

Despite proven clinical benefit, there are no studies that have examined the relationship between pancreatic stent caliber and its impact on PEP [post-endoscopic retrograde cholangiopancreatogram (ERCP) pancreatitis] in high-risk patients.

AIM

To study the relationship between stent caliber and PEP rates in patients with confirmed sphincter of Oddi dysfunction (SOD).

METHODS

A retrospective review was conducted of ERCP's in patients with SOD from 2002 to 2012 from a prospectively maintained, Institutional Review Board approved database.

RESULTS

A total of 243/7659 (3.2%) patients underwent 3Fr or 5Fr pancreatic stent placement following sphincterotomy for manometry-proven SOD. Of these, 133 (54.7%) underwent 3Fr stent placement, while 110 (45.3%) underwent 5Fr stent placement. There was no significant difference between the two groups in terms of baseline characteristics, demographics, and previous cholecystectomy. Cannulation and stent placement success rates were 100% in both groups. There was no significant difference in rates of PEP and overall complications, 12% versus 12.7%; P = 0.89 and 13.5% versus 15.5%; P = 0.54, between the 3Fr and 5Fr cohorts, respectively. There were more mild PEP rates recorded in 5Fr group (93% vs 56% P = 0.0549) that was not statistically significant.

CONCLUSIONS

There appears to be no relationship between stent characteristics and the risk or severity of PEP in patients with manometrically proven SOD.

Management of pancreatic ductal leaks and fistulae

Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Manifestations of leaks include pseudocysts, pancreatic ascites, high amylase pleural effusions, disconnected duct syndrome, and internal and external pancreatic fistulas. Patient presentations are highly variable and range from asymptomatic pancreatic cysts to patients with severe abdominal pain and sepsis from infected fluid collections. The diagnosis can often be made by high-quality cross-sectional imaging or during endoscopic retrograde cholangiopancreatography (ERCP). Because of their complexity, pancreatic leak patients are best managed by a multidisciplinary team comprised of therapeutic endoscopists, interventional radiologists, and surgeons in the field of pancreatic interventions. Minor leaks will often resolve with conservative management while severe leaks will frequently require interventions. Endoscopic treatments for pancreatic duct leaks have replaced surgical interventions in many situations. Interventional radiologists also have the ability to offer therapeutic interventions for many leak patients. The mainstay of endotherapy for pancreatic leaks is transpapillary pancreatic duct stenting with a stent that bridges the leak if possible, but varies based on the manifestation and clinical presentation. Fluid collections that result from leaks, such as pseudocysts, can often be treated by endoscopic transluminal drainage with or without endoscopic ultrasound or by percutaneous drainage. Endoscopic interventions have been shown to be effective and have an acceptable complication rate.

Prevention of post-ERCP pancreatitis

Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pancreatography (ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for "ERCP" and "pancreatitis" and "post-ERCP pancreatitis". in PubMed and Medline. This review looks at the diagnosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and pharmacological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnecessary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction (SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stenting of patients with SOD and rectally administered nonsteroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP is associated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49 (0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.

Association of greater intravenous volume infusion with shorter hospitalization for patients with post-ERCP pancreatitis

BACKGROUND AND AIM

There are no data specifically correlating early intravenous volume infusion (IVI) with the length of hospitalization for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

We conducted a retrospective cohort study of patients admitted within 24 h after ERCP to our institute with PEP. IVI during the first 24 h after ERCP was assessed. Primary outcome was severity of PEP, defined by length of hospitalization according to consensus guidelines: mild ≤ 3, moderate 4-10, and severe > 10 days.

RESULTS

Of 72 eligible patients, 41 (56.9%) had mild and 31 (43.1%) moderate/severe PEP. Both groups had comparable demographics, indications, and procedural factors except patients with moderate/severe PEP were older (median age 49 vs 36 years, P = 0.05) and more likely to be discharged and readmitted within the first 24 h (41.9% vs 14.6%, P < 0.01). Patients with mild PEP received significantly greater IVI during the first 24 h (2834 mL [2046, 3570] vs 2044 mL [1227, 2875], P < 0.02) and 50% more fluid post-ERCP (2270 mL [1435, 2961] vs 1515 [950-2350], P < 0.02) compared with those with at least moderate PEP.

CONCLUSION

In patients with PEP, greater IVI during the first 24 h after ERCP is associated with reduced length of hospitalization. Lower IVI was more commonly observed in individuals who were discharged and then readmitted during the first 24 h.

A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis

OBJECTIVES

Acute pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Recent data suggest that indomethacin can reduce the risk of post-ERCP pancreatitis (PEP) in high-risk individuals. However, whether the combination of indomethacin and sublingual nitrates is superior to indomethacin alone is unknown. Therefore, we aimed to evaluate the efficacy of rectally administered indomethacin plus sublingual nitrate compared with indomethacin alone to prevent PEP.

METHODS

During a 17-month period, all eligible patients who underwent ERCP were enrolled in this study. We excluded patients who had undergone a prior endoscopic sphincterotomy. In a double-blind controlled randomized trial, patients received a suppository containing 100 mg of indomethacin, plus 5 mg of sublingual nitrate (group A), or a suppository containing 100 mg of indomethacin, plus sublingual placebo (group B), before ERCP. Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP.

RESULTS

Of the 300 enrolled patients, 150 received indomethacin plus nitrate. Thirty-three patients developed pancreatitis: 10 (6.7%) in group A and 23 (15.3%) in group B (P=0.016, risk ratio=0.39, 95% confidence intervals (CI): 0.18-0.86). More than 80% of the patients were at high risk of developing pancreatitis after ERCP. Absolute risk reduction, relative risk reduction, and number needed to treat for the prevention of PEP were 8.6% (95% CI: 4.7-14.5), 56.2% (95% CI: 50.6-60.8), and 12 (95% CI: 7-22), respectively.

CONCLUSIONS

Combination of rectal indomethacin and sublingual nitrate given before ERCP was significantly more likely to reduce the incidence of PEP than indomethacin suppository alone. Multicenter trials to confirm these promising findings are needed.

Pharmacologic prophylaxis alone is not adequate to prevent post-ERCP pancreatitis

Post-ERCP pancreatitis (PEP) remains the most common complication following ERCP. Although once considered unpredictable, understanding patient and procedure-related risk factors, and measures such as pancreatic stent placement and pharmacoprophylaxis have been shown to substantially decrease the risk of PEP. In this issue of the Journal, the role of pharmacoprophylaxis is explored in a study comparing rectal indomethacin plus sublingual nitrates vs. rectal indomethacin alone. While showing improved efficacy, dual pharmacoprophylaxis does not appear adequate to obviate the importance of technique-related variables and pancreatic stents. Rather, a comprehensive approach is likely to be the most efficacious strategy to reduce PEP.

Clinicopathologic characteristics associated with complications and long-term outcomes of endoscopic papillectomy for adenoma

PURPOSE

Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP.

MATERIALS AND METHODS

Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11).

RESULTS

The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months.

CONCLUSION

If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.

Do larger periprocedural fluid volumes reduce the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis?

OBJECTIVE

Fluid therapy is a cornerstone of the early treatment of acute pancreatitis (AP), but data are conflicting on whether it affects disease severity. Administering greater fluid volumes (FVs) during induction of experimental AP preserves pancreatic perfusion and reduces severity but does not prevent onset of AP. We hypothesized that administering larger FV during endoscopic retrograde cholangiopancreatography (ERCP) associates with less severe post-ERCP pancreatitis (PEP).

METHODS

In a retrospective cohort study, we identified 6505 patients who underwent 8264 ERCPs between January 1997 and March 2009; 211 of these patients developed PEP (48 mild, 141 moderate, and 22 severe). Data for FVs were available for 173 patients with PEP.

RESULTS

In univariable analysis, only 1 of 16 variables was significantly associated with moderate to severe PEP--larger periprocedural FV was protective (0.94 T 0.3 L vs 0.81 T 0.4 L; P = 0.0129). Similarly,multivariable analysis of moderate to severe PEP identified 1 independent predictor-- larger periprocedural FV was protective (odds ratio, 0.20; 95% confidence interval, 0.05-0.83). Conversely, moderate to severe disease correlated with larger FV administered after PEP diagnosis(reflecting treatment decisions).

CONCLUSIONS

This hypothesis-generating study suggests that administering larger periprocedural FVs is protective against moderate to severe PEP. Prospective studies on this topic are warranted.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy.

METHODS: MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency.

RESULTS: Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%.

CONCLUSION: Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

UK wide survey on the prevention of post-ERCP pancreatitis

OBJECTIVE

In 2010, the European Society of Gastrointestinal Endoscopy delivered guidelines on the prophylaxis of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP). These included Grade A recommendations advising the use of prophylactic pancreatic stent (PPS) and non-steroidal anti-inflammatory drugs (NSAIDs) in high-risk cases. Our study aim was to capture the current practice of UK biliary endoscopists in the prevention of PEP.

DESIGN

In summer 2012, an anonymous online 15-item survey was emailed to 373 UK consultant gastroenterologists, gastrointestinal surgeons and radiologists identified to perform ERCP.

RESULTS

The response rate was 59.5% (222/373). Of the respondents, 52.5% considered ever using PPS for the prevention of PEP. PPS users always attempted insertion for the following procedural risk factors: pancreatic sphincterotomy (48.9%), suspected sphincter of Oddi dysfunction (46.5%), pancreatic duct instrumentation (35.9%), previous PEP (25.2%), precut sphincterotomy (8.5%) and pancreatic duct injection (7.8%). Prophylactic NSAID use was significantly associated with attempts at PPS placement (p<0.001). 64.1% of non-PPS users cited a lack of conviction in their benefit as the main reason for their decision. Self-reported pharmacological use rates for PEP prevention were: NSAIDs (34.6%), antibiotics (20.6%), rapid intravenous fluids (13.2%) and octreotide (1.6%). 6% routinely measured amylase post-ERCP.

CONCLUSIONS

Despite strong evidence-based guidelines for prevention of PEP, less than 53% of ERCP practitioners use pancreatic stenting or NSAIDs. This suggests a need for the development of British Society of Gastroenterology guidelines to increase awareness in the UK. Even among stent users, PPS are being underused for most high-risk cases. Prophylactic pharmacological measures were rarely used as was routine post-ERCP serum amylase measurement.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis

OBJECTIVES

Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP).

METHODS

A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1.

RESULTS

Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34-0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32-0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24-0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients.

CONCLUSIONS

Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.

How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the target patients, the type of NSAID, the route of administration and the time of drug delivery remain unclear, as well as the potential efficacy in reducing the severity of pancreatitis, length of hospital stay and mortality. The objective of the study was to evaluate these questions by performing a systematic review and meta-analysis.

METHODS

Multiple searches were performed in the main databases. Randomized controlled trials (RCTs) comparing NSAIDs vs. placebo in the prevention of post-ERCP pancreatitis were included. Primary endpoint of the study was the efficacy for pancreatitis prevention. Sub-analyses were performed to determine the risk reduction in high and low risk patients, and to define optimal time, route of administration, and type of NSAID. Secondary endpoints were safety, moderate to severe pancreatitis prevention and reduction of hospital stay and mortality.

RESULTS

Nine RCTs enrolling 2133 patients were included. The risk of pancreatitis was lower in the NSAID group than in the placebo group (RR 0.51; 95%CI 0.39-0.66). The number needed to treat was 14. The risk of moderate to severe pancreatitis was also lower in the NSAID group. (RR 0.46; 95%CI 0.28-0.76). No adverse events related to NSAID use were reported. NSAIDs were effective in both high-risk and unselected patients (RR 0.53; 95%CI 0.30-0.93 and RR 0.57; 95%CI 0.37-0.88). In the subanalyses, only rectal administration of either indomethacin (RR 0.54; 95%CI 0.38-0.75) or diclofenac (RR 0.42; 95%CI 0.21-0.84) was shown to be effective. There were not enough data to perform a meta-analysis in hospital stay reduction. No deaths occurred.

CONCLUSION

A single rectal dose of indomethacin or diclofenac before or immediately after ERCP is safe and prevents procedure-related pancreatitis both in high risk and in unselected patients.

Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most frequent complication of ERCP. Several meta-analyses have examined the effects of protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) and non-steroidal anti-inflammatory drugs (NSAIDs) on post-ERCP pancreatitis, but the results have been confusing. Since the previous meta-analysis, several new studies have been published on this topic. To provide an updated quantitative assessment of the effectiveness of protease inhibitors and NSAIDs in preventing post-ERCP pancreatitis, we conducted a meta-analysis of randomized trials for patients at risk of post-ERCP pancreatitis. Twenty-six articles were included in this meta-analysis. Nafamostat mesilate (summary RR = 0.41; 95 %CI 0.28-0.59; n = 4 studies) and NSAIDs (summary RR = 0.58; 95 %CI = 0.44-0.76; n = 7 studies) were associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. However, gabexate mesilate (summary RR = 0.64; 95 %CI = 0.36-1.13; n = 6 studies) and ulinastatin (summary RR = 0.65; 95 %CI = 0.33-1.30; n = 2 studies) were not associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. This is the first meta-analysis to compare the effects of three protease inhibitors. Solid evidence supports the use of nafamostat mesilate and NSAIDs for preventing post-ERCP pancreatitis.

A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Clinical trials evaluating the protective effect of nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) have yielded inconclusive results. Our objective was to conduct a meta-analysis of the data to date to evaluate the efficacy and safety of rectal NSAIDs for PEP prophylaxis. We did a systematic search of PubMed/MEDLINE, Embase, and Web of Science databases and the Cochrane Central Register of Controlled Trials. The meta-analysis was performed using a fixed-effect method because of the absence of significant heterogeneity in the included trials. Seven randomized, controlled trials involving 2133 patients were included. The meta-analysis showed that rectal NSAIDs decreased the overall incidence of PEP (risk ratio, 0.44; 95% confidence interval, 0.34-0.57; P < 0.01). The number needed to treat was 11. The NSAID prophylaxis also decreased the incidence of moderate to severe PEP (risk ratio, 0.37; 95% confidence interval, 0.27-0.63; P < 0.01). The number needed to treat was 34. No differences of the adverse events attributable to NSAIDs were observed. In conclusion, prophylactic use of rectal NSAIDs reduces the incidence and severity of PEP. There is neither a difference in efficacy between rectal indomethacin and diclofenac nor a difference in efficacy between the timing of administration of rectal NSAIDs, that is, immediate pre-ERCP and post-ERCP.

Prevention of post-ERCP pancreatitis

Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pancreatography (ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for “ERCP” and “pancreatitis” and “post-ERCP pancreatitis”. in PubMed and Medline. This review looks at the diagnosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and pharmacological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnecessary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction (SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stenting of patients with SOD and rectally administered nonsteroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP is associated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49 (0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.

Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.

Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS

Pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). We performed a pilot study to determine whether aggressive periprocedural hydration with lactated Ringer's solution reduces the incidence of pancreatitis after ERCP.

METHODS

Patients who underwent first-time ERCP were randomly assigned to groups (2:1) that received aggressive hydration with lactated Ringer's solution (3 mL/kg/h during the procedure, a 20-mL/kg bolus after the procedure, and 3 mL/kg/h for 8 hours after the procedure, n = 39) or standard hydration with the same solution (1.5 mL/kg/h during and for 8 hours after procedure, n = 23). Serum levels of amylase, visual analogue pain scores (scale of 0-10), and volume overload were assessed at baseline and 2, 8, and 24 hours after ERCP. The primary end point, post-ERCP pancreatitis, was defined as hyperamylasemia (level of amylase >3 times the upper limit of normal) and increased epigastric pain (≥3 points on visual analogue scale) persisting for ≥24 hours after the procedure. Secondary end points included hyperamylasemia, increased pain, and volume overload.

RESULTS

None of the patients who received aggressive hydration developed post-ERCP pancreatitis, compared with 17% of patients who received standard hydration (P = .016). Hyperamylasemia developed in 23% of patients who received aggressive hydration vs 39% of those who received standard hydration (P = .116, nonsignificant); increased epigastric pain developed in 8% of patients who received aggressive hydration vs 22% of those who received standard hydration (P = .146, nonsignificant). No patients had evidence of volume overload.

CONCLUSIONS

On the basis of a pilot study, aggressive intravenous hydration with lactated Ringer's solution appears to reduce the development of post-ERCP pancreatitis and is not associated with volume overload. ClinicalTrials.gov, Number: NCT 01758549.

Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis

BACKGROUND AND AIM

Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP.

METHODS

We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP.

RESULTS

Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95 % confidence interval (CI) 0.29-0.53; P < 0.001]. Subgroup analysis stratified according to the severity of PEP showed that a PS was beneficial in patients with mild to moderate PEP (RR 0.45; 95 % CI 0.32-0.62; P < 0.001) and in patients with severe PEP (RR 0.26; 95 %CI 0.09-0.76; P = 0.01). In addition, subgroup analysis performed according to patient selection demonstrated that PS placement was effective for both high-risk and mixed case groups.

CONCLUSIONS

This meta-analysis showed that PS placement prevented PEP after ERCP as compared with no PS placement. We therefore recommend PS placement after ERCP for the prevention of PEP.

A primer on effectiveness and efficacy trials

Although efficacy and effectiveness studies are both important when evaluating interventions, they serve distinct purposes and have different study designs. Unfortunately, the distinction between these two types of trials is often poorly understood. In this primer, we highlight several differences between these two types of trials including study design, patient populations, intervention design, data analysis, and result reporting.

Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of the present study was to investigate patient- and procedure-related risk factors for post-ERCP complications in a large-scale study of procedures performed by a single experienced endoscopist.

METHODS

This is a retrospective cohort study which included a total of 2,715 therapeutic ERCPs enrolled in the final analysis. Potential important patient- and procedure-related risk factors for overall post-ERCP complications, pancreatitis and post-endoscopic sphincterotomy (ES) bleeding were investigated by univariate and multivariate analyses.

RESULTS

Following the first therapeutic ERCP, 327 patients suffered complications; pancreatitis was observed in 132 (4.9%) patients, hemorrhage in 122 (4.5%) patients, cholangitis in 63 (2.3%) patients, perforation in 3 (0.11%) patients, and basket impaction in 7 (0.26%) patients. History of acute pancreatitis was more common in patients with post-ERCP complications (P<0.001). Female gender, young age (<40 years), periampullary diverticulum, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct and suprapapillary fistulotomy were not found to be risk factors for overall post-ERCP complications and post-ERCP pancreatitis (PEP). Multivariate analysis showed a history of acute pancreatitis, difficult cannulation, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first and second class pancreatic ductules and acinarization as independent risk factors for overall complications and PEP, whereas antiplatelet and anticoagulation drug use were not found to be independent risk factors for post-ES bleeding.

CONCLUSIONS

The results of this study demonstrate that the endoscopist's experience reduces patient- and procedure-related risk factors for post-ERCP complications.

Rectal NSAIDs for the prevention of post-ERCP pancreatitis: a meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Acute pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). We conducted a meta-analysis to evaluate the efficacy and safety of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis (PEP).

METHODS

PubMed and Embase databases were searched through April 2013. Results are reported as relative risk (RR) or weighted mean difference (WMD) with 95% confidence interval (95% CI). The primary outcome measure was the incidence of PEP. Secondary outcome measures included the severity of PEP and serum amylase level 2 h, 24 h after ERCP.

RESULTS

Seven trials containing 1846 patients were eligible. Rectal NSAIDs significantly reduced the incidence of PEP (RR 0.45, 95% CI 0.34-0.61, P < 0.001). The results were maintained in subsequent subgroup analysis. Rectal NSAIDs also was associated with a reduction in the incidence of mild PEP (RR 0.54, 95% CI 0.35-0.83, P = 0.005), moderate to severe PEP (RR 0.39, 95% CI 0.22-0.70, P = 0.002), or serum amylase level 2 h after ERCP (WMD -91.09 IU/L, 95% CI -149.78 to -32.40, P = 0.002).

CONCLUSIONS

Rectal NSAIDs reduced the incidence and severity of PEP, as well as serum amylase level 2 h after ERCP.

Effects of new-type NSAIDs in preventing post-ERCP pancreatitis

AIM: To compare the effects of new-type versus traditional non-steroid antiinflammtory drugs (NSAIDs) in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS: One hundred and ninety-seven patients who underwent ERCP for choledocholithiasis between May 2012 and May 2013 were randomly divided into three groups: a lornoxicam group, a parecoxib group and a control group. Different drugs were applied for each group. Mean visual analogue score (VAS) and serum levels of amylase and C-reactive protein (CRP) were measured before ERCP and 4, 24 and 48 h after ERCP. Incidences of hyperamylasemia and PEP were observed.

RESULTS: The incidences of PEP in the lornoxicam group, parecoxib group and control group were 4.55%, 9.09% and 10.8%, respectively, and the difference was statistically significant between the parecoxib group and control group (P < 0.05), but not between the lornoxicam group and control group (P > 0.05). The incidences of post-ERCP hyperamylasemia in the parecoxib group and lornoxicam group were significantly lower than that in the control group (9.09%, 15.2% vs 21.5%, both P < 0.01). Serum CRP level at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01). Mean VAS at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01).

CONCLUSION: NSAIDs like lornoxicam and parecoxib can prevent the occurrence of hyperamylasemia induced by ERCP. Parecoxib could prevent the occurrence of PEP. Both drugs can alleviate pain and inflammatory reactions after the endoscopic procedure. As a new type of NSAIDs, selective cyclooxygenase-2 (COX-2) inhibitors might be more useful in preventing PEP.

Results of the Tokyo trial of prevention of post-ERCP pancreatitis with risperidone-2: a multicenter, randomized, placebo-controlled, double-blind clinical trial

BACKGROUND

Our previous study suggested that a combination of ulinastatin and risperidone reduced post-ERCP pancreatitis (PEP) compared with ulinastatin alone.

OBJECTIVE

The aim of this study was to evaluate the efficacy of risperidone alone for prevention of PEP.

DESIGN

A multicenter, randomized, placebo-controlled, double-blind clinical trial.

SETTING

Two academic hospitals and 5 referral hospitals in Tokyo and Saitama, Japan.

PATIENTS

Patients undergoing therapeutic or interventional-diagnostic ERCP.

INTERVENTION

The patients were randomized to receive 2 mg of oral risperidone or oral placebo at 0.5 to 2 hours before ERCP.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was the incidence of PEP. Secondary endpoints were the incidence of hyperenzymemia and enzyme levels (amylase, pancreatic amylase, lipase). Risk factors for PEP were evaluated.

RESULTS

We initially enrolled 500 patients in the study (250 in the risperidone group and 250 in the placebo group), but 17 (11 in the risperidone and 6 in the placebo group) were excluded after randomization. PEP developed in 24 patients (10.0%) in the risperidone group and 21 patients (8.6%) in the placebo group (P = .587). Serum amylase levels at 3 hours after ERCP were lower in the risperidone group (P = .007 in a single test of hypothesis, significance removed by Bonferroni correction for multiple testing). In multivariate analysis, a small papilla of Vater, total procedure time ≥40 minutes, and stenosis of the intrahepatic duct were significantly associated with PEP.

LIMITATIONS

Multiplicity of study centers and a relatively wide time range of drug administration time.

CONCLUSION

Risperidone did not show a benefit in prevention of PEP in this trial. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT000004592.).

Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis

BACKGROUND

The efficacy of many pharmacological agents for preventing post-ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta-analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs.

AIM

To evaluate pharmacological agents for the prevention of PEP by conducting a network meta-analysis of RCTs.

METHODS

We searched MEDLINE, EMBASE and Cochrane Library databases for RCTs that evaluated the efficacy of agents for preventing PEP. RCTs were simultaneously analysed using random-effects network meta-analysis under the Bayesian framework to identify the best agents. The efficacy of agents was ordered according to the probability of being ranked as any of the top three best performing agents.

RESULTS

The network meta-analysis included 99 RCTs evaluating 16 agents in 25 313 patients. Topical epinephrine (adrenaline) was the most efficacious agent with 85.9% probability of ranking among the top three agents, followed by nafamostat (51.4%), antibiotics (44.5%) and NSAIDs (42.8%). However, in a sensitivity analysis including only rectal NSAIDs, NSAIDs moved from fourth rank to second (58.1%). Patients receiving topical epinephrine, compared with placebo, had a 75% reduced risk of PEP (OR 0.25, 95% probability interval 0.06-0.66).

CONCLUSIONS

Topical epinephrine and rectal NSAIDs are the most efficacious agents for preventing post-ERCP pancreatitis, based on existing RCTs. Combinations of these agents, which act on different steps in the pathogenesis of post-ERCP pancreatitis, should be evaluated in future trials.

Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: a retrospective analysis

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for diagnosis and therapeutic interventions in recipients of liver transplantation (LT) who develop biliary complications. Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PEP) is the most common major adverse event after ERCP; however, the frequency of PEP in LT recipients is not well established. We aimed to determine the rate of PEP in this population and to identify its predictors, especially among immunosuppressive agents. We reviewed all ERCP procedures performed in LT recipients after duct-to-duct biliary anastomoses at 2 high-volume transplant centers. Patients who had undergone sphincterotomy or had a surgically altered pancreaticobiliary anatomy before LT were excluded. Electronic medical records and endoscopy databases were used to obtain clinical, endoscopic, and medication data. A multivariate logistic regression analysis was used to determine predictors of PEP in this cohort. In all, 730 ERCP procedures were performed in 301 patients during the study period with an observed PEP rate of 3% (22/730). A univariate analysis revealed an increased risk of PEP with index ERCP after LT [odds ratio (OR) = 4.04, 95% confidence interval (CI) = 1.40-11.65] and in cases with difficult biliary cannulation (OR = 2.89, 95% CI = 1.10-7.65), whereas prednisone use was found to have a protective effect in both univariate (OR = 0.34, 95% CI = 0.14-0.84) and multivariate analyses (OR = 0.22, 95% CI = 0.09-0.57) after adjustments for difficult biliary cannulation and post-LT index ERCP. This retrospective analysis demonstrates that corticosteroid therapy has a protective role in the development of PEP in LT recipients. Further studies are warranted to confirm our findings.

Detection of painless pancreatitis by computed tomography in patients with post-endoscopic retrograde cholangiopancreatography hyperamylasemia

OBJECTIVES

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is diagnosed on the basis of pancreatic pain and hyperamylasemia. However, because the diagnosis of abdominal pain is not objective, there may be some cases of painless pancreatitis among patients with post-ERCP hyperamylasemia (PEH). We reviewed the computed tomography (CT) findings of PEH cases to determine the incidence of painless pancreatitis.

METHODS

Between July, 2005 and December, 2011, CT was performed in 91 patients with hyperamylasemia 18 h after ERCP. We reviewed the CT findings and graded the severity of pancreatitis according to the Balthazar grading system. Grades C, D, and E were defined as pancreatitis.

RESULTS

Thirty-four patients (37%) had pancreatitis according to the CT findings. There was a significant difference in the serum amylase levels between the positive- and negative-CT finding groups (1306 ± 833 vs. 786 ± 315 IU/L, respectively; p = 0.0012). Receiver operating characteristic curve analysis showed that the amylase cut-off value for discriminating between the 2 groups was 795 IU/L (6.36 times the upper normal limit).

CONCLUSIONS

Thirty-seven percent of PEH patients had painless pancreatitis. CT is useful to determine pancreatitis in patients taking analgesics, steroids, or anti-immunological drugs and those with diabetes mellitus and 18-h serum amylase levels of >6 times the normal upper limit.

Prevention of post-ERCP pancreatitis

Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.

Meta-analysis: rectal indomethacin for the prevention of post-ERCP pancreatitis

BACKGROUND

Despite initial evidence in the literature, nonsteroidal anti-inflammatory drugs (NSAIDs) have not been widely used to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

AIM

To complete a meta-analysis of high-quality RCTs that included the latest available literature published after past meta-analytical efforts

METHODS

A comprehensive electronic literature search was carried out for RCTs comparing peri-procedural rectal indomethacin and placebo in preventing PEP. Methodological quality was assessed by the Cochrane risk of bias tool. Fixed model Mantel-Haenszel meta-analysis, Q test and I(2) index were used. Several subgroup and sensitivity analyses were planned.

RESULTS

A total of four of 61 retrieved trials between 2007 and 2012 (n = 1470) were included. No significant publication bias existed. All studies used similar criteria to detect pancreatitis. The pooled proportion estimate of the rate of pancreatitis was 5.1% with indomethacin and 10.3% with placebo. After excluding the high-risk patients, the rates were 3.9% and 7.9% respectively. Fixed model meta-analysis showed that the rate of pancreatitis was significantly lower using indomethacin as compared with placebo [OR = 0.49(0.34-0.71); P = 0.0002]. Number needed to treat was 20. There was no significant statistical or clinical heterogeneity. In subgroup analysis, the difference remained unchanged for average-risk population [OR = 0.49(0.28-0.85); P = 0.01] or in preventing severe PEP [OR = 0.41(0.21-0.78); P = 0.007]. The result of the main outcome remained robust in multiple sensitivity analyses.

CONCLUSIONS

Rectal indomethacin used immediately before or after ERCP significantly reduces the risk of PEP to half in both low- and high-risk patients, and with both statistically and clinically significant conclusions. These results suggest that a possible change in routine practice for patients at both low and high risk of developing PEP should be advocated.

Preventing pancreatitis after endoscopic retrograde cholangiopancreatography

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.

American College of Gastroenterology guideline: management of acute pancreatitis

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

Intraductal delivery of adenoviruses targets pancreatic tumors in transgenic Ela-myc mice and orthotopic xenografts

Gene-based anticancer therapies delivered by adenoviruses are limited by the poor viral distribution into the tumor. In the current work we have explored the feasibility of targeting pancreatic tumors through a loco-regional route. We have taken advantage of the ductal network in the pancreas to retrogradelly inject adenoviruses through the common bile duct in two different mouse models of pancreatic carcinogenesis: The transgenic Ela-myc mice that develop mixed neoplasms displaying both acinar-like and duct-like neoplastic cells affecting the whole pancreas; and mice bearing PANC-1 and BxPC-3 orthotopic xenografts that constitute a model of localized human neoplastic tumors. We studied tumor targeting and the anticancer effects of newly thymidine kinase-engineered adenoviruses both in vitro and in vivo, and conducted comparative studies between intraductal or intravenous administration. Our data indicate that the intraductal delivery of adenovirus efficiently targets pancreatic tumors in the two mouse models. The in vivo application of AduPARTKT plus ganciclovir (GCV) treatment induced tumor regression in Ela-myc mice. Moreover, the intraductal injection of ICOVIR15-TKT oncolytic adenoviruses significantly improved mean survival of mice bearing PANC-1 and BxPC-3 pancreatic xenografts from 30 to 52 days and from 20 to 68 days respectively (p less than 0.0001) when combined with GCV. Of notice, both AduPARTKT and ICOVIR15-TKT antitumoral responses were stronger by ductal viral application than intravenously, in line with the 38-fold increase in pancreas transduction observed upon ductal administration. In summary our data show that cytotoxic adenoviruses retrogradelly injected to the pancreas can be a feasible approach to treat localized pancreatic tumors.

The results of the Tokyo trial of prevention of post-ERCP pancreatitis with risperidone (Tokyo P3R): a multicenter, randomized, phase II, non-placebo-controlled trial

BACKGROUND

A previous study suggested that ulinastatin effectively prevented post-ERCP pancreatitis (PEP) and hyperenzymemia (PEH) in patients at average risk. In experimental models, risperidone, a selective serotonin 2A antagonist, ameliorated acute pancreatitis. We assessed the effect of risperidone combined with ulinastatin for the prevention of PEP in high-risk patients.

METHODS

In a multicenter, randomized, controlled, phase II trial, patients undergoing therapeutic ERCP were randomly assigned to receive ulinastatin (150000 U) with or without risperidone (1 mg). A risperidone tablet was taken orally 30-60 min before ERCP and ulinastatin was administered intravenously for 10 min immediately prior to ERCP. The primary end point was the incidence of PEP; secondary end points were PEH severity and enzyme levels (amylase, pancreatic amylase, lipase).

RESULTS

A total of 226 patients (113 per group) were included in the study. Six patients in the risperidone + ulinastatin group and ten patients in the ulinastatin group developed pancreatitis (5.3 vs. 8.8 %, p = 0.438). The incidence of moderate/severe PEP was lower in the risperidone + ulinastatin group (1.8 %) than in the ulinastatin group (4.4 %), but this difference was not significant. Although the incidence of PEH did not differ significantly, post-ERCP levels of all pancreatic enzymes were significantly lower in the risperidone + ulinastatin group.

CONCLUSIONS

Prophylactic oral risperidone administration in combination with ulinastatin did not reduce the incidence and severity of PEP in high-risk patients as compared with ulinastatin alone. However, risperidone showed an additive effect with ulinastatin, reducing serum pancreatic enzyme levels.

Improving ERCP quality and decreasing risk to patients and providers

Endoscopic retrograde cholangiopancreatography (ERCP) continues to be one of the most complex gastrointestinal procedures and carries the highest risk of complications. Optimizing the outcome of ERCP requires a fine balance between the risk and the benefit of every maneuver performed. This fine balance has to include an analysis of the indication for the procedure, the optimal timing, the setting where the procedure is performed, the endoscopist and staff training and expertise, availability of surgical and interventional radiology support, the risk of every maneuver and ways to minimize this risk. As in any other procedure, it is very important to know one's limitations and have a plan for failed procedures including consulting a colleague or referring the patient to a center with more expertise. In addition, a process of quality improvement is integral to every endoscopy center to address areas of underperformance, improve patient care and decrease liability.

Risk models for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP): smoking and chronic liver disease are predictors of protection against PEP

OBJECTIVES

We investigated which variables independently associated with protection against or development of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and severity of PEP. Subsequently, we derived predictive risk models for PEP.

METHODS

In a case-control design, 6505 patients had 8264 ERCPs, 211 patients had PEP, and 22 patients had severe PEP. We randomly selected 348 non-PEP controls. We examined 7 established- and 9 investigational variables.

RESULTS

In univariate analysis, 7 variables predicted PEP: younger age, female sex, suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate-difficult cannulation (MDC), pancreatic stent placement, and lower Charlson score. Protective variables were current smoking, former drinking, diabetes, and chronic liver disease (CLD, biliary/transplant complications). Multivariate analysis identified seven independent variables for PEP, three protective (current smoking, CLD-biliary, CLD-transplant/hepatectomy complications) and 4 predictive (younger age, suspected SOD, pancreatic sphincterotomy, MDC). Pre- and post-ERCP risk models of 7 variables have a C-statistic of 0.74. Removing age (seventh variable) did not significantly affect the predictive value (C-statistic of 0.73) and reduced model complexity. Severity of PEP did not associate with any variables by multivariate analysis.

CONCLUSIONS

By using the newly identified protective variables with 3 predictive variables, we derived 2 risk models with a higher predictive value for PEP compared to prior studies.

Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure used to treat problems associated with biliary and pancreatic diseases. The benefits of ERCP over surgical treatment are well documented; however, complications including infection, pancreatitis, hemorrhage, and perforation can occur even in expert hands. Several factors, such as patient selection, skill of the operator, and the complexity of the procedure, can add to the intrinsic risks of ERCP This review outlines the current knowledge regarding ERCP complications and solutions for improved outcomes.

Early measures of hemoconcentration and inflammation are predictive of prolonged hospitalization from post- endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

Hemoconcentration markers are predictors of severe acute pancreatitis but have not been specifically evaluated in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS

Case-control study of patients undergoing ERCP for suspected sphincter of Oddi dysfunction. We identified patients with PEP (PEP positive) and controls (PEP negative) in a 1:2 ratio. blood urea nitrogen (BUN) and hematocrit (Hct) were measured before procedure, upon admission, and 24 hours later. Preprocedure levels of BUN and Hct were analyzed to control for confounders. Among the PEP-positive patients, BUN level, Hct level, and systemic inflammatory response syndrome are compared between severe and mild/moderate cases.

RESULTS

There were 149 PEP-positive patients, including 18 patients (12.1%) with severe PEP and 301 PEP-negative controls. After adjusting, higher preprocedure BUN level (odds ratio [OR], 1.05 [1.01, 1.10]; P < 0.02) and pancreatic sphincterotomy (OR, 1.60 [1.01, 2.55]; P < 0.05) were associated with PEP, whereas older age (OR, 0.98 [0.96, 0.99]; P < 0.02) and a greater body mass index (OR, 0.97 [0.94, 0.99]; P < 0.03) with a lower rate.Difference in BUN level of 0.0 or greater (failure to decline) had a sensitivity of 71% and a specificity of 79% for differentiating severe from mild/moderate PEP. Patients with severe PEP were more likely to have systemic inflammatory response syndrome upon admission (44.4% [21.5, 67.4]) and after 24 hours (61.1% [38.6, 83.6] versus mild/moderate (9.2% [4.2, 14.1], 10.6% [5.4,16.0]; P < 0.0001 for each).

CONCLUSIONS

Preprocedure BUN level is associated with the development of PEP. The preprocedure BUN level and failure of the BUN level to decline during the first 24 hours are associated with prolonged hospitalization.

Rectal nonsteroidal anti-inflammatory drugs are superior to pancreatic duct stents in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a network meta-analysis

BACKGROUND & AIMS

Placement of pancreatic duct (PD) stents prevents pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). There is evidence that rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) also prevents post-ERCP pancreatitis, but the 2 approaches alone have not been compared directly. We conducted a network meta-analysis to indirectly compare the efficacies of these procedures.

METHODS

PubMed and Embase were searched by 2 independent reviewers to identify full-length clinical studies, published in English, investigating use of PD stent placement and rectal NSAIDs to prevent post-ERCP pancreatitis. We identified 29 studies (22 of PD stents and 7 of NSAIDs). We used network meta-analysis to compare rates of post-ERCP pancreatitis among patients who received only rectal NSAIDs, only PD stents, or both.

RESULTS

Placement of PD stents and rectal administration of NSAIDs were each superior to placebo in preventing post-ERCP pancreatitis. The combination of rectal NSAIDs and stents was not superior to either approach alone. Pooled results showed that rectal NSAIDs alone were superior to PD stents alone in preventing post-ERCP pancreatitis (odds ratio, 0.48; 95% confidence interval, 0.26-0.87).

CONCLUSIONS

Based on a network meta-analysis, rectal NSAIDs alone are superior to PD stents alone in preventing post-ERCP pancreatitis, and should be considered first-line therapy for selected patients. However, these findings were limited by the small number of studies assessed (only 29 studies), potential publication bias, and the indirect nature of the comparison. High-quality, randomized, controlled trials are needed to compare these 2 interventions and confirm these findings.

Clinical management of patients with acute pancreatitis

Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.

Indomethacin for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

AIM: To assess the effectiveness and safety of indomethacin in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS: Electronic searches were conducted to retrieve randomized controlled trials (RCTs) comparing indomethacin to placebo in the prevention of PEP from the PubMed, Embase, CBM, CNKI, WANFANG and VIP databases. Data collection and literature evaluation were performed by two reviewers independently. Review Manager 5.0 was used for statistical analysis.

RESULTS: A total of 11 RCTs involving 2718 patients were included. The meta-analysis showed that indomethacin could reduce the incidence of PEP (OR = 0.39, 95%CI: 0.30-0.52, P < 0.00001) and hyperamylasemia (OR = 0.50, 95%CI: 0.37-0.67, P < 0.00001).

CONCLUSION: Indomethacin is safe and effective in reducing the incidence of PEP and hyperamylasemia.

Wire-guided biliary cannulation technique does not reduce the risk of post-ERCP pancreatitis: multicenter randomized controlled trial

AIM

To evaluate the effect of wire-guided biliary cannulation (WGC) on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

We investigated the impact of the WGC technique on the incidence of PEP by comparing the conventional cannulation (CC) technique in selective bile duct cannulation during ERCP with a cross-over design in a prospective multicenter randomized controlled trial and the potential risk factors for PEP. This involved six tertiary referral centers and three university hospitals. A total of 322 patients with indications for ERCP requiring selective biliary cannulation were enrolled from April 2008 to March 2009.

RESULTS

One hundred and sixty-three patients were assigned to the WGC group and 159 to the CC group. The incidence of PEP was the same between the groups (6.1% vs 6.3%, P = 0.95). Primary successful biliary cannulation was achieved in 136 patients (83%) in the WGC group and in 138 (87%) in the CC group (P = 0.40). The mean time required for primary successful biliary cannulation was 7.4 ± 8.3 min and 7.2 ± 7.9 min, respectively (P = 0.83). Multivariate analysis demonstrated that accidental guidewire insertions and unintended injections of contrast into the main pancreatic duct were the only independent risk factors for PEP (P = 0.001, relative risk [RR]: 8.70, 95% confidence interval [CI]: 2.46-30.81).

CONCLUSION

The WGC technique does not reduce the risk of PEP and also does not improve the success rate of selective bile duct cannulation.

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.