Comparison between ulinastatin and gabexate mesylate for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized trial

Ulinastatin in the treatment of severe acute pancreatitis: A single-center randomized controlled trial

BACKGROUND

Severe acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract and carries a significant financial burden with high disability and mortality. There are no effective drugs in the clinical management of severe AP, and there is an absence of evidence-based medicine concerning the treatment of severe AP.

AIM

To explore whether ulinastatin (UTI) can improve the outcome of severe AP.

METHODS

The present research included patients who were hospitalized in intensive critical care units (ICUs) after being diagnosed with severe AP. Patients received UTI (400000 IU) or placebos utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures were 7-d mortality, clinical efficacy, inflammatory response, coagulation function, infection, liver function, renal function, and drug-related adverse effects were evaluated.

RESULTS

A total of 181 individuals were classified into two groups, namely, the placebo group (n = 90) and the UTI group (n = 91). There were no statistically significant differences in baseline clinical data between the two groups. The 7-d mortality and clinical efficacy in the UTI group were remarkably improved compared with those in the placebo group. UTI can protect against hyperinflammation and improve coagulation dysfunction, infection, liver function, and renal function. UTI patients had markedly decreased hospital stays and hospitalization expenditures compared with the placebo group.

CONCLUSION

The findings from the present research indicated that UTI can improve the clinical outcomes of patients with severe AP and has fewer adverse reactions.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

The Global Status and Trends of Enteropeptidase: A Bibliometric Study

Background

Enteropeptidase (EP) is a type II transmembrane serine protease and a physiological activator of trypsinogen. Extensive studies related to EP have been conducted to date. However, no bibliometric analysis has systematically investigated this theme. Our study aimed to visualize the current landscape and frontier trends of scientific achievements on EP, provide an overview of the past 120 years and insights for researchers and clinicians to facilitate future collaborative research and clinical intervention.

Methods

Quantitative analysis of publications relating to EP from 1900 to 2020 was interpreted and graphed through the Science Citation Index Expanded of Web of Science Core Collection (limited to SCIE). Microsoft office 2019, GraphPad Prism 8, VOSviewer, and R-bibliometrix were used to conduct the bibliometric analysis.

Results

From 1900 to 2020, a total of 1,034 publications were retrieved. The USA had the largest number of publications, making the greatest contribution to the topic (n = 260, 25.15%). Active collaborations between countries/regions were also enrolled. Grant and Hermontaylor were perhaps the most impactful researchers in the landscape of EP. Protein Expression and Purification and the Journal of Biological Chemistry were the most prevalent (79/1,034, 7.64%) and cited journals (n = 2,626), respectively. Using the top 15 citations and co-citations achievements clarified the theoretical basis of the EP research field. Important topics mainly include the structure of EP, the affective factors for activating substrates by EP, EP-related disorders, and inhibitors of EP.

Conclusion

Based on the bibliometric analysis, we have gained a comprehensive analysis of the global status and research frontiers of studies investigating EP, which provides some guidance and reference for researchers and clinicians engaged in EP research.

Clinical practice guideline for post-ERCP pancreatitis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed.

METHODS

The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline.

RESULTS

In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP.

CONCLUSIONS

We reported here the essence of the clinical practice guideline for PEP.

Prophylactic ulinastatin administration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

The objective of the present study was to perform a meta-analysis of all available studies on the effect of prophylactic ulinastatin administration on preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The PubMed, Web of Knowledge and Chinese National Knowledge Infrastructure databases were searched to identify all relevant studies published in English or Chinese prior to April 2016. Cochrane Review Manager was used to calculate the pooled risk ratio (RR) and 95% confidence interval (CI) to determine the effect of prophylactic ulinastatin on PEP, post-ERCP hyperamylasemia (PEHA) and post-ERCP abdominal pain. The analysis revealed that prophylactic ulinastatin administration significantly reduced the PEP risk (RR=0.49; 95% CI: 0.33–0.74; P=0.0006; I²=24); however, such significant risk reduction occurred only in patients with low or average risk for PEP and high-dosage ulinastatin (150,000 or 200,000 U) administration, and when the ulinastatin administration began prior to or during ERCP. Pre-ERCP ulinastatin administration alone without additional administration after ERCP was sufficient. Prophylactic ulinastatin also significantly reduced the PEHA risk (RR=0.68; 95% CI: 0.56–0.83; P=0.0001; I²=19) and marginally reduced the incidence of post-ERCP abdominal pain (RR=0.67; 95% CI: 0.45–1.00; P=0.05; I²=67). In conclusion, prophylactic ulinastatin administration significantly reduced the risk of PEP in patients with low or average risk for PEP when administered at a high dosage prior to or during ERCP. High-quality studies, particularly on high-risk patients, are warranted.

Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques

Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.

A novel thermosensitive in-situ gel of gabexate mesilate for treatment of traumatic pancreatitis: An experimental study

Gabexate mesilate (GM) is a trypsin inhibitor, and mainly used for treatment of various acute pancreatitis, including traumatic pancreatitis (TP), edematous pancreatitis, and acute necrotizing pancreatitis. However, due to the characteristics of pharmacokinetics, the clinical application of GM still needs frequently intravenous administration to keep the blood drug concentration, which is difficult to manage. Specially, when the blood supply of pancreas is directly damaged, intravenous administration is difficult to exert the optimum therapy effect. To address it, a novel thermosensitive in-situ gel of gabexate mesilate (GMTI) was developed, and the optimum formulation of GMTI containing 20.6% (w/w) P-407 and 5.79% (w/w) P188 with different concentrations of GM was used as a gelling solvent. The effective drug concentration on trypsin inhibition was examined after treatment with different concentrations of GMTI in vitro, and GM served as a positive control. The security of GMTI was evaluated by hematoxylin-eosin (HE) staining, and its curative effect on grade II pancreas injury was also evaluated by testing amylase (AMS), C-reactive protein (CRP) and trypsinogen activation peptide (TAP), and pathological analysis of the pancreas. The trypsin activity was slightly inhibited at 1.0 and 5.0 mg/mL in GM group and GMTI group, respectively (P<0.05 vs. P-407), and completely inhibited at 10.0 and 20.0 mg/mL (P<0.01 vs. P-407). After local injection of 10 mg/mL GMTI to rat leg muscular tissue, muscle fiber texture was normal, and there were no obvious red blood cells and infiltration of inflammatory cells. Furthermore, the expression of AMS, CRP and TAP was significantly increased in TP group as compared with control group (P<0.01), and significantly decreased in GM group as compared with TP group (P<0.01), and also slightly inhibited after 1.0 and 5.0 mg/mL GMTI treatment as compared with TP group (P<0.05), and significantly inhibited after 10.0 and 20.0 mg/mL GMTI treatment as compared with TP group (P<0.01). HE staining results demonstrated that pancreas cells were uniformly distributed in control group, and they were loosely arranged, partially dissolved, with deeply stained nuclei in TP group. Expectedly, after gradient GMTI treatment, pancreas cells were gradually restored to tight distribution, with slightly stained nuclei. This preliminary study indicated that GMTI could effectively inhibit pancreatic enzymes, and alleviate the severity of trauma-induced pancreatitis, and had a potential drug developing and clinic application value.

Nafamostat mesilate for prevention of post-ERCP pancreatitis: a meta-analysis of prospective, randomized, controlled trials

OBJECTIVES

We aimed to evaluate the efficacy of nafamostat on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

Medline, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched until April 18, 2014.

RESULTS

Seven randomized controlled trials and 2956 patients met the search criteria. When compared with nonnafamostat, the incidence of PEP was reduced to 53% in the patients who received nafamostat (risk ratio [RR], 0.47; 95% confidence interval [CI], 0.34-0.63). Further analyses were conducted based on the different risk classifications (n = 641 in patients with high risks: RR, 0.54; 95% CI, 0.30-0.96 and n = 944 with low risks: RR, 0.31; 95% CI, 0.17-0.56), PEP severities (n = 1654: RR, 0.38; 95% CI, 0.25-0.59 for mild; RR, 0.37; 95% CI, 0.15-0.96 for moderate; RR, 0.92; 95% CI, 0.13-6.38 for severe), and nafamostat doses (n = 1902: RR, 0.42; 95% CI, 0.28-0.63 for 20 mg; n = 1150: RR, 0.40; 95% CI, 0.25-0.63 for 50 mg). However, there was no reduction of the incidence of post-ERCP hyperamylasemia (n = 1585; 95% CI, 0.68-1.45) or cannulation difficulty (n = 1585; 95% CI, 0.91-1.23).

CONCLUSIONS

Pooled analyses from current randomized controlled trials support the effectiveness of nafamostat for prophylaxis of PEP.

Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVE

The objective of this study was to investigate whether prophylactic administration of nafamostat mesilate reduces the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its efficacy, and risk factors for PEP.

METHODS

Potential subjects comprised 876 patients who underwent ERCP between September 2008 and February 2011. Of these, 58 patients were excluded after meeting exclusion criteria, and 818 patients were randomized. Patients in the nafamostat mesilate group were administered 20 mg of nafamostat mesilate dissolved in 500 mL of 5% glucose solution, whereas the control group received 500 mL of 5% glucose solution alone, over 2 hours from the start of ERCP.

RESULTS

Post-ERCP pancreatitis occurred in 5.1% (41 patients) overall, with a significantly lower frequency in the nafamostat mesilate group (3.5%) than in the control group (6.7%; P = 0.0349). Analysis of the 322 patients who had undergone ERCP for the first time (n = 158 in the nafamostat mesilate group; n = 164 in the control group) found that PEP again significantly less frequently occurred in the nafamostat mesilate group (5.7%) than in the control group (13.4%; P = 0.0172).

CONCLUSIONS

Our randomized controlled study suggested that short-term administration of nafamostat mesilate 20 mg may reduce the incidence of PEP.

Effect of diclofenac on the levels of lipoxin A4 and Resolvin D1 and E1 in the post-ERCP pancreatitis

OBJECTIVES

Acute pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Numerous studies have shown that administered nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the incidence of acute pancreatitis after ERCP. Little is known, however, about the mechanism of NSAIDs in preventing pancreatitis (PEP).

METHODS

In this study, we assigned patients to receive a single dose of intramuscular diclofenac 75 mg immediately after ERCP (diclofenac group) or without (control group). The primary outcome measure was the occurrence of PEP. The serum amylase levels were measured before ERCP and at 3 and 24 h post-procedure in all patients. The Lipoxin A4 (LXA4), Resolvin D1 (Rvd1), and Resolvin E1 (RvE1) levels were measured before ERCP, and 3 and 24 h after the procedure in 30 patients from the diclofenac group and 30 patients from the control group.

RESULTS

A total of 120 patients were enrolled and completed the follow-up. The overall incidence of PEP was 13.3% (16/120). It occurred in four of 60 patients (6.67%) in the diclofenac group and in 12 of 60 patients (20.00%) in the control group (p = 0.032). The LxA4, RvD1, and RvE1 levels in the diclofenac group at 3 h after ERCP were significantly increased compared with before ERCP (p < 0.05). Compared with the control group, the LxA4, RvD1, and RvE1 levels in the diclofenac group at 3 and 24 h after ERCP were significantly increased (p < 0.05).

CONCLUSIONS

Intramuscular diclofenac after ERCP can reduce the incidence of PEP. This may be related to the fact that diclofenac can increase the levels of LxA4, RvD1, and RvE1.

Ulinastatin activates the renin-angiotensin system to ameliorate the pathophysiology of severe acute pancreatitis

BACKGROUND AND AIM

Ulinastatin is a drug used effectively to alleviate symptoms and improve the pathophysiology of various types of pancreatitis. However, the molecular mechanism responsible for its action remains unknown. Therefore, we further explore the therapeutic effects of ulinastatin and investigate possible molecular pathways modulated by this drug in the development of severe acute pancreatitis (SAP).

METHODS

SAP mouse model was created by administering intraperitoneal injections of cerulein and lipopolysaccharide. Pancreatic injury was assessed by performing biochemical and histological assays and by measuring the inflammatory response of the pancreas. Specifically, we examined changes in the expression of components of the rennin-angiotensin system (RAS), including angiotensin-converting enzyme (ACE)-angiotensin II (Ang II)-angiotensin type 1 receptor (AT-1R), and ACE2-Ang-(1-7)-Mas receptor.

RESULTS

When SAP mouse models were treated with ulinastatin at a dosage of 50,000 U/kg body weight, we found, through biochemical and histopathological analyses, that the pancreatic injury was significantly ameliorated. Administration of ulinastatin to SAP mice led to increased expression of ACE2, Ang-(1-7), and Mas receptor, decreased expression of serum Ang II and pancreatic AT-1R, and no alterations in the expression of pancreatic ACE and Ang II when compared to cerulein-treated control group that did not receive ulinastatin.

CONCLUSIONS

This study shows that ulinastatin has differential effects on the two axes of the RAS during SAP. Our results further suggest that upregulation of components of the ACE2-Ang-(1-7)-Mas pathway might be an important mechanism contributing to the therapeutic role of ulinastatin in alleviating pancreatitis-associated symptoms.

Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: a prospective, randomized trial

OBJECTIVES

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications.

METHODS

A total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6-8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain.

RESULTS

The overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001).

CONCLUSIONS

There was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.

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.

The effect of somatostatin, ulinastatin and Salvia miltiorrhiza on severe acute pancreatitis treatment

BACKGROUND

The aim of this study was to evaluate the efficacy of somatostatin, ulinastatin and Salvia miltiorrhiza for treatment of severe acute pancreatitis.

METHODS

Three hundred six patients with severe acute pancreatitis were divided randomly into 5 groups: basic treatment, somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza. Amount of time for resolution of abdominal pain/distention, recovery to normal heart and respiratory rates, amylase and blood glucose levels, Acute Physiology and Chronic Health Evaluation II scores, and levels of tumor necrosis factor-α, interleukin (IL)-6, and IL-10 were analyzed and recorded for all 5 subgroups.

RESULTS

Tumor necrosis factor-α and IL-6 levels on the fourth and seventh days, and Acute Physiology and Chronic Health Evaluation II scores on the seventh day after treatment showed significant decrease in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. IL-10 levels on the fourth and seventh days were significantly improved in the somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. The incidences of pancreatic sepsis, multiple organ dysfunction syndrome and mortality were lower in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup.

CONCLUSIONS

Somatostatin is effective for the treatment of acute pancreatitis and both ulinastatin and S miltiorrhiza demonstrate improvement in therapeutic benefits.

Can postendoscopic retrograde cholangiopancreatography pancreatitis be prevented by a pharmacological approach?

Acute pancreatitis remains the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP), with reported incidence rates that have changed little over several decades. Patient- and procedure-related risk factors for post-ERCP pancreatitis (PEP) are well-defined. Effective measures to prevent PEP have been identified, including improvements in cannulation techniques and pancreatic stenting, as well as pharmacological intervention. Pharmacotherapy has been widely studied in the prevention of PEP, but the effect in averting PEP has been inconclusive. Although pharmacological prophylaxis is appealing, attempts to find an ideal drug are incomplete. Most available data on the efficacy of pharmacological agents for PEP prophylaxis have been obtained from patients at average risk for PEP. However, recently, a randomized prospective controlled trial of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent PEP in high-risk patients was published. The results revealed that rectal indomethacin reduced the incidence of PEP significantly. Thus, rectal administration of diclofenac or indomethacin immediately before or after ERCP is used routinely to prevent PEP. However, additional studies with NSAIDs using large numbers of subjects are necessary to confirm the prophylactic effect of these drugs and to establish whether they act synergistically with other prophylactic interventions, including pancreatic stenting.

Losartan to prevent hyperenzymemia after endoscopic retrograde cholangiopan-creatography: A randomized clinical trial

AIM: To study if the angiotensin II receptor blockers (ARB) losartan counteracts pancreatic hyperenzymemia as measured 24 h after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: A triple-blind and placebo-controlled randomized clinical trial was performed at two Swedish hospitals in 2006-2008. Patients over 18 years of age undergoing ERCP, excluding those with current pancreatitis, current use of ARB, and severe disease, such as sepsis, liver and renal failure. One oral dose of 50 mg losartan or placebo was given one hour before ERCP. The relative risk of hyperenzymemia 24 h after ERCP was estimated using multivariable logistic regression, and expressed as odds ratio with 95% confidence intervals (CIs), including adjustment for potential remaining confounding.

RESULTS: Among 76 participating patients, 38 were randomized to the losartan and the placebo group, respectively. The incidence rates of hyperenzymemia and acute pancreatitis among all 76 participating patients were 21% and 12%, respectively. Hyperenzymemia was detected in 9 and 7 patients in the losartan and placebo group, respectively. There were no major differences between the comparison groups regarding cannulation difficulty, findings, or proportion of patients requiring drainage of the bile ducts. There were, however, more pancreatic duct injections, a greater extent of pancreatography, and more biliary sphincterotomies in the losartan group than in the placebo group. Losartan was not associated with risk of hyperenzymemia compared to the placebo group after multi-varible logistic regression analysis (odds ratio 1.6, 95%CI 0.3-7.8).

CONCLUSION: In this randomized trial 50 mg losartan given orally had no prophylactic effect on development of hyperenzymemia after ERCP.

The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background/Aims

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP.

Methods

From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia.

Results

PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05).

Conclusions

Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

Infusion of ulinastatin via the pancreatic duct for prophylaxis of pancreatic injury after endoscopic retrograde cholangiopancreatography in dogs

AIM: To evaluate the prophylactic effect of infusion of ulinastatin via the pancreatic duct on pancreatic injury after endoscopic retrograde cholangiopancreatography (ERCP) in a canine model.

METHODS: Twenty-four dogs were randomized into three groups: ulinastatin group (group A), iobitridol group (group B) and normal group (group C). A duodenoscope was routinely inserted to the duodenal papilla under general anesthesia in dogs of each group. A guide wire was introduced into the bile duct in groups A and B to inject 10.0 mL of iobitridol, and the guide wire was then introduced into the pancreatic duct to slowly administer 100 000 units of ulinastatin and 8.0 mL of sodium chloride in group A and 10.0 mL of sodium chloride in group B. Five minutes later, 10.0 mL of iobitrdol was transfused into the pancreatic ducts in both groups within less than 1 min. A guide wire was introduced into the bile duct in group C to administer 10.0 mL of iobitridol. The contents of serum IL-6, IL-8, amylase and plasma TAP were determined by ELISA. Pancreatic tissues were pathologically examined 6 days after ERCP.

RESULTS: The contents of serum IL-6, IL-8, amylase and plasma TAP were significantly lower in group A than in group B (391.0 U/L ± 67.2 U/L vs 1 077.0 U/L ± 246.1 U/L, 51.91 ng/L ± 4.87 ng/L vs 78.11 ng/L ± 11.25 ng/L,

4.070 μg/L ± 0.089 μg/L vs 4.520 μg/L ± 0.195 μg/L, 3.234 nmol/L ± 0.185 nmol/L vs

4.001 nmol/L ± 0.237 nmol/L (all P < 0.05), and significantly higher in groups A and B than in group C. Under light microscopy, the pathological changes in pancreatic tissues in the ulinastatin group were less significant than those in other groups.

CONCLUSION: Pancreatic injury induced by ERCP could be ameliorated effectively and safety by infusion of ulinastatin via the pancreatic duct in dogs.

Protease inhibitors for preventing complications associated with ERCP: an updated meta-analysis

BACKGROUND AND OBJECTIVES

The prophylactic use of protease inhibitors in patients undergoing ERCP is still controversial. Our purpose was to evaluate the efficacy of protease inhibitors in preventing ERCP-associated complications.

DESIGN AND SETTING

Meta-analysis; randomized trials that evaluated the efficacy of protease inhibitors were identified.

PATIENTS

A total of 4966 patients were evaluated.

MAIN OUTCOME MEASUREMENTS

ERCP-associated pancreatitis, hyperamylasemia, abdominal pain, and death.

RESULTS

Eighteen studies (19 cohorts) met the inclusion criteria. Overall results for protease inhibitors showed a significant but small risk reduction in ERCP-associated pancreatitis (pooled risk difference [RD]: -0.029; 95% CI, -0.051 to -0.008 and the number needed to treat, 34.5; 95% CI, 19.6-125). Subgroup analysis in 8 high-quality studies showed a borderline significant efficacy (pooled RD, -0.027; 95% CI, -0.051 to -0.004). Subgroup analysis in 8 gabexate studies did not show significant efficacy (pooled RD, -0.030; 95% CI, -0.062 to 0.003). Subgroup analysis in 5 ulinastatin studies was significant (pooled RD, -0.035; 95% CI, -0.063 to -0.006). Two high-quality studies on ulinastatin yielded nonsignificant results. Analyses for the other outcomes were all nonsignificant. Sensitivity analysis showed that the effect size and level of statistical significance were decreased with increasing study quality.

CONCLUSIONS

At present, there is no solid evidence to support the use of protease inhibitors to prevent ERCP-associated complications. Although overall and ulinastatin subgroup analyses showed a small risk reduction for pancreatitis, it seems very possible that low-quality primary studies produced a veneer of efficacy.

Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized, double-blind, controlled trial

OBJECTIVES

Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic nafamostat mesilate, a synthetic protease inhibitor, would reduce the frequency and severity of post-ERCP pancreatitis.

METHODS

A total of 286 patients were randomized to receive either intravenous nafamostat mesilate or placebo 60 minutes before ERCP and for 6 hours after ERCP. A database was prospectively collected by a defined protocol. Standardized criteria were used to diagnose and grade the severity of pancreatitis.

RESULTS

The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 5.9%. It occurred in 4 (2.8%) of 143 patients in the nafamostat group and in 13 (9.1%) of 143 patients in the control group (P = 0.03). Pancreatitis was graded mild in 2.1% and moderate in 0.7% of the nafamostat group and mild in 7.0% and moderate in 2.1% of the control group. There was no significant difference between the groups in the severity of pancreatitis.

CONCLUSIONS

Prophylactic intravenous nafamostat mesilate reduces the frequency of post-ERCP pancreatitis.

Role of ulinastatin in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: the Emperor's New Clothes or Aladdin's Magic Lamp?

OBJECTIVES

The role of prophylactic ulinastatin in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is debated. A meta-analysis of all published randomized clinical trials was performed to evaluate the efficacy of ulinastatin on post-ERCP pancreatitis.

METHODS

Searches were conducted in multiple databases composed of PubMed, EMBASE, the Cochrane Library, the Science Citation Index Expanded, and the China National Knowledge Infrastructure series full-text database. Primary outcome was post-ERCP pancreatitis, with or without hyperamylasemia.

RESULTS

Seven randomized clinical trials fulfilling the inclusion criteria were selected for meta-analysis, 5 comparing ulinastatin with placebo and 2 for ulinastatin versus gabexate. The incidence of post-ERCP pancreatitis was reduced by ulinastatin (odds ratio, 0.53; 95% confidence interval, 0.31-0.89; P = 0.02; test for heterogeneity: I = 0%; P = 0.51), so was the event of hyperamylasemia (odds ratio, 0.42; 95% confidence interval, 0.30-0.59; P < 0.00001; test for heterogeneity: I = 13%; P = 0.33). Subsequent sensitivity and subgroup analyses produced conflicting results.

CONCLUSIONS

Ulinastatin shows to be of value on preventing post-ERCP pancreatitis and hyperamylasemia for patients in average risk, when given intravenously at a dose of not less than 150,000 U, just before ERCP. More high-quality trials are needed for further confirmation.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

Comparison between emergency and elective endoscopic sphincterotomy in patients with acute cholangitis due to choledocholithiasis: is emergency endoscopic sphincterotomy safe?

PURPOSE

We retrospectively assessed post-EST complications and examined whether combination therapy comprising endoscopic biliary drainage (EBD) plus endoscopic sphincterotomy (EST) as the initial treatment is safe in patients with acute cholangitis due to choledocholithiasis.

METHODS

Among the 363 consecutive patients with acute cholangitis due to choledocholithiasis who were treated in our hospital between December 1992 and December 2006, the subjects comprised 127 patients with moderate acute cholangitis for whom EBD and EST were carried out. Factors influencing risk factors for post-EST pancreatitis, hemorrhage and hospitalization were determined by multivariate analysis.

RESULTS

Multivariate analysis revealed that only precut sphincterotomy (PST) was a significant risk factor for post-EST pancreatitis, and the incidence of pancreatitis in patients who underwent PST was significantly higher than that in those who did not (P = 0.041). Only age was a significant risk factor for post-EST hemorrhage, and younger patients were likely to experience hemorrhage after EST (P = 0.021). Total bilirubin and the timing of EST were significant factors associated with hospitalization. Hospitalization in patients who underwent EBD plus EST as the initial treatment (emergency EST) was significantly shorter than that in those who palliatively underwent EST after EBD (elective EST; 11.8 vs. 16.2 days, P = 0.001).

CONCLUSIONS

Combination therapy comprising EBD plus EST as the initial treatment for patients with moderate acute cholangitis due to choledocholithiasis was safe and did not prolong the period of hospitalization.

Post-ERCP pancreatitis

Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has developed following ERCP, and its diagnosis and severity assessment should be made according to the diagnostic criteria and severity assessment of the Japanese Ministry of Health, Labour and Welfare. The incidence of acute pancreatitis associated with diagnostic and therapeutic ERCP is 0.4-1.5 and 1.6-5.4%, respectively. Endoscopic papillary balloon dilation is associated with a high risk of acute pancreatitis compared with endoscopic sphincterotomy. It was made clear that important risk factors include dysfunction of the Oddi sphincter, being of the female sex, past history of post-ERCP pancreatitis, and performance of pancreaticography. Temporary prophylactic placement of pancreatic stents in the high-risk group is useful for the prevention of post-ERCP pancreatitis [odds ratio (OR) 3.2, 95% confidence interval (CI) 1.6-6.4, number needed to treat (NNT) 10]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a reduction in the development of post-ERCP pancreatitis (OR 0.46, 95% CI 0.32-0.65). Single rectal administration of NSAIDs is useful for the prevention of post-ERCP pancreatitis [relative risk (RR) 0.36, 95% CI 0.22-0.60, NNT 15] and decreases the development of pancreatitis in both the low-risk group (RR 0.29, 95% CI 0.12-0.71) and the high-risk group (RR 0.40, 95% CI 0.23-0.72) of post-ERCP pancreatitis. As for somatostatin, a bolus injection may be most useful compared with short- or long-term infusion (OR 0.271, 95% CI 0.138-0.536, risk difference 8.2%, 95% CI 4.4-12.0%). The usefulness of gabexate mesilate was not apparent in any of the following conditions: acute pancreatitis (control 5.7 vs. 4.8% for gabexate mesilate), hyperamylasemia (40.6 vs. 36.9%), and abdominal pain (1.7 vs. 8.9%). Formulation of diagnostic criteria for post-ERCP pancreatitis is needed. Temporary prophylactic placement of pancreatic stents in the high-risk group offers the most promise as a means of preventing post-ERCP pancreatitis. As for pharmacological attempts, there are high expectations concerning NSAIDs because they are excellent in terms of cost-effectiveness, ease of use, and safety. There was no evidence of effective prophylaxis with the use of protease inhibitors, especially gabexate mesilate.

Prophylactic use of ulinastatin against post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review

AIM: To evaluate the efficacy of ulinastatin in the prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

METHODS: A method recommended by the Cochrane Collaboration was used to perform a meta-analysis of randomized controlled trials (RCTs) of ulinastatin in the prevention of post-ERCP pancreatitis (PEP). A total of four RCTs were included.

RESULTS: Two RCTs that focus on the comparison of ulinastatin and placebo for 446 patients undergoing ERCP and two RCTs that focus on the comparison of ulinastatin and gabexate for 207 patients were included. Analysis of these RCTs revealed the presence of statistical homogeneity among them. In ulinastatin versus placebo trials, the odds ratio associated with treatment with ulinastatin for PEP was 0.35 (95%CI: 0.14-0.88). In ulinastatin versus gabexate trials, the odds ratio associated with treatment with ulinastatin for PEP was 1.57 (95%CI: 0.39-6.24). A comparison of low-dose ulinastatin and gabexate was also performed, and the odds ratio associated with treatment with ulinastatin for PEP was 1.69 (95%CI: 0.39-7.32).

CONCLUSION: Current best evidence demonstrates that ulinastatin can prevent post-ERCP pancreatitis, and ulinastatin has very similar efficacy to gabexate in the prevention of post-ERCP pancreatitis.

Effect of pretreatment with high-dose ulinastatin in preventing radiation-induced pulmonary injury in rats

In order to develop a better management strategy for radiation-induced pulmonary injury, we compared the protective effect of pretreatment and aftertreatment with different doses of ulinastatin. Two hundred and forty female Sprague-Dawley rats were randomized into five groups. Group R received radiation only, groups P1 and P2 were pretreated with different doses of i.v. ulinastatin for 3 days pre- and 4 days post-irradiation, and groups A1 and A2 were treated for 7 days post-irradiation only. Rats were sacrificed at 2 h, and at 4, 8, 16, and 24 weeks post-irradiation. The expressions of TGF-beta1, TNF-alpha, IL-6, hydroxyproline and laminin were determined. No adverse toxicological effects of ulinastatin pretreatment were observed. Mortality and ratio of fibrotic area was lowest in group P1(5/45; 30.6+/-3.11%, P<0.05 vs. A2). Expressions of TGF-beta1 and IL-6 in group P1 were significantly lowest at 4 weeks (3.01+/-0.35, 549+/-58, 32.3+/-3.27, P<0.01), and expressions of hydroxyproline and laminin were also lowest at 24 weeks (741+/-68 and 82.6+/-6.91, P<0.01) in comparison with other groups. Significant differences were observed in expression of TGF-beta1 and TNF-alpha in lung between group P1 and group A1 at 4 weeks (263+/-11% vs. and 187+/-9%, 189+/-8% vs. 154+/-9%, P<0.01, P<0.05 respectively). Pretreatment with high dose ulinastatin resulted in a milder inflammatory response and suppressed pulmonary fibrosis, which may serve as a favorable management strategy.

Randomized clinical trial to assess the efficacy of ulinastatin for postoperative pancreatitis following pancreaticoduodenectomy

BACKGROUND AND OBJECTIVES

Ulinastatin, an intrinsic trypsin inhibitor, has proved to be effective for the prevention of acute pancreatitis after endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the efficacy of ulinastatin for postoperative pancreatitis following pancreaticoduodenectomy in a randomized clinical trial.

METHODS

Patients undergoing pancreaticoduodenectomy were randomized to receive perioperative ulinastatin or placebo. Levels of serum amylase, drain amylase, and urine trypsinogen-2 were measured.

RESULTS

A total of 42 patients were enrolled (20 in the ulinastatin group, 20 in the placebo group, 2 excluded). Two patients in the ulinastatin group and nine patients in the placebo group developed hyperamylasemia (P = 0.013) No patient in the ulinastatin group and five patients in the placebo group developed pancreatitis (P = 0.016). One patient in the ulinastatin group and two patients in the placebo group developed grade A pancreatic fistula (P = 0.548). Serum amylase levels at 4 hr and postoperative days 1, 2, and 3, and drain amylase levels on days 2 and 3 were significantly lower in the ulinastatin group than in the placebo group.

CONCLUSIONS

Prophylactic administration of ulinastatin reduced the levels of serum and drain amylase and the incidence of postoperative pancreatitis following pancreaticoduodenectomy.

Acute pancreatitis

PURPOSE OF REVIEW

To review advances over the last year in the prevention, diagnosis and management of acute pancreatitis.

RECENT FINDINGS

Obesity is an independent risk factor for severity in acute pancreatitis, and heavy alcohol consumption for the development of necrosis in severe acute pancreatitis. Biochemical markers have been further tested, including carbohydrate-deficient transferrin for the diagnosis of alcohol-induced acute pancreatitis, urinary trypsinogen-2 as a diagnostic marker for acute pancreatitis, and interleukin-6 and procalcitonin as markers of disease severity. A new, simple stratification system, the 'panc 3 score', has been described. There are conflicting data on the use of antibiotic prophylaxis in acute necrotizing pancreatitis, and on the chemoprevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Enteral feeding is established as standard practice early in the management of acute pancreatitis of all aetiologies; probiotics and other compounds may also play a role.

SUMMARY

Over the last year, there have been further innovations in the risk stratification and management of acute pancreatitis. Unresolved issues include chemoprevention of endoscopic retrograde cholangiopancreatography-induced acute pancreatitis, the indications for antibiotic prophylaxis in severe acute pancreatitis and nutritional supplementation with probiotics and synbiotics.