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Elmunzer BJ, Foster LD, Serrano J, Coté GA, Edmundowicz SA, Wani S, Shah R, Bang JY, Varadarajulu S, Singh VK, Khashab M, Kwon RS, Scheiman JM, Willingham FF, Keilin SA, Papachristou GI, Chak A, Slivka A, Mullady D, Kushnir V, Buxbaum J, Keswani R, Gardner TB, Forbes N, Rastogi A, Ross A, Law J, Yachimski P, Chen YI, Barkun A, Smith ZL, Petersen B, Wang AY, Saltzman JR, Spitzer RL, Ordiah C, Spino C, Durkalski-Mauldin V. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403:450-458. [PMID: 38219767 PMCID: PMC10872215 DOI: 10.1016/s0140-6736(23)02356-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. METHODS In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. FINDINGS Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. INTERPRETATION For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines. FUNDING US National Institutes of Health.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ji Young Bang
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Shyam Varadarajulu
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Nauzer Forbes
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew Ross
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Joanna Law
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yen-I Chen
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Zachary L Smith
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bret Petersen
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Y Wang
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Collins Ordiah
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Valerie Durkalski-Mauldin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
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2
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Agarwal A, Mahapatra SJ, Sethia R, Agarwal S, Elhence A, Mohta S, Gunjan D, Garg PK. Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis. Indian J Gastroenterol 2023; 42:370-378. [PMID: 37160838 DOI: 10.1007/s12664-023-01354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 02/03/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. METHODS All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. RESULTS Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30 minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30 minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. CONCLUSION Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.
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Affiliation(s)
- Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, 342 005, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Rahul Sethia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Srikanth Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Pramod Kumar Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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Kumar A, Sondhi P. A closer look at universal prophylactic rectal NSAIDs in prevention of post-ERCP pancreatitis. Indian J Gastroenterol 2023; 42:311-314. [PMID: 37314683 DOI: 10.1007/s12664-023-01404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ajay Kumar
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India.
| | - Pulkit Sondhi
- BLK Max Institute of Digestive and Liver Diseases, New Delhi, 110 005, India
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Keswani RN, Duloy A, Nieto JM, Panganamamula K, Murad MH, Bazerbachi F, Shaukat A, Elmunzer BJ, Day LW. Interventions to improve the performance of ERCP and EUS quality indicators. Gastrointest Endosc 2023; 97:825-838. [PMID: 36967249 DOI: 10.1016/j.gie.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/11/2022] [Indexed: 04/21/2023]
Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Duloy
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jose M Nieto
- Digestive Disease Consultants, Jacksonville, Florida, USA
| | - Kashyap Panganamamula
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, New York, New York, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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5
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Palamaru AL, Toader E. Assessing the Burden of Choledochian Lithiasis and Cholangiocarcinoma in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography, Using Disability-Adjusted Life Years. Health (London) 2023. [DOI: 10.4236/health.2023.151005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Koshitani T, Konaka Y, Ohishi T, Yasuda T, Morinushi T, Mita M, Masuda M, Nakano K, Fuki S, Nakagawa S. Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using Temporary Pancreatic Stents Versus Rectal Nonsteroidal Anti-inflammatory Drugs: A Randomized Controlled Trial. Pancreas 2022; 51:663-670. [PMID: 36099496 DOI: 10.1097/mpa.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Both pancreatic stenting and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of the study was to compare post-ERCP pancreatitis (PEP) prophylaxis using pancreatic stents and/or rectal NSAIDs prospectively. METHODS A total of 321 patients undergoing ERCP were studied. Each patient was randomly allocated to receive pancreatic stent placement (PS), 50 mg of rectal diclofenac (NSAID), or both (PS + NSAID) for PEP prophylaxis. The primary outcome was the occurrence rate of PEP, and secondary outcomes included the severity of PEP and serum pancreatic amylase and lipase levels on the day after ERCP. RESULTS Five patients (PS: 2/101, NSAID: 1/106, PS + NSAID: 2/102) developed PEP, and the overall occurrence rate of PEP was 1.6% (5/309). The occurrence rates of PEP in the PS, NSAID, and PS + NSAID groups were statistically equivalent with an equivalent margin of 10%. The severity of PEP was mild in all 5 patients. Median serum pancreatic amylase and lipase levels in the NSAID group were significantly lower than those in the PS and PS + NSAID groups. CONCLUSIONS Rectal administration of 50 mg of diclofenac may become a first-line therapy for PEP prophylaxis in our country.
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Affiliation(s)
- Tatsuya Koshitani
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Yoshitomo Konaka
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Takashi Ohishi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tomoyo Yasuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Tatsuo Morinushi
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masaki Mita
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Masataka Masuda
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Keimei Nakano
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
| | - Shuichi Fuki
- From the Department of Gastroenterology, Japan Community Health Care Organization, Kobe Central Hospital
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7
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Park CH. [The Latest Knowledge on Endoscopic Retrograde Cholangiopancreatography-related Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:195-198. [PMID: 35610548 DOI: 10.4166/kjg.2022.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 11/03/2022]
Abstract
ERCP has been established as a golden diagnostic and therapeutic modality in various pancreatobiliary diseases, including gallstones and malignancy. On the other hand, ERCP is a relatively invasive procedure with radiation hazards and major complications. Among the major complications, ERCP-related pancreatitis has been reported in more than 14.7% of high-risk patients, which might lead to extended hospitalization and a substantial burden for both patients and physicians. Recent guidelines have defined the high-risk factors for ERCP-related pancreatitis. In addition, several outstanding studies have shown that rectal non-steroidal anti-inflammatory drugs, aggressive hydration with lactated Ringer's solution, and pancreatic stents can reduce ERCP-related pancreatitis in high-risk patients or all patients. A prevention algorithm for ERCP-related pancreatitis was provided based on advanced research.
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Affiliation(s)
- Chang-Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Radadiya D, Brahmbhatt B, Reddy C, Devani K. Efficacy of Combining Aggressive Hydration With Rectal Indomethacin in Preventing Post-ERCP Pancreatitis: A Systematic Review and Network Meta-Analysis. J Clin Gastroenterol 2022; 56:e239-e249. [PMID: 33769395 DOI: 10.1097/mcg.0000000000001523] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
Postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography pancreatitis (ERCP). No randomized controlled trial (RCT) has compared the efficacy of the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy recommended interventions for PEP prevention. We assessed the effectiveness of these interventions using network meta-analysis. PubMed, EMBASE, and Cochrane databases were searched to identify RCTs investigating guideline-recommended interventions and their combinations [rectal nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin or diclofenac, pancreatic stent (PS), aggressive hydration (AH), sublingual nitrate) for PEP prevention. We performed direct and Bayesian network meta-analysis, and the surface under the cumulative ranking curve to rank interventions. Subgroup network meta-analysis for high-risk populations was also performed. We identified a total of 38 RCTs with 10 different interventions. Each intervention was protective against PEP on direct and network meta-analysis compared with controls. Except AH+diclofenac and NSAIDs+ sublingual nitrate, AH+indomethacin was associated with a significant reduction in risk of PEP compared with PS [odds ratio (OR), 0.09; credible interval (CrI), 0.003-0.71], indomethcin+PS (OR, 0.09; CrI, 0.003-0.85), diclofenac (OR, 0.09; CrI, 0.003-0.65), AH (OR, 0.09; CrI, 0.003-0.65), sublingual nitrate (OR, 0.07; CrI, 0.002-0.63), and indomethacin (OR, 0.06; CrI, 0.002-0.43). AH with either rectal NSAIDs or sublingual nitrate had similar efficacy. AH+indomethacin was the best intervention for preventing PEP with 95.3% probability of being ranked first. For high-risk patients, although the efficacy of PS and indomethacin were comparable, PS had an 80.8% probability of being ranked first. AH+indomethacin seems the best intervention for preventing PEP. For high-risk patients, PS seems the most effective strategy. The potential of combination of interventions need to be explored further.
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Affiliation(s)
| | - Bhaumik Brahmbhatt
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | - Chakradhar Reddy
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, East Tennessee State University, Johnson City, TN
| | - Kalpit Devani
- Department of Internal Medicine, Division of Gastroenterology and Liver Disease, Prisma Health, School of Medicine, University of South Carolina, Greenville, SC
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9
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Park TY, Kang H, Choi GJ, Oh HC. Rectal NSAIDs-based combination modalities are superior to single modalities for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis. Korean J Intern Med 2022; 37:322-339. [PMID: 35168302 PMCID: PMC8925947 DOI: 10.3904/kjim.2021.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Different modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP. METHODS We performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities. RESULTS The NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer's solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups. CONCLUSION Rectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.
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Affiliation(s)
- Tae Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
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10
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Thiruvengadam NR, Saumoy M, Schneider Y, Attala S, Triggs J, Lee P, Kochman ML. A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States. Clin Gastroenterol Hepatol 2022; 20:216-226.e42. [PMID: 34481952 DOI: 10.1016/j.cgh.2021.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective. METHODS We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs). RESULTS Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs). CONCLUSIONS Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Monica Saumoy
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sara Attala
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Triggs
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peter Lee
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael L Kochman
- Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Dietrich CF, Bekkali NL, Burmeister S, Dong Y, Everett SM, Hocke M, Ignee A, On W, Hebbar S, Oppong K, Sun S, Jenssen C, Braden B. Controversies in ERCP: Indications and preparation. Endosc Ultrasound 2021; 11:186-200. [PMID: 34677145 PMCID: PMC9258020 DOI: 10.4103/eus-d-21-00106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
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Affiliation(s)
- Christoph F Dietrich
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China; Johann Wolfgang Goethe University, Frankfurt/Main, Germany; Department of Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Noor L Bekkali
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Meiningen, Germany
| | - Andre Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Wei On
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Srisha Hebbar
- University Hospitals of North Midlands, North Midlands, United Kingdom
| | - Kofi Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Siyu Sun
- Endoscopy Center, Sheng Jing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Markisch-Oderland, Strausberg; Brandenburg Institute for Clinical Ultrasound at Medical University Brandenburg, Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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Icacan G, Onalan E, Yucesoy M. Comparison of stent and indomethacin suppository efficacy in the prevention of acute pancreatitis after ERCP. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021178. [PMID: 34487093 PMCID: PMC8477098 DOI: 10.23750/abm.v92i4.10962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022]
Abstract
Objective: We aimed to compare stent and indomethacin suppository efficacy in the prevention of acute pancreatitis after ERCP. Materials and Methods: 76 high-risk patients undergoing ERCP were included in the study. The patients were divided into three groups as indomethacin group, stent group and control group. Indomethacin group (n = 32) received 100 mg rectal indomethacin immediately after ERCP. A 5F pancreatic stent was applied to the stent group (n = 16) during ERCP. No prophylaxis was given to the control group (n = 28). Results: There was no difference between the groups in terms of age and gender. ERCP pancreatitis was seen in 9.2% (7/76) of the patients. The incidence of ERCP-induced pancreatitis (PEP) was 3.1% (1/32) in the indomethacin group and 21.4% (6/28) in the control group. PEP was not seen in the stent group (0/16). The incidence of PEP was significantly lower in the indomethacin group than in the control group (p = 0.043). However, no significant difference was found between the stent and control groups, stent and indomethacin groups in terms of PEP frequency (p = 0.072, p: 0.90 respectively). Conclusion: According to the results of our study, rectal indomethacin administration decreased the frequency of PEP in high-risk patients. However, there was no significant difference in PEP prophylaxis between the stent and indomethacin groups.
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Affiliation(s)
- Gamze Icacan
- Fırat University, Deparment of Nephrology, Faculty of Medicine, Elazığ,Turkey.
| | - Erhan Onalan
- Department of Internal Medicine, Faculty of Medicine, Firat Univeristy, 23000, Elazig, Turkey.
| | - Mehmet Yucesoy
- Erciyes University, Deparment of Internal Medicine, Faculty of Medicine, Kayseri,Turkey.
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13
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Wang X, Luo H, Luo B, Ren G, Liang S, Wang X, Tao Q, Zhang L, Kang X, Guo X, Pan Y. Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching. J Gastroenterol Hepatol 2021; 36:1905-1912. [PMID: 33444486 DOI: 10.1111/jgh.15402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/27/2020] [Accepted: 01/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Rectal indomethacin and pancreatic duct stenting (PDS) are recommended for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN). METHODS Patients with native papilla who underwent endoscopic retrograde cholangiopancreatography in eight tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administered. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was PEP. RESULTS Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs 10.2%, P = 0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs 18.2%, P = 0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs 19.4%, P = 0.036). CONCLUSIONS The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.
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Affiliation(s)
- Xu Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bing Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qin Tao
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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14
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Issak A, Elangovan A, Ferguson RD, Waghray N, Sandhu DS. Underutilization of prophylactic rectal indomethacin and pancreatic duct stent for prevention of post-ERCP Pancreatitis. Endosc Int Open 2021; 9:E979-E985. [PMID: 34222616 PMCID: PMC8211473 DOI: 10.1055/a-1460-7776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/23/2021] [Indexed: 10/27/2022] Open
Abstract
Background and study aims Incidence of Post-ERCP pancreatitis (PEP) ranges from 1 % to 10 % in unselected patients and as high as 25 % to 30 % in high-risk patients. Rectal indomethacin administered before or immediately after an ERCP and prophylactic pancreatic duct stent placement (PPS) are associated with a reduction in the incidence of PEP. We sought to investigate the utilization rate for prophylactic rectal indomethacin and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. Patients and methods We performed a retrospective analysis in the IBM Explorys database, a pooled, national de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States from 2014 to 2019. Average and high-risk patients undergoing ERCP were identified using Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) diagnosis codes. PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. Results Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8 %) had a PEP prophylaxis. Rectal indomethacin and PPS accounted for 82.4 % and 12.9 % respectively. Individuals with three risk factors had the highest PEP rates followed by individuals with two risk factors. Conclusions Only one-third of all patients undergoing ERCP received prophylaxis in the form of rectal indothemacin and/or PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.
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Affiliation(s)
- Abdulfatah Issak
- Division of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States,Department of Internal Medicine, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States
| | - Abbinaya Elangovan
- Division of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States,Department of Internal Medicine, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States
| | - Roy D. Ferguson
- Division of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States,Department of Internal Medicine, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States
| | - Nisheet Waghray
- Division of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States,Department of Internal Medicine, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States
| | - Dalbir S. Sandhu
- Division of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, United States
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15
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Akshintala VS, Sperna Weiland CJ, Bhullar FA, Kamal A, Kanthasamy K, Kuo A, Tomasetti C, Gurakar M, Drenth JPH, Yadav D, Elmunzer BJ, Reddy DN, Goenka MK, Kochhar R, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:733-742. [PMID: 34214449 DOI: 10.1016/s2468-1253(21)00170-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, pancreatic stents, or combinations of these have been evaluated in randomised controlled trials (RCTs) for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the comparative efficacy of these treatments remains unclear. Our aim was to do an exploratory network meta-analysis of previous RCTs to systematically compare the direct and indirect evidence and rank NSAIDs, intravenous fluids, pancreatic stents, or combinations of these to determine the most efficacious method of prophylaxis for post-ERCP pancreatitis. METHODS We searched PubMed, Embase, and the Cochrane Central Register from inception to Nov 15, 2020, for full-text RCTs that evaluated the efficacy of NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for post-ERCP pancreatitis prevention in adult (aged ≥18 years) patients undergoing ERCP. Summary data from intention-to-treat analyses were extracted from published reports. We analysed incidence of post-ERCP pancreatitis across studies using network meta-analysis under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the confidence rating. This study is registered with PROSPERO, CRD42020172606. FINDINGS We identified 1503 studies, of which 55 RCTs evaluating 20 interventions in 17 062 patients were included in the network meta-analysis. The mean incidence of post-ERCP pancreatitis in the placebo or active control group was 12·2% (95% CI 11·4-13·0). Normal saline plus rectal indometacin (OR 0·02, 95% CI 0·00-0·40), intramuscular diclofenac 75 mg (0·24, 0·09-0·69), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·30, 0·16-0·55), intravenous high-volume Ringer's lactate (0·31, 0·12-0·78), 5-7 Fr pancreatic stents (0·35, 0·26-0·48), rectal diclofenac 100 mg (0·36, 0·25-0·52), 3 Fr pancreatic stents (0·47, 0·26-0·87), and rectal indometacin 100 mg (0·60, 0·50-0·73) were all more efficacious than placebo for preventing post-ERCP pancreatitis in pairwise comparisons. 5-7 Fr pancreatic stents (0·59, 0·41-0·84), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·49, 0·26-0·94), intravenous standard-volume normal saline plus rectal indometacin 100 mg (0·04, 0·00-0·66), and rectal diclofenac 100 mg (0·59, 0·40-0·89) were more efficacious than rectal indometacin 100 mg. The GRADE confidence rating was low to moderate for 98·3% of the pairwise comparisons. INTERPRETATION This systematic review and network meta-analysis summarises the available literature on NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for prophylaxis of post-ERCP pancreatitis. Rectal diclofenac 100 mg is the best performing rectal NSAID in this network meta-analysis. Combinations of prophylaxis might be more effective, but there is little evidence. These findings help to establish prophylaxis of post-ERCP pancreatitis for future research and practice, and could reduce costs and increase adoption of prophylaxis. FUNDING None.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Albert Kuo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cristian Tomasetti
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Biostatistics & Bioinformatics, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mahesh K Goenka
- Department of Gastroenterology, Apollo Gleneagles Hospital, Kolkata, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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16
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Weissman S, Ahmed M, Baniqued MR, Ehrlich D, Tabibian JH. Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastrointest Endosc 2021; 13:161-169. [PMID: 34163563 PMCID: PMC8209540 DOI: 10.4253/wjge.v13.i6.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/14/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide. With the widespread reliance on endoscopic retrograde cholangiopancreatography (ERCP) for the management of pancreaticobiliary conditions, post-ERCP pancreatitis (PEP) has come to represent an important etiology of acute pancreatitis. Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder, findings have been heterogeneous, and considerable variation in clinical practice exists. Herein, we review the literature regarding PEP with the goal to raise awareness of this entity, discuss recent data, and present evidence-based best practices. We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Mohamed Ahmed
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Matthew R Baniqued
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Dean Ehrlich
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, Los Angeles, CA 91342, United States
| | - James H Tabibian
- Director of Endoscopy, Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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17
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Oh HC, Kang H, Park TY, Choi GJ, Lehman GA. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis with a combination of pharmacological agents based on rectal non-steroidal anti-inflammatory drugs: A systematic review and network meta-analysis. J Gastroenterol Hepatol 2021; 36:1403-1413. [PMID: 33068012 DOI: 10.1111/jgh.15303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Rectally administered non-steroidal anti-inflammatory drugs (NSAIDs) are effective but suboptimal in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis or PEP. New trials with the combination of rectal NSAIDs and other pharmacological agents have been conducted. This network meta-analysis (NMA) aimed to determine the relative efficacy of combination regimens and identify an optimal regimen for preventing PEP. METHODS We performed a systematic and comprehensive search to identify and analyze all the randomized controlled studies published until October 15, 2019, examining rectal NSAIDs and their combination with other pharmacological agents for the prevention of PEP. The primary outcome was the frequency of PEP. We conducted an NMA to combine the direct and indirect comparisons of rectal NSAIDs and their combination with other pharmacological agents. RESULTS The NMA included 24 studies evaluating 14 regimens in 11 321 patients. According to predictive interval plot and surface under the cumulative ranking curve values, indomethacin + lactated Ringer's solution, followed by diclofenac + nitrate and indomethacin + normal saline, is the most efficacious combination of pharmacological agents for the overall prevention of PEP. Rectal indomethacin alone is the most efficacious agent for prevention of moderate to severe PEP, and rectal diclofenac is the most useful agent for prevention of PEP among the high-risk group. CONCLUSIONS Rectal indomethacin with intravenous hydration and rectal diclofenac with sublingual nitrate are the most efficacious combination regimens for the overall prevention of PEP.
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Affiliation(s)
- Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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18
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Dubravcsik Z, Hritz I, Keczer B, Novák P, Lovász BD, Madácsy L. Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis. Pancreatology 2021; 21:704-713. [PMID: 33926821 DOI: 10.1016/j.pan.2021.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients. METHODS We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values. RESULTS Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method. CONCLUSION Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary.
| | - István Hritz
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Center for Therapeutic Endoscopy, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Péter Novák
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary
| | | | - László Madácsy
- Department of Gastroenterology, BKM Hospital, Kecskemét, Hungary; Endo-kapszula Private Medical Center, Székesfehérvár, Hungary
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19
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Ribeiro IB, do Monte Junior ES, Miranda Neto AA, Proença IM, de Moura DTH, Minata MK, Ide E, dos Santos MEL, Luz GDO, Matuguma SE, Cheng S, Baracat R, de Moura EGH. Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review. World J Gastroenterol 2021; 27:2495-2506. [PMID: 34092971 PMCID: PMC8160616 DOI: 10.3748/wjg.v27.i20.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/30/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.
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Affiliation(s)
- Igor Braga Ribeiro
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Antonio Afonso Miranda Neto
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Igor Mendonça Proença
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Mauricio Kazuyoshi Minata
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Edson Ide
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | | | - Gustavo de Oliveira Luz
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Sergio Eiji Matuguma
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Spencer Cheng
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
| | - Renato Baracat
- Department of Gastrointestinal Endoscopy Unit, University of São Paulo School of Medicine, São Paulo 05403-010, Brazil
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Michael FA, Gerber L, Weiler N, Hunyady PM, Abedin N, de la Vera ALL, Stoffers P, Filmann N, Zeuzem S, Bojunga J, Friedrich-Rust M, Dultz G. Transabdominal ultrasonography to reduce the burden of X-ray imaging in prophylactic pancreatic stent localization after ERCP-A prospective trial. United European Gastroenterol J 2021; 9:469-477. [PMID: 33887119 PMCID: PMC8259253 DOI: 10.1002/ueg2.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/13/2021] [Accepted: 02/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background Before performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X‐ray imaging is recommended to confirm the stents position in the pancreatic duct. Objectives The aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X‐ray imaging, which is currently the golden standard. Methods All patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X‐ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention. Results Fourty‐one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty‐nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8). Conclusion Transabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X‐ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.
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Affiliation(s)
| | - Ludmilla Gerber
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nina Weiler
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Marton Hunyady
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Nada Abedin
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Philipp Stoffers
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Georg Dultz
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
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21
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Sperna Weiland CJ, Smeets XJNM, Kievit W, Verdonk RC, Poen AC, Bhalla A, Venneman NG, Witteman BJM, da Costa DW, van Eijck BC, Schwartz MP, Römkens TEH, Vrolijk JM, Hadithi M, Voorburg AMCJ, Baak LC, Thijs WJ, van Wanrooij RL, Tan ACITL, Seerden TCJ, Keulemans YCA, de Wijkerslooth TR, van de Vrie W, van der Schaar P, van Dijk SM, Hallensleben NDL, Sperna Weiland RL, Timmerhuis HC, Umans DS, van Hooft JE, van Goor H, van Santvoort HC, Besselink MG, Bruno MJ, Fockens P, Drenth JPH, van Geenen EJM. Aggressive fluid hydration plus non-steroidal anti-inflammatory drugs versus non-steroidal anti-inflammatory drugs alone for post-endoscopic retrograde cholangiopancreatography pancreatitis (FLUYT): a multicentre, open-label, randomised, controlled trial. Lancet Gastroenterol Hepatol 2021; 6:350-358. [PMID: 33740415 DOI: 10.1016/s2468-1253(21)00057-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) is considered as standard of care to reduce the risk of post-ERCP pancreatitis. It has been suggested that aggressive hydration might further reduce this risk. Guidelines already recommend aggressive hydration in patients who are unable to receive rectal NSAIDs, although it is laborious and time consuming. We aimed to evaluate the added value of aggressive hydration in patients receiving prophylactic rectal NSAIDs. METHODS FLUYT, a multicentre, open-label, randomised, controlled trial done across 22 Dutch hospitals, included patients aged between 18 and 85 years with moderate to high risk of post-ERCP pancreatitis. Patients were randomly assigned (1:1) by a web-based module with varying block sizes to a combination of aggressive hydration and rectal NSAIDs (100 mg diclofenac or indomethacin; aggressive hydration group) or rectal NSAIDs (100 mg diclofenac or indomethacin) alone (control group). Randomisation was stratified according to treatment centre. Aggressive hydration comprised 20 mL/kg intravenous Ringer's lactate solution within 60 min from the start of ERCP, followed by 3 mL/kg per h for 8 h. The control group received normal intravenous saline with a maximum of 1·5 mL/kg per h and 3 L per 24 h. The primary endpoint was post-ERCP pancreatitis and was analysed on a modified intention-to-treat basis (including all patients who underwent randomisation and an ERCP and for whom data regarding the primary outcome were available). The trial is registered with the ISRCTN registry, ISRCTN13659155. FINDINGS Between June 5, 2015, and June 6, 2019, 826 patients were randomly assigned, of whom 388 in the aggressive hydration group and 425 in the control group were included in the modified intention-to-treat analysis. Post-ERCP pancreatitis occurred in 30 (8%) patients in the aggressive hydration group and in 39 (9%) patients in the control group (relative risk 0·84, 95% CI 0·53-1·33, p=0·53). There were no differences in serious adverse events, including hydration-related complications (relative risk 0·99, 95% CI 0·59-1·64; p=1·00), ERCP-related complications (0·90, 0·62-1·31; p=0·62), intensive care unit admission (0·37, 0·07-1·80; p=0·22), and 30-day mortality (0·95, 0·50-1·83; p=1·00). INTERPRETATION Aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk of developing this complication who routinely received prophylactic rectal NSAIDs. Therefore, the burden of laborious and time-consuming aggressive periprocedural hydration to further reduce the risk of post-ERCP pancreatitis is not justified. FUNDING Netherlands Organisation for Health Research and Development and Radboud University Medical Center.
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Affiliation(s)
- Christina J Sperna Weiland
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, Hagaziekenhuis, The Hague, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Ben J M Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Hoofddorp, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Annet M C J Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, Netherlands
| | - Lubbertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Roy L van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Yolande C A Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland Hospital, Heerlen, Netherlands
| | - Thomas R de Wijkerslooth
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Peter van der Schaar
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Sven M van Dijk
- Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nora D L Hallensleben
- Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands; Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, Netherlands
| | | | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands
| | - Devica S Umans
- Department of Research and Development, St Antonius Hospital, Nieuwegein, Netherlands; Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
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Shou-xin Y, Shuai H, Fan-guo K, Xing-yuan D, Jia-guo H, Tao P, Lin Q, Yan-sheng S, Ting-ting Y, Jing Z, Fang L, Hao-liang Q, Man L. Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A network meta-analysis. Medicine (Baltimore) 2020; 99:e22672. [PMID: 33080710 PMCID: PMC7571888 DOI: 10.1097/md.0000000000022672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND 100 mg rectal nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents both significantly reduce the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparison of randomized controlled trials (RCTs) between them in high-risk patients is absent. We conducted this network meta-analysis to indirectly compare the efficacies of 100 mg rectal NSAIDs and pancreatic stents in preventing post-ERCP pancreatitis (PEP) in high-risk patients and help us decide which is preferred in clinical practice. METHODS A comprehensive search was done to identify RCTs published in English full-text. Interventions included 100 mg rectal NSAIDs (diclofenac or indomethacin) and pancreatic stents. Only studies with high-risk patients of PEP were included. Meta-analyses of NSAIDs and pancreatic stents were conducted respectively. A network meta-analysis using the Bayesian method was performed. RESULTS We included 14 RCTs, 8 on pancreatic stents and 6 on 100 mg rectal NSAIDs in high-risk patients. There was no direct comparison between them. After excluding an outlier study on NSAIDs (n = 144), meta-analyses showed they both significantly and statistically reduced the incidence of PEP in high-risk patients (pancreatic stents: n = 8 studies, random-effects risk ratio (RR)0.41, 95%CI 0.30-0.56, I = 0%; NSAIDs: n = 5 studies, random-effects RR 0.37, 95%CI 0.25-0.54, I = 0%). And network meta-analysis showed efficacy of 100 mg rectal NSAIDs was equal to pancreatic stents (random-effects RR 0.94, 95%CI 0.50-1.8). CONCLUSIONS The efficacy of 100 mg rectal NSAIDs (diclofenac or indomethacin) seems equally significant to pancreatic stents in preventing PEP in high-risk patients. Considering the cost-effectiveness and safety, 100 mg diclofenac or indomethacin may be preferred.
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23
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Kalantzis I, Poulou A, Papatheodorou A, Gkoumas K. Rectal versus intramuscular diclofenac in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: experience of a Greek tertiary referral center. Ann Gastroenterol 2020; 33:412-417. [PMID: 32624663 PMCID: PMC7315719 DOI: 10.20524/aog.2020.0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/15/2019] [Indexed: 01/31/2023] Open
Abstract
Background: Independent patient-related and procedure-related factors increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis [PEP]). Non-steroidal anti-inflammatory drugs (NSAIDs) have demonstrated efficacy in reducing the incidence of PEP. This study investigated the difference in the incidence of PEP between intramuscular and rectal prophylactic administration of diclofenac before ERCP. Methods: We performed a retrospective analysis of data from 516 patients who underwent ERCP during the period 2014-2017. The route of diclofenac administration (rectal or intramuscular), patient-related and procedure-related risk factors, as well as serum amylase levels 18 h after the endoscopic procedure and immediate bleeding during ERCP were recorded and evaluated. Results: The overall incidence of PEP was 4.5%, without significant differences between the rectal (5.2%) and intramuscular (3.9%) routes of administration. The factor that appeared to be of significance was pre-cut sphincterotomy, since patients who underwent that procedure showed a higher probability of PEP (P=0.05; odds ratio 2.67, 95% confidence interval). Intraprocedural bleeding was almost twice as frequent in the rectal compared to the intramuscular group. Pancreatic stent placement did not appear to be statistically significant in the prevention of PEP, either alone or in combination with diclofenac administration. Conclusions: The results of our study did not reveal any statistically significant difference between the rectal or intramuscular administration of diclofenac in the prevention of PEP, contradicting the results of the majority of studies and meta-analyses published so far. One of the known risk factors associated with increased risk of PEP was also confirmed.
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Affiliation(s)
- Ioannis Kalantzis
- Department of Gastroenterology (Ioannis Kalantzis, Androniki Poulou, Konstantinos Gkoumas)
| | - Androniki Poulou
- Department of Gastroenterology (Ioannis Kalantzis, Androniki Poulou, Konstantinos Gkoumas)
| | - Athanasios Papatheodorou
- Department of Radiology (Athanasios Papatheodorou), Korgialeneio-Mpenakeio Hellenic Red Cross Hospital, Athens, Greece
| | - Konstantinos Gkoumas
- Department of Gastroenterology (Ioannis Kalantzis, Androniki Poulou, Konstantinos Gkoumas)
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24
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Devani K, Radadiya D, Brahmbhatt B. Pancreatic stent is the best tool to prevent post-ERCP pancreatitis in high-risk patients: Is the result from recent network meta-analysis valid? Endosc Int Open 2020; 8:E722-E723. [PMID: 32490155 PMCID: PMC7247900 DOI: 10.1055/a-1135-8883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Kalpit Devani
- Division of Gastroenterology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Dhruvil Radadiya
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, United States
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25
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Geng C, Li X, Li Y, Song S, Wang C. Nonsteroidal anti-inflammatory drugs alleviate severity of post-endoscopic retrograde cholangiopancreatography pancreatitis by inhibiting inflammation and reducing apoptosis. J Gastroenterol Hepatol 2020; 35:896-904. [PMID: 32064683 DOI: 10.1111/jgh.15012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/08/2020] [Accepted: 02/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM The prophylactic effect of nonselective nonsteroidal anti-inflammatory drugs on post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis has been observed for a long time. However, whether the selective nonsteroidal anti-inflammatory drugs possess similar abilities and the mechanisms by which nonsteroidal anti-inflammatory drugs work remain unclear. The present study aimed to determine the protective effects of nonsteroidal anti-inflammatory drugs on post-ERCP pancreatitis in a rat model and examine underlying mechanisms. METHODS Thirty-two female rats were equally and randomly divided into four groups: the sham group, post-ERCP pancreatitis model group, indomethacin-pretreated group, and parecoxib-pretreated group. Indomethacin or parecoxib was delivered 30 min prior to surgery; 24 h after post-ERCP pancreatitis establishment, the rats were sacrificed. Serum amylase and lipase activities, inflammatory cytokine release, pancreatic histopathological scores, neutrophil infiltration, and the expression pattern cyclooxygenase at the protein level and pancreatic apoptosis were quantified and analyzed. RESULTS Both indomethacin and parecoxib inhibited the activities of serum amylase and lipase and reduced the severity of pancreatic histopathology. Mechanistically, both drugs decreased the expression level of cyclooxygenase 2; however, they had no influence on the cyclooxygenase 1 protein level. Moreover, they reduced inflammatory cytokine release, neutrophil infiltration into the pancreas, and NF-κB p65 activation. Notably, we found that apoptotic cells in the pancreas were remarkably diminished after the administration of both nonsteroidal anti-inflammatory drugs. CONCLUSIONS Both selective and nonselective nonsteroidal anti-inflammatory drugs exert protective effects against post-ERCP pancreatitis by restraining inflammation and reducing acinar cell apoptosis through the inhibition of cyclooxygenase 2.
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Affiliation(s)
- Chong Geng
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiao Li
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
| | - Yanni Li
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
| | - Shuailing Song
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
| | - Chunhui Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
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26
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Park TY, Oh HC, Fogel EL, Lehman GA. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis with rectal non-steroidal anti-inflammatory drugs. Korean J Intern Med 2020; 35:535-543. [PMID: 32392660 PMCID: PMC7214369 DOI: 10.3904/kjim.2020.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/25/2020] [Indexed: 12/29/2022] Open
Abstract
Acute pancreatitis is the most common and feared adverse event associated with performance of endoscopic retrograde cholangiopancreatography (ERCP). Unremitting effort has been made for over 40 years to minimize the frequency and severity of this complication. Recently, the use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) have opened a new era for its prevention. This review focuses on the role of NSAIDs in pancreatitis, the pharmacokinetics of these agents, and summarizes the results of clinical trials with rectal NSAIDs alone and combination regimens in the prevention of post-ERCP pancreatitis.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Hyoung-Chul Oh
- Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Korea
- Correspondence to Hyoung-Chul Oh, M.D. Division of Gastroenterology, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea Tel: +82-2-6299-3149 Fax: +82-2-6299-3119 E-mail:
| | - Evan L. Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Njei B, McCarty TR, Muniraj T, Sharma P, Jamidar PA, Aslanian HR, Varadarajulu S, Navaneethan U. Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis. Endosc Int Open 2020; 8:E29-E40. [PMID: 31921982 PMCID: PMC6949176 DOI: 10.1055/a-1005-6366] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. Methods A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringer's (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = - 0.69, 95 % CI [-1.18; - 0.21]), pancreatic stent (B = - 1.25, 95 % CI [-1.81 to -0.69]), LR (B = - 0.67, 95 % CI [-1.20 to -0.13]), and combination of LR plus rectal NSAIDs (B = - 1.58; 95 % CI [-3.0 to -0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment. Conclusions Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.
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Affiliation(s)
- Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Thomas R. McCarty
- Department of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Thiruvengadam Muniraj
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Prabin Sharma
- Department of Gastroenterology and Hepatology, Yale New Haven Health-Bridgeport Hospital, Bridgeport, Connecticut, United States
| | - Priya A. Jamidar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Harry R. Aslanian
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, University of Central Florida College of Medicine, Orlando, Florida, United States
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, University of Central Florida College of Medicine, Orlando, Florida, United States
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28
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Zhang K, Arora P, Sati N, Béliveau A, Troke N, Veroniki AA, Rodrigues M, Rios P, Zarin W, Tricco AC. Characteristics and methods of incorporating randomized and nonrandomized evidence in network meta-analyses: a scoping review. J Clin Epidemiol 2019; 113:1-10. [DOI: 10.1016/j.jclinepi.2019.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 03/04/2019] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
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29
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Serum lipase as a biomarker for early prediction and diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis. Ir J Med Sci 2019; 189:163-170. [PMID: 31463894 DOI: 10.1007/s11845-019-02089-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lipase is one of the diagnostic criteria for acute pancreatitis; however, the value of serum lipase in the early prediction and diagnosis for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis remains controversial. AIMS We evaluate the 3-h post-ERCP serum amylase and lipase activities for early prediction of postoperative pancreatitis (PEP) and compare the 24-h post-ERCP serum amylase and lipase activities in the diagnosis of PEP. METHODS Clinical information of patients who underwent ERCP from January 2017 to December 2018 at our hospital were retrospectively reviewed. Receiver operating characteristic (ROC) curves were performed for 3-h and 24-h post-ERCP serum amylase and lipase activities to evaluate predictive and diagnostic values, respectively. RESULTS A total of 498 cases with ERCP were finally enrolled, in which 36 cases of PEP were confirmed. ROC curves for 3-h post-ERCP amylase and lipase activities depicted areas under the curve (AUCs) of 0.88 (P < 0.001, 95% confidence intervals [CI] 0.82-0.93) and 0.90 (P < 0.001, 95% CI 0.86-0.93), respectively. The difference showed no significance using Z test (Z = 0.69, P > 0.05). AUCs for 24-h amylase and lipase activities were 0.83 (P < 0.001, 95% CI 0.77-0.89) and 0.94 (P < 0.001, 95% CI 0.90-0.99), respectively, and the difference was significant (Z = 3.04, P < 0.05). CONCLUSIONS For early prediction of PEP, 3-h post-ERCP serum lipase activity is at least as good as that of amylase. For diagnosis of PEP, 24-h post-ERCP serum lipase is a much better indicator than that of amylase. Together, this study suggests that serum lipase should be given priority in the early prediction and diagnosis of PEP.
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Phillip V, Pukitis A, Epstein A, Hapfelmeier A, Haf D, Schwab M, Demir IE, Rosendahl J, Hoffmeister A, Schmid RM, Weber A, Algül H. Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial. Endosc Int Open 2019; 7:E860-E868. [PMID: 31281872 PMCID: PMC6609234 DOI: 10.1055/a-0886-6384] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 - 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.
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Affiliation(s)
- Veit Phillip
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Aldis Pukitis
- Pauls Stradins Clinical University Hospital, Center of Gastroenterology, Hepatology and Nutrition, Riga, Latvia
| | - Alexey Epstein
- First Clinical Hospital named after E.E. Volosevich, Arkhangelsk, Russia
| | - Alexander Hapfelmeier
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - David Haf
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Miriam Schwab
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ihsan Ekin Demir
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jonas Rosendahl
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Andreas Weber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany,Corresponding author Prof. Dr. Hana Algül, MPH Klinikum rechts der Isar, Technische Universität MünchenKlinik und Poliklinik für Innere Medizin IIIsmaningerstr. 22, 81675 MünchenGermany+49089-4140-4115
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Luo H, Wang X, Zhang R, Liang S, Kang X, Zhang X, Lou Q, Xiong K, Yang J, Si L, Liu W, Liu Y, Zhou Y, Wang S, Yang M, Chen W, Han Y, Shang G, Yang X, He Y, Zou Q, Guo W, Dai Y, Zeng W, Zhu X, Gong R, Li X, Nie Z, Wang Q, Wang L, Pan Y, Guo X, Fan D. Rectal Indomethacin and Spraying of Duodenal Papilla With Epinephrine Increases Risk of Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2019; 17:1597-1606.e5. [PMID: 30391434 DOI: 10.1016/j.cgh.2018.10.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rectal indomethacin and spraying of the duodenal papilla with epinephrine might reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We performed a randomized trial to compare the effects of the combination of indomethacin and epinephrine (IE) vs indomethacin plus saline (IS) in prophylaxis of post-ERCP pancreatitis (PEP). METHODS We performed a double-blind trial at 10 centers in China, from February 2017 to October 2017, of 1158 patients with native papilla undergoing ERCP. The patients were assigned randomly to groups given IE (n = 576) or IS (n = 582). All patients received a single dose of rectal indomethacin within 30 minutes before ERCP; 20 mL of dilute epinephrine (IE group) or saline (IS group) then was sprayed on the duodenal papilla at the end of ERCP. The primary outcome was the incidence of overall PEP. Data were analyzed on an intention-to-treat principle. RESULTS The study was terminated at the interim analysis for safety concerns and futility. The groups had similar baseline characteristics. PEP developed in 49 patients in the IE group (8.5%) and in 31 patients in the IS group (5.3%) (relative risk, 1.60, 95% CI, 1.03-2.47; P = .033). There were no significant differences between groups in proportions of patients with postsphincterotomy bleeding (2.1% in the IE group and 1.5% in the IS group) and biliary infection (1.2% in the IE group and 2.2% in the IS group). CONCLUSIONS In a randomized trial, we found the combination of rectal indomethacin with papillary epinephrine spraying increased the risk of PEP compared with indomethacin alone. Spray epinephrine should not be used with rectal indomethacin for prevention of post-ERCP pancreatitis. ClincialTrials.gov no: NCT03057769.
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Affiliation(s)
- Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Rongchun Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qifeng Lou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kangwei Xiong
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lijuan Si
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Wenming Liu
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Yunpeng Liu
- Department of Gastroenterology, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Yi Zhou
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Suli Wang
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Mei Yang
- Department of Gastroenterology, No 451 Military Hospital, Xi'an, China
| | - Wei Chen
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Yanzhi Han
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Guochen Shang
- Department of Gastroenterology, The First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, China
| | - Xiaocui Yang
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Yongfeng He
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Qiang Zou
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Wenwei Guo
- Endoscopy Center, Ankang Central Hospital, Ankang, China
| | - Yichen Dai
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Wei Zeng
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Xiaosan Zhu
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Rongqing Gong
- Department of Gastroenterology, Chenggong Hospital of Xiamen University, Xiamen, China
| | - Xun Li
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zhanguo Nie
- Department of Gastroenterology, Urumqi General Hospital of Lanzhou Military Region, Urumqi, China
| | - Qi Wang
- Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ling Wang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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van Wanrooij RLJ, van Hooft JE. Prevention of post-ERCP pancreatitis: NSAID or pancreatic stent or both? Endosc Int Open 2019; 7:E869-E870. [PMID: 31288260 PMCID: PMC6609235 DOI: 10.1055/a-0889-7796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- R. L. J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J. E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Single Versus Dual Prophylactic Modalities. Pancreas 2019; 48:e24. [PMID: 30973466 DOI: 10.1097/mpa.0000000000001281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Knowledge of pancreatitis in the 20th century was shaped predominantly by animal data and clinical trials. Several large general population-based cohort studies and comprehensive systematic literature reviews in the 21st century have had a major effect on our understanding of pancreatitis and its sequelae. This Review provides precise and up-to-date data on the burden of acute pancreatitis, chronic pancreatitis and post-pancreatitis diabetes mellitus. Exocrine pancreatic insufficiency and altered bone metabolism following pancreatitis are also discussed. Furthermore, the article introduces a framework for the holistic prevention of pancreatitis with a view to providing guidance on strategies and intervention objectives at primary, secondary and tertiary levels. Concerted efforts by not only gastroenterologists and surgeons but also primary care physicians, endocrinologists, radiologists, pain specialists, dietitians, epidemiologists and public health specialists will be required to reduce meaningfully the burden of pancreatitis and its sequelae over the ensuing decades.
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Affiliation(s)
- Maxim S. Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,
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Risk Factors for Post-ERCP Pancreatitis in High-Risk Patients Receiving Post-procedure Rectal Indomethacin. J Gastrointest Surg 2018; 22:1903-1910. [PMID: 29980976 DOI: 10.1007/s11605-018-3864-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-ERCP pancreatitis (PEP) is the most common adverse event of ERCP. Rectal indomethacin has been widely administered to decrease the incidence of PEP in high-risk patients. However, it cannot completely prevent the occurrence of PEP. The purpose of the study was to evaluate the risk factors for PEP in high-risk patients receiving post-ERCP indomethacin. METHODS From June 2012 to July 2015, patients undergoing ERCP and at high risk for PEP in three tertiary hospitals in China were enrolled. All patients received indomethacin after the procedure. Patient-related and procedure-related risk factors for PEP were collected. Logistic regression analysis was used to investigate the risk factors. RESULTS Seven hundred ninety patients at high risk for PEP received post-ERCP indomethacin. The incidence of overall PEP and moderate-to-severe PEP was 8.0 and 1.5%, respectively. In multivariate analysis, suspected sphincter of Oddi dysfunction (SOD) (OR 2.73; 95%CI 1.38-5.43; p = 0.004), the presence of hilar obstruction (OR 4.53; 95%CI 1.60-12.81; p = 0.004), number of cannulation attempts ≥ 13 (OR 2.00; 95%CI 1.07-3.77; p = 0.030), inadvertent pancreatic duct (PD) cannulation ≥ 1 (OR 2.26; 95%CI 1.04-4.90; p = 0.040), and pancreatic contrast injections ≥ 1 (OR 2.30; 95%CI 1.02-5.23; p = 0.046) were high risk factors for overall PEP. For moderate-to-severe PEP, suspected SOD (OR 4.67; 1.19-18.35; p = 0.027), the presence of hilar obstruction (OR 7.95; 1.39-44.97; p = 0.010), and more cannulation attempts (OR 3.71; 1.09-12.65; p = 0.036) were three independent risk factors. CONCLUSIONS A substantial number of high-risk patients had PEP even receiving post-ERCP rectal indomethacin. The independent risk factors included suspected SOD, hilar stricture, more cannulation attempts, inadvertent PD cannulation, and PD contrast injections. TRIAL REGISTRATION NCT02709421.
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Leerhøy B, Elmunzer BJ. How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2018; 28:439-454. [PMID: 30241637 DOI: 10.1016/j.giec.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatitis remains the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Recent advances in prophylaxis have improved but not eliminated this problem, underscoring the importance of ongoing research toward this goal. This review aims to provide an evidence-based approach to post-ERCP pancreatitis prevention through patient selection, risk stratification, procedural technique, and multimodality prophylaxis, and discusses ongoing and future research initiatives in this important area.
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Affiliation(s)
- Bonna Leerhøy
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen Nielsine Nielsens Vej 11, entrance 8, Copenhagen DK-2400, Denmark
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty Street, Suite 249, Charleston, SC 29425, USA.
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Smeets XJNM, da Costa DW, Fockens P, Mulder CJJ, Timmer R, Kievit W, Zegers M, Bruno MJ, Besselink MGH, Vleggaar FP, van der Hulst RWM, Poen AC, Heine GDN, Venneman NG, Kolkman JJ, Baak LC, Römkens TEH, van Dijk SM, Hallensleben NDL, van de Vrie W, Seerden TCJ, Tan ACITL, Voorburg AMCJ, Poley JW, Witteman BJ, Bhalla A, Hadithi M, Thijs WJ, Schwartz MP, Vrolijk JM, Verdonk RC, van Delft F, Keulemans Y, van Goor H, Drenth JPH, van Geenen EJM. Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): study protocol for a randomized controlled trial. Trials 2018; 19:207. [PMID: 29606135 PMCID: PMC5879873 DOI: 10.1186/s13063-018-2583-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP and may run a severe course. Evidence suggests that vigorous periprocedural hydration can prevent PEP, but studies to date have significant methodological drawbacks. Importantly, evidence for its added value in patients already receiving prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs) is lacking and the cost-effectiveness of the approach has not been investigated. We hypothesize that combination therapy of rectal NSAIDs and periprocedural hydration would significantly lower the incidence of post-ERCP pancreatitis compared to rectal NSAIDs alone in moderate- to high-risk patients undergoing ERCP. Methods The FLUYT trial is a multicenter, parallel group, open label, superiority randomized controlled trial. A total of 826 moderate- to high-risk patients undergoing ERCP that receive prophylactic rectal NSAIDs will be randomized to a control group (no fluids or normal saline with a maximum of 1.5 mL/kg/h and 3 L/24 h) or intervention group (lactated Ringer’s solution with 20 mL/kg over 60 min at start of ERCP, followed by 3 mL/kg/h for 8 h thereafter). The primary endpoint is the incidence of post-ERCP pancreatitis. Secondary endpoints include PEP severity, hydration-related complications, and cost-effectiveness. Discussion The FLUYT trial design, including hydration schedule, fluid type, and sample size, maximize its power of identifying a potential difference in post-ERCP pancreatitis incidence in patients receiving prophylactic rectal NSAIDs. Trial registration EudraCT: 2015-000829-37. Registered on 18 February 2015. ISRCTN: 13659155. Registered on 18 May 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2583-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands.
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marieke Zegers
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, PO 85500, 3508 GA, Utrecht, The Netherlands
| | - Rene W M van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, PO 417, 2000 AK, Haarlem, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Klinieken, PO 10400, 8000 GK, Zwolle, The Netherlands
| | - Gerbrand D N Heine
- Department of Gastroenterology and Hepatology, Noord-West Hospital, PO 501, 1800 AM, Alkmaar, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Lubbertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090 HM, Amsterdam, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200 ME, s'Hertogenbosch, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300 AK, Dordrecht, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800 RK, Breda, The Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500 GS, Nijmegen, The Netherlands
| | - Annet M C J Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis, PO 80250, 3508 TG, Utrecht, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, PO 9025, 6710 HN, Ede, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA Hospital, PO 40551, 2504 LN, The Hague, The Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, PO 9100, 3007 AC, Rotterdam, The Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700 RM, Groningen, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, PO 1502, 3800 BM, Amersfoort, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800 TA, Arnhem, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland, PO 5500, 6130 MB, Sittard-Geleen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
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Yaghoobi M, Alzahrani MA, McNabb-Baltar J, Martel M, Barkun AN. Rectal Indomethacin Prevents Moderate to Severe Post-ERCP Pancreatitis and Death and Should Be Used Before the Procedure: A Meta-Analysis of Aggregate Subgroup Data. J Can Assoc Gastroenterol 2018; 1:67-75. [PMID: 31294402 PMCID: PMC6487993 DOI: 10.1093/jcag/gwy006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Despite overall evidence in the literature favoring rectal indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its role in preventing potentially fatal complications is not well explored. Method A comprehensive electronic literature search was done to select randomized controlled trials (RCTs) comparing rectal indomethacin and placebo in preventing PEP. Methodological quality was assessed using the Cochrane risk of bias tool. Statistical heterogeneity was characterized. Random effect model meta-analysis was used. Several subgroup, sensitivity and aggregate subgroup data analyses were completed based on specific risk factors or patient characteristics to identify patient populations who may benefit most from rectal indomethacin. Results A total of eight out of 336 trials published between 2007 and 2016 (n=3324) were included. Analysis showed administering rectal indomethacin before rather than during or after ERCP significantly reduced PEP rates (odds ratio (OR): 0.56 [0.40-079]). Rectal indomethacin also significantly decreased the rate of moderate to severe PEP and death amongst all patients (OR: 0.53 [0.31-0.89] and 0.10 [0.02-0.65], respectively). Rectal indomethacin significantly prevented PEP in patients with sphincter of Oddi dysfunction (SOD) (OR: 0.49 [0.30-0.78]) and those undergoing biliary sphincterotomy (OR: 0.63 [0.42-0.95]), but not in those undergoing precut or pancreatic sphincterotomy or prophylactic pancreatic stent placement. Sensitivity analysis showed that the effect remained significant after two studies with high risk of bias were excluded. Conclusion Rectal indomethacin significantly decreases the occurrence of moderate to severe PEP and death in all patients, only if given before the procedure.
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Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton, ON, Canada.,Cochrane Upper GI and Pancreatic Group, Hamilton, ON, Canada
| | | | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Sciences, Montreal QC, Canada
| | - Alan N Barkun
- Cochrane Upper GI and Pancreatic Group, Hamilton, ON, Canada.,Division of Gastroenterology, McGill University Health Sciences, Montreal QC, Canada
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Abstract
Pancreatitis is the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in significant morbidity, occasional mortality, and increased health-care expenditure. Accordingly, the prevention of post-ERCP pancreatitis (PEP) remains a major clinical and research priority. Strategies to reduce the incidence of PEP include thoughtful patient selection, appropriate risk-stratification, sound procedural technique, prophylactic pancreatic stent placement, and pharmacoprevention. Despite advances in all these areas, however, the incidence of PEP remains as high as 15% in high-risk cases. Thus, additional research towards the goal of eliminating PEP is necessary. Herein is an evidence-based review of strategies to prevent pancreatitis after ERCP, focusing on recent important developments in the field.
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Affiliation(s)
- B Joseph Elmunzer
- The Peter B. Cotton Endowed Chair in Endoscopic Innovation, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, USA
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40
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Patai Á, Solymosi N, Mohácsi L, Patai ÁV. Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials. Gastrointest Endosc 2017; 85:1144-1156.e1. [PMID: 28167118 DOI: 10.1016/j.gie.2017.01.033] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Diclofenac and indomethacin are the most studied drugs for preventing post-ERCP pancreatitis (PEP). However, there are no prospective, randomized multicenter trials with a sufficient number of patients for correct evaluation of their efficacy. Our aim was to evaluate all prospective trials published in full text that studied the efficacy of diclofenac or indomethacin and were controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP. METHODS Systematic search of databases (PubMed, Scopus, Web of Science, Cochrane) for relevant studies published from inception to 30 June 2016. RESULTS Our meta-analysis of 4741 patients from 17 trials showed that diclofenac or indomethacin significantly decreased the risk ratio (RR) of PEP to 0.60 (95% confidence interval [CI], 0.46-0.78; P = .0001), number needed to treat (NNT) was 20, and the reduction of RR of moderate to severe PEP was 0.64 (95% CI, 0.43-0.97; P = .0339). The efficacy of indomethacin compared with diclofenac was similar (P = .98). The efficacy of indomethacin or diclofenac did not differ according to timing (P = .99) or between patients with average-risk and high-risk for PEP (P = .6923). The effect of non-rectal administration of indomethacin or diclofenac was not significant (P = .1507), but the rectal route was very effective (P = .0005) with an NNT of 19. The administration of indomethacin or diclofenac was avoided in patients with renal failure. Substantial adverse events were not detected. CONCLUSIONS The use of rectally administered diclofenac or indomethacin before or closely after ERCP is inexpensive and safe and is recommended in every patient (without renal failure) undergoing ERCP. (Registration number: CRD42016042726, http://www.crd.york.ac.uk/prospero/.).
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Affiliation(s)
- Árpád Patai
- Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - Norbert Solymosi
- Biometeorology Research Group, University of Veterinary Medicine, Budapest, Hungary
| | - László Mohácsi
- Department of Computer Science, Corvinus University of Budapest, Budapest, Hungary
| | - Árpád V Patai
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
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41
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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42
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Bekkali NLH, Johnson GJ. Training in ERCP and EUS in the UK anno 2017. Frontline Gastroenterol 2017; 8:124-128. [PMID: 28839896 PMCID: PMC5369444 DOI: 10.1136/flgastro-2016-100771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/11/2016] [Indexed: 02/06/2023] Open
Abstract
In the last 20 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a diagnostic procedure to being almost exclusively therapeutic. Similarly, endoscopic ultrasound (EUS) is developing into ever-increasing therapeutic roles. Operator technique is central to diagnostic accuracy in EUS, as is effective and safer therapy for both ERCP and therapeutic EUS. Hence, effective training and robust standards for certification and revalidation are required to ensure ERCP and EUS in the UK are as effective and as safe as possible.
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Affiliation(s)
- Noor LH Bekkali
- GI Services, University College London Hospitals, London, UK,Pancreatobiliary Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gavin J Johnson
- GI Services, University College London Hospitals, London, UK
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43
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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44
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Parekh PJ, Majithia R, Sikka SK, Baron TH. The "Scope" of Post-ERCP Pancreatitis. Mayo Clin Proc 2017; 92:434-448. [PMID: 28160947 DOI: 10.1016/j.mayocp.2016.10.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/22/2016] [Accepted: 10/31/2016] [Indexed: 12/14/2022]
Abstract
Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.
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Affiliation(s)
- Parth J Parekh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tulane University, New Orleans, LA
| | - Raj Majithia
- Division of Gastroenterology and Hepatology, University of North Carolina-Johnston Healthcare, Smithfield
| | - Sanjay K Sikka
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tulane University, New Orleans, LA
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill.
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45
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Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, Ponnudurai R, Lakhtakia S, Lee DK, Ratanachu-Ek T, Yasuda I, Dy FT, Ho SH, Makmun D, Liang HL, Draganov PV, Rerknimitr R, Wang HP. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85:295-304. [PMID: 27720741 DOI: 10.1016/j.gie.2016.09.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/28/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Phonthep Angsuwatcharakon
- Department of Anatomy and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Global Hopsitals, Parel, Mumbai, India
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher J L Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Ryan Ponnudurai
- Division of Gastroenterology, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Dong-Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Thawee Ratanachu-Ek
- Department of Surgery, Rajavithi Hospital, Rangsit Medical College, Bangkok, Thailand
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | | | - Shiaw-Hooi Ho
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dadang Makmun
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Huei-Lung Liang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Peter V Draganov
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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46
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 444] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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47
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Endoscopic and pharmacological treatment for prophylaxis against postendoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis and systematic review. Eur J Gastroenterol Hepatol 2016; 28:1415-1424. [PMID: 27580214 DOI: 10.1097/meg.0000000000000734] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) is the most common complication following ERCP. We carried out a systematic review and meta-analysis of the global literature on PEP prevention to provide clinical guidance and a framework for future research in this important field. METHODS PubMed, Embase, Science Citation Index, Ovid, and the Cochrane Controlled Trials Register were searched by two independent reviewers to identify full-length, prospective, randomized controlled trials (RCTs) published up until March 2016 investigating the use of pancreatic duct stents and pharmacological agents to prevent PEP. RESULTS Twelve RCTs comparing the risk of PEP after pancreatic duct stent placement (1369 patients) and 30 RCTs comparing pharmacological agents over placebo (10251 patients) fulfilled the inclusion criteria and were selected for final review and analysis. Meta-analysis showed that prophylactic pancreatic stents significantly decreased the odds of post-ERCP pancreatitis [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.18-0.42]. Significant OR reduction of PEP was also observed in relation to rectal administration of diclofenac (OR, 0.24; 95% CI, 0.12-0.48) and rectal administration of indometacin (OR, 0.59; 95% CI, 0.44-0.79) compared with placebo. Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). CONCLUSION Pancreatic stent placement, rectal diclofenac, and bolus administration of somatostatin appear to be most effective in preventing post-ERCP pancreatitis.
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48
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Wang AY, Strand DS, Shami VM. Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques. Clin Gastroenterol Hepatol 2016; 14:1521-1532.e3. [PMID: 27237430 DOI: 10.1016/j.cgh.2016.05.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
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49
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Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30:793-805. [PMID: 27931637 DOI: 10.1016/j.bpg.2016.10.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 01/31/2023]
Abstract
Even though considered safe, endoscopic retrograde cholangiopancreatography (ERCP) is among the endoscopic procedures associated with the highest rate of complications. Post ERCP pancreatitis (PEP) is the most common complication of ERCP. Several independent risk factors have been associated with PEP. Prophylactic PD stenting has been shown to be highly effective in preventing PEP. More recent studies have suggested that NSAIDs, especially rectal indomethacin, could by itself be effective in preventing PEP. However, head to head RCTs comparing PD stents with NSAIDs would be required to confirm this. Other complications include ERCP induced bleeding, perforation, and cholangitis. Bleeding is related to morphological, procedural, and patient related factors. Early identification and correction of the risk factors are of paramount importance in preventing bleeding. Risk of infection is particularly high during ERCP. It is important to ensure complete drainage of obstructed biliary system in order to reduce the risk of post-ERCP cholangitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India; Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India.
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50
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Cho YD, Cha SW. [Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 68:64-9. [PMID: 27554212 DOI: 10.4166/kjg.2016.68.2.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.
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Affiliation(s)
- Young Deok Cho
- Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Seoul, Korea
| | - Sang Woo Cha
- Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Seoul, Korea
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