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Akshintala VS, Singh VK. Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Pathophysiology and Prevention. Gastrointest Endosc Clin N Am 2023; 33:771-787. [PMID: 37709410 DOI: 10.1016/j.giec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreato-biliary disorders. Pancreatitis remains the most frequent complication of the ERCP procedure, and it is, therefore, necessary to recognize the pathophysiology and risk factors contributing to the development of pancreatitis and understand the methods to prevent this complication.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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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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Sperna Weiland CJ, Engels MML, Poen AC, Bhalla A, Venneman NG, van Hooft JE, Bruno MJ, Verdonk RC, Fockens P, Drenth JPH, van Geenen EJM. Increased Use of Prophylactic Measures in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2021; 66:4457-4466. [PMID: 33630216 PMCID: PMC8589790 DOI: 10.1007/s10620-020-06796-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic duct stenting, and intensive intravenous hydration have been proven to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Trial participation and guideline changes demanded an assessment of the clinical practice of post-ERCP pancreatitis prophylaxis. AIMS The surveys aim to identify points of improvement to inform and educate ERCPists about current evidence-based practice. METHODS Two anonymous surveys were conducted among Dutch gastroenterologists in 2013 (n = 408) and 2020 (n = 575) for longitudinal views and attitudes pertaining to post-ERCP pancreatitis prophylaxis and recognition of post-ERCP pancreatitis risk factors. RESULTS In 2013 and 2020, respectively, 121 and 109 ERCPists responded. In the 2013 survey, 98% of them utilized NSAID prophylaxis and 62% pancreatic duct stent prophylaxis in specific cases. In the 2020 survey, the use of NSAIDs (100%), pancreatic duct stents (78%), and intensive intravenous hydration (33%) increased among ERCPists. NSAID prophylaxis was the preferred prophylactic measure for all risk factors in the 2020 survey, except for ampullectomy, pancreatic duct contrast injection, and pancreatic duct cannulation, for which NSAID prophylaxis and pancreatic duct stent combined was equally favored or preferred. CONCLUSION Rectal NSAIDs are the most applied post-ERCP pancreatitis prophylaxis in the Netherlands, followed by pancreatic duct stents and intensive intravenous hydration. Additionally, there is reason to believe that recent guideline updates and active research participation have led to increased prophylaxis implementation.
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Affiliation(s)
- Christina J. Sperna Weiland
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands ,Department of Research and Development, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Megan M. L. Engels
- Department of Research and Development, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, Hagaziekenhuis, The Hague, The Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost P. H. Drenth
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
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Reichstein JB, Patel V, Mekaroonkamol P, Dacha S, Keilin SA, Cai Q, Willingham FF. Practice Patterns and Use of Endoscopic Retrograde Cholangiopancreatography in the Management of Recurrent Acute Pancreatitis. Clin Endosc 2019; 53:73-81. [PMID: 31273969 PMCID: PMC7003016 DOI: 10.5946/ce.2019.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022] Open
Abstract
Background/Aims There are conflicting opinions regarding the management of recurrent acute pancreatitis (RAP). While some physicians recommend endoscopic retrograde cholangiopancreatography (ERCP) in this setting, others consider it to be contraindicated in patients with RAP. The aim of this study was to assess the practice patterns and clinical features influencing the management of RAP in the US.
Methods An anonymous 35-question survey instrument was developed and refined through multiple iterations, and its use was approved by our Institutional Review Board. The survey was distributed via email to 408 gastroenterologists to assess the practice patterns in the management of RAP in multiple clinical scenarios.
Results The survey was completed by 65 participants representing 36 of the top academic/tertiary care centers across the country. Approximately 90.8% of the participants indicated that they might offer or recommend ERCP in the management of RAP. Multinomial logistic regression analysis revealed that ductal dilatation and presence of symptoms were the most predictive variables (p<0.001) for offering ERCP.
Conclusions A preponderance of the respondents would consider ERCP among patients with RAP presenting to tertiary care centers in the US. Ductal dilatation, presence of symptoms, and pancreas divisum significantly increased the likelihood of a recommendation for ERCP.
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Affiliation(s)
| | - Vaishali Patel
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Parit Mekaroonkamol
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Sunil Dacha
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Field F Willingham
- Division of Digestive Disease, Department of Medicine, Emory University, Atlanta, GA, USA
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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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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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Shen C, Shi Y, Liang T, Su P. Rectal NSAIDs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in unselected patients: Systematic review and meta-analysis. Dig Endosc 2017; 29:281-290. [PMID: 28112441 DOI: 10.1111/den.12816] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Efficacy of rectal non-steroidal anti-inflammatory drugs (NSAIDs) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis in unselected patients remained controversial. The aim of the present study was to evaluate the efficacy of rectal NSAIDs in the prevention of PEP in unselected patients. METHODS An electronic literature search in the Cochrane Library, Embase, and PubMed was carried out for randomized controlled trials comparing rectal indomethacin or diclofenac with placebo in the prevention of PEP in unselected patients. Cochrane risk of bias tool was used to evaluate methodological quality. The data were carried out in forest plots using fixed-effect methods, and random-effect methods were used when heterogeneity was significant. RESULTS A total of nine trials were included in our final analysis. Rectal NSAIDs were effective to reduce the incidence of PEP in unselected patients (RR, 0.61; 95% CI, 0.46-0.79), especially for moderate-to-severe PEP (RR, 0.37; 95% CI, 0.17-0.79). Both indomethacin (RR, 0.67; 95% CI, 0.50-0.88) and diclofenac (RR, 0.29; 95% CI, 0.12-0.69) were significantly efficacious. Rectal NSAIDs given pre-ERCP showed significant efficacy (RR, 0.53; 95% CI, 0.39-0.71), whether when given within 30 min pre-ERCP (RR, 0.62; 95% CI, 0.42-0.92) or not (RR, 0.43; 95% CI, 0.28-0.67). CONCLUSION Rectal NSAIDs are effective in the prevention of PEP in unselected patients.
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Affiliation(s)
- Chongrong Shen
- The Second Clinical Medical School, Southern Medical University, Guangzhou City, China
| | - Yanqiang Shi
- The Second Clinical Medical School, Southern Medical University, Guangzhou City, China
| | - Tianyu Liang
- The Second Clinical Medical School, Southern Medical University, Guangzhou City, China
| | - Peizhu Su
- Department of Gastroenterology, First People's Hospital of Foshan Affiliated to Sun Yat-sen University, Foshan City, China
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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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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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Elmunzer BJ, Serrano J, Chak A, Edmundowicz SA, Papachristou GI, Scheiman JM, Singh VK, Varadarajulu S, Vargo JJ, Willingham FF, Baron TH, Coté GA, Romagnuolo J, Wood-Williams A, Depue EK, Spitzer RL, Spino C, Foster LD, Durkalski V. Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials 2016; 17:120. [PMID: 26941086 PMCID: PMC4778337 DOI: 10.1186/s13063-016-1251-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/23/2016] [Indexed: 12/15/2022] Open
Abstract
Background The combination of prophylactic pancreatic stent placement (PSP) – a temporary plastic stent placed in the pancreatic duct – and rectal non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Preliminary data, however, suggest that PSP may be unnecessary if rectal NSAIDs are administered. Given the costs and potential risks of PSP, we aim to determine whether rectal indomethacin obviates the need for pancreatic stent placement in patients undergoing high-risk ERCP. Methods/Design The SVI (Stent vs. Indomethacin) trial is a comparative effectiveness, multicenter, randomized, double-blind, non-inferiority study of rectal indomethacin alone versus the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases. One thousand four hundred and thirty subjects undergoing high-risk ERCP, in whom PSP is planned solely for PEP prevention, will be randomized to indomethacin alone or combination therapy. Those who are aware of study group assignment, including the endoscopist, will not be involved in the post-procedure care of the patient for at least 48 hours. Subjects will be assessed for PEP and its severity by a panel of independent and blinded adjudicators. Indomethacin alone will be declared non-inferior to combination therapy if the two-sided 95 % upper confidence bound of the treatment difference is less than 5 % between the two groups. Biological specimens will be obtained from trial participants and centrally banked. Discussion The SVI trial is designed to determine whether PSP remains necessary in the era of NSAIDs pharmacoprevention. The associated bio-repository will establish the groundwork for important scientific breakthrough. Trial registration NCT02476279, registered June 2015.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Jose Serrano
- Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA.
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA.
| | - John J Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | | | - April Wood-Williams
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Emily K Depue
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Cathie Spino
- Department of Public Health, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Valerie Durkalski
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
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Elmunzer BJ. Preventing Postendoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:725-36. [PMID: 26431600 DOI: 10.1016/j.giec.2015.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postendoscopic retrograde cholangiopancreatography pancreatitis is a common and potentially devastating complication of endoscopic retrograde cholangiopancreatography. Advances in risk-stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the ability to prevent this complication. This article presents the evidence-based approaches to preventing postendoscopic retrograde cholangiopancreatography pancreatitis and discusses timely research questions in this important area.
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Affiliation(s)
- 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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12
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Choksi NS, Fogel EL, Cote GA, Romagnuolo J, Elta GH, Scheiman JM, Chak A, Mosler P, Higgins PDR, Korsnes SJ, Schmidt SE, Sherman S, Lehman GA, Elmunzer BJ. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement. Gastrointest Endosc 2015; 81:150-5. [PMID: 25527053 DOI: 10.1016/j.gie.2014.07.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/11/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP). OBJECTIVE To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk. DESIGN Secondary analysis of randomized, controlled trial data. SETTING University of Michigan and Indiana University. PATIENTS A total of 577 clinical trial participants at elevated risk for PEP. INTERVENTIONS Pancreatic stent placement. MAIN OUTCOME MEASUREMENTS Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort. RESULTS The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP. LIMITATIONS Low event rate, FPS not prospectively captured. CONCLUSION FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases.
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Affiliation(s)
- Neel S Choksi
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Evan L Fogel
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Gregory A Cote
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Joseph Romagnuolo
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Patrick Mosler
- Division of Digestive Diseases and Nutrition, University of Kentucky Medical Center, Lexington, Kentucky, USA; Division of Gastroenterology and Hepatology, Kantonsspital Graubuenden, Chur, Switzerland
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Sheryl J Korsnes
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Suzette E Schmidt
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Chang WI, Min YW, Yun HS, Lee KH, Lee JK, Lee KT, Rhee PL. Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study. Gut Liver 2014; 8:306-12. [PMID: 24827628 PMCID: PMC4026649 DOI: 10.5009/gnl.2014.8.3.306] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background/Aims We investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy. Methods This retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis. Results There was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection. Conclusions Our data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.
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Affiliation(s)
- Woo Ik Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwan Sic Yun
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kyun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hanna MS, Portal AJ, Dhanda AD, Przemioslo R. UK wide survey on the prevention of post-ERCP pancreatitis. Frontline Gastroenterol 2014; 5:103-110. [PMID: 24724007 PMCID: PMC3977499 DOI: 10.1136/flgastro-2013-100323] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 08/08/2013] [Accepted: 08/14/2013] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE In 2010, the European Society of Gastrointestinal Endoscopy delivered guidelines on the prophylaxis of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP). These included Grade A recommendations advising the use of prophylactic pancreatic stent (PPS) and non-steroidal anti-inflammatory drugs (NSAIDs) in high-risk cases. Our study aim was to capture the current practice of UK biliary endoscopists in the prevention of PEP. DESIGN In summer 2012, an anonymous online 15-item survey was emailed to 373 UK consultant gastroenterologists, gastrointestinal surgeons and radiologists identified to perform ERCP. RESULTS The response rate was 59.5% (222/373). Of the respondents, 52.5% considered ever using PPS for the prevention of PEP. PPS users always attempted insertion for the following procedural risk factors: pancreatic sphincterotomy (48.9%), suspected sphincter of Oddi dysfunction (46.5%), pancreatic duct instrumentation (35.9%), previous PEP (25.2%), precut sphincterotomy (8.5%) and pancreatic duct injection (7.8%). Prophylactic NSAID use was significantly associated with attempts at PPS placement (p<0.001). 64.1% of non-PPS users cited a lack of conviction in their benefit as the main reason for their decision. Self-reported pharmacological use rates for PEP prevention were: NSAIDs (34.6%), antibiotics (20.6%), rapid intravenous fluids (13.2%) and octreotide (1.6%). 6% routinely measured amylase post-ERCP. CONCLUSIONS Despite strong evidence-based guidelines for prevention of PEP, less than 53% of ERCP practitioners use pancreatic stenting or NSAIDs. This suggests a need for the development of British Society of Gastroenterology guidelines to increase awareness in the UK. Even among stent users, PPS are being underused for most high-risk cases. Prophylactic pharmacological measures were rarely used as was routine post-ERCP serum amylase measurement.
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Affiliation(s)
- Mina S Hanna
- Department of Gastroenterology and Hepatology, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Andrew J Portal
- Department of Gastroenterology and Hepatology, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Ashwin D Dhanda
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Robert Przemioslo
- Department of Gastroenterology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is performed commonly for therapy. Its role in pancreaticobiliary diagnostic imaging has significantly decreased over time. Despite advances in our knowledge of the risk factors, complications, (especially post-ERCP pancreatitis), remain a significant problem. This review highlights the risk factors as related to the patient, procedure and the endoscopist, and the possible means to prevent complications. The best way to avoid any complication is "to avoid any procedure where the indication is not strong" and especially to refrain from doing diagnostic ERCP when alternate noninvasive imaging such as magnetic resonance cholangiopancreatography is available.
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Affiliation(s)
- Nalini M Guda
- St. Luke's Medical Center and University of Wisconsin School of Medicine and Public Health, Milwaukee, USA
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Sun HL, Han B, Zhai HP, Cheng XH, Ma K. Rectal NSAIDs for the prevention of post-ERCP pancreatitis: a meta-analysis of randomized controlled trials. Surgeon 2013; 12:141-7. [PMID: 24332479 DOI: 10.1016/j.surge.2013.10.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 10/26/2013] [Accepted: 10/28/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Acute pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). We conducted a meta-analysis to evaluate the efficacy and safety of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis (PEP). METHODS PubMed and Embase databases were searched through April 2013. Results are reported as relative risk (RR) or weighted mean difference (WMD) with 95% confidence interval (95% CI). The primary outcome measure was the incidence of PEP. Secondary outcome measures included the severity of PEP and serum amylase level 2 h, 24 h after ERCP. RESULTS Seven trials containing 1846 patients were eligible. Rectal NSAIDs significantly reduced the incidence of PEP (RR 0.45, 95% CI 0.34-0.61, P < 0.001). The results were maintained in subsequent subgroup analysis. Rectal NSAIDs also was associated with a reduction in the incidence of mild PEP (RR 0.54, 95% CI 0.35-0.83, P = 0.005), moderate to severe PEP (RR 0.39, 95% CI 0.22-0.70, P = 0.002), or serum amylase level 2 h after ERCP (WMD -91.09 IU/L, 95% CI -149.78 to -32.40, P = 0.002). CONCLUSIONS Rectal NSAIDs reduced the incidence and severity of PEP, as well as serum amylase level 2 h after ERCP.
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Affiliation(s)
- Hong-Li Sun
- Department of Biliary Vascular Surgery, Shenjing Hospital of China Medical University, Shenyang 110004, China
| | - Bing Han
- Department of Biliary Vascular Surgery, Shenjing Hospital of China Medical University, Shenyang 110004, China
| | - Hong-Peng Zhai
- Department of General Surgery, Central Hospital of Shenyang Medical College, Shenyang 110004, China
| | - Xin-Hua Cheng
- Department of Biliary Vascular Surgery, Shenjing Hospital of China Medical University, Shenyang 110004, China
| | - Kai Ma
- Department of Biliary Vascular Surgery, Shenjing Hospital of China Medical University, Shenyang 110004, China.
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Kubiliun NM, Elmunzer BJ. Preventing pancreatitis after endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23:769-86. [PMID: 24079789 DOI: 10.1016/j.giec.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Gastroenterology, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109, USA
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Takenaka M, Fujita T, Sugiyama D, Masuda A, Shiomi H, Sugimoto M, Sanuki T, Hayakumo T, Azuma T, Kutsumi H. What is the most adapted indication of prophylactic pancreatic duct stent within the high-risk group of post-endoscopic retrograde cholangiopancreatography pancreatitis? Using the propensity score analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:275-80. [PMID: 24039185 DOI: 10.1002/jhbp.24] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Conducting randomized controlled trial (RCT) for each of the risk factors associated with prophylactic pancreatic duct stent (PPDS) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is difficult owing to the volume of cases and ethical considerations. In this study, we tried to reveal the degree of preventive effects of PPDS for each individual risk factor within the high-risk group of PEP using the propensity score analysis. METHODS The clinical data of 1131 ERCP practices performed at Kobe University Hospital from April 2006 to February 2009 were collected prospectively. We investigated their clinical characteristics including the risk factors of PEP, the use of PPDS and complications of ERCP. We conducted the stratification analysis using the propensity score matching analysis. RESULTS In 210 propensity score-matched ERCPs, PPDS proved to be effective in preventing PEP in patients with a history of pancreatitis (odds ratio 0.11, 95% CI 0.01-0.76, P = 0.01) and cases of difficult cannulation (requiring more than 30 min) (odds ratio 0.13, 95% CI 0.01-1.14, P = 0.08). CONCLUSIONS Patients with a history of pancreatitis and cases of difficult cannulation are strongly recommended for PPDS placement. The propensity score analysis can be adapted to the ERCP-related analysis with many procedure-related factors with using retrospective data, and may be adapted to investigate the matters that are unsuitable for RCT by volume and ethical issue.
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Affiliation(s)
- Mamoru Takenaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Kobayashi G, Fujita N, Imaizumi K, Irisawa A, Suzuki M, Murakami A, Oana S, Makino N, Komatsuda T, Yoneyama K. Wire-guided biliary cannulation technique does not reduce the risk of post-ERCP pancreatitis: multicenter randomized controlled trial. Dig Endosc 2013; 25:295-302. [PMID: 23368891 DOI: 10.1111/j.1443-1661.2012.01372.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/20/2012] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the effect of wire-guided biliary cannulation (WGC) on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS We investigated the impact of the WGC technique on the incidence of PEP by comparing the conventional cannulation (CC) technique in selective bile duct cannulation during ERCP with a cross-over design in a prospective multicenter randomized controlled trial and the potential risk factors for PEP. This involved six tertiary referral centers and three university hospitals. A total of 322 patients with indications for ERCP requiring selective biliary cannulation were enrolled from April 2008 to March 2009. RESULTS One hundred and sixty-three patients were assigned to the WGC group and 159 to the CC group. The incidence of PEP was the same between the groups (6.1% vs 6.3%, P = 0.95). Primary successful biliary cannulation was achieved in 136 patients (83%) in the WGC group and in 138 (87%) in the CC group (P = 0.40). The mean time required for primary successful biliary cannulation was 7.4 ± 8.3 min and 7.2 ± 7.9 min, respectively (P = 0.83). Multivariate analysis demonstrated that accidental guidewire insertions and unintended injections of contrast into the main pancreatic duct were the only independent risk factors for PEP (P = 0.001, relative risk [RR]: 8.70, 95% confidence interval [CI]: 2.46-30.81). CONCLUSION The WGC technique does not reduce the risk of PEP and also does not improve the success rate of selective bile duct cannulation.
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Affiliation(s)
- Go Kobayashi
- Tohoku Bilio-pancreatic Interventional Endoscopy Group, Tohoku.
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Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data. Am J Gastroenterol 2013; 108:410-5. [PMID: 23295278 PMCID: PMC3947644 DOI: 10.1038/ajg.2012.442] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES A recent large-scale randomized controlled trial (RCT) demonstrated that rectal indomethacin administration is effective in addition to pancreatic stent placement (PSP) for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. We performed a post hoc analysis of this RCT to explore whether rectal indomethacin can replace PSP in the prevention of PEP and to estimate the potential cost savings of such an approach. METHODS We retrospectively classified RCT subjects into four prevention groups: (1) no prophylaxis, (2) PSP alone, (3) rectal indomethacin alone, and (4) the combination of PSP and indomethacin. Multivariable logistic regression was used to adjust for imbalances in the prevalence of risk factors for PEP between the groups. Based on these adjusted PEP rates, we conducted an economic analysis comparing the costs associated with PEP prevention strategies employing rectal indomethacin alone, PSP alone, or the combination of both. RESULTS After adjusting for risk using two different logistic regression models, rectal indomethacin alone appeared to be more effective for preventing PEP than no prophylaxis, PSP alone, and the combination of indomethacin and PSP. Economic analysis revealed that indomethacin alone was a cost-saving strategy in 96% of Monte Carlo trials. A prevention strategy employing rectal indomethacin alone could save approximately $150 million annually in the United States compared with a strategy of PSP alone, and $85 million compared with a strategy of indomethacin and PSP. CONCLUSIONS This hypothesis-generating study suggests that prophylactic rectal indomethacin could replace PSP in patients undergoing high-risk ERCP, potentially improving clinical outcomes and reducing healthcare costs. A RCT comparing rectal indomethacin alone vs. indomethacin plus PSP is needed.
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Vila JJ, Artifon ELA, Otoch JP. Post-endoscopic retrograde cholangiopancreatography complications: How can they be avoided? World J Gastrointest Endosc 2012; 4:241-6. [PMID: 22720126 PMCID: PMC3377867 DOI: 10.4253/wjge.v4.i6.241] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 02/23/2012] [Accepted: 05/27/2012] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has a significant complication rate which can be lowered by adopting technical variations of proven beneficial effect and prophylactic maneuvers such as pancreatic stenting during ERCP or periprocedural non-steroidal anti-inflammatory drug administration. However, adoption of these prophylactic maneuvers by endoscopists is not uniform. In this editorial we discuss the beneficial effects of the aforementioned maneuvers.
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Affiliation(s)
- Juan J Vila
- Juan J Vila, Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona 31008, Spain
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Kawaguchi Y, Ogawa M, Omata F, Ito H, Shimosegawa T, Mine T. Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18:1635-41. [PMID: 22529693 PMCID: PMC3325530 DOI: 10.3748/wjg.v18.i14.1635] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/28/2011] [Accepted: 06/21/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the effectiveness of pancreatic duct (PD) stent placement for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high risk patients.
METHODS: Authors conducted a single-blind, randomized controlled trial to evaluate the effectiveness of a pancreatic spontaneous dislodgement stent against post-ERCP pancreatitis, including rates of spontaneous dislodgement and complications. Authors defined high risk patients as having any of the following: sphincter of Oddi dysfunction, difficult cannulation, prior history of post-ERCP pancreatitis, pre-cut sphincterotomy, pancreatic ductal biopsy, pancreatic sphincterotomy, intraductal ultrasonography, or a procedure time of more than 30 min. Patients were randomized to a stent group (n = 60) or to a non-stent group (n = 60). An abdominal radiograph was obtained daily to assess spontaneous stent dislodgement. Post-ERCP pancreatitis was diagnosed according to consensus criteria.
RESULTS: The mean age (± standard deviation) was 67.4 ± 13.8 years and the male: female ratio was 68:52. In the stent group, the mean age was 66 ± 13 years and the male: female ratio was 33:27, and in the non-stent group, the mean age was 68 ± 14 years and the male: female ratio was 35:25. There were no significant differences between groups with respect to age, gender, final diagnosis, or type of endoscopic intervention. The frequency of post-ERCP pancreatitis in PD stent and non-stent groups was 1.7% (1/60) and 13.3% (8/60), respectively. The severity of pancreatitis was mild in all cases. The frequency of post-ERCP pancreatitis in the stent group was significantly lower than in the non-stent group (P = 0.032, Fisher’s exact test). The rate of hyperamylasemia were 30% (18/60) and 38.3% (23 of 60) in the stent and non-stent groups, respectively (P = 0.05, χ2 test). The placement of a PD stent was successful in all 60 patients. The rate of spontaneous dislodgement by the third day was 96.7% (58/60), and the median (range) time to dislodgement was 2.1 (2-3) d. The rates of stent migration, hemorrhage, perforation, infection (cholangitis or cholecystitis) or other complicationss were 0% (0/60), 0% (0/60), 0% (0/60), 0% (0/60), 0% (0/60), respectively, in the stent group. Univariate analysis revealed no significant differences in high risk factors between the two groups. The pancreatic spontaneous dislodgement stent safely prevented post-ERCP pancreatitis in high risk patients.
CONCLUSION: Pancreatic stent placement is a safe and effective technique to prevent post-ERCP pancreatitis. Therefore authors recommend pancreatic stent placement after ERCP in high risk patients.
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Prophylactic pancreatic stents: does size matter? A comparison of 4-Fr and 5-Fr stents in reference to post-ERCP pancreatitis and migration rate. Dig Dis Sci 2011; 56:3058-64. [PMID: 21487771 DOI: 10.1007/s10620-011-1695-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 03/25/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The ideal pancreatic stent to prevent post-ERCP pancreatitis (PEP) has yet to be determined. The aim of our study was to assess the relative benefit of 4-Fr versus 5-Fr stents in a population at high risk for post-ERCP pancreatitis, and the relative frequency of spontaneous migration. PATIENTS AND METHODS All patients with prophylactic pancreatic stent (PPS) from 2002 to 2009 were reviewed. Patients were classified into two groups according to stent size and compared based on outcome; spontaneous migration or endoscopic removal. RESULTS A total of 346 PPS were placed in 308 patients (224 women, 84 men). The average age was 48.9 years. The most common indication for PPS was sphincter of Oddi dysfunction. Needle knife papillotomy was the most common procedure performed. Forty-seven patients had PEP, 4 Fr (14.6%) and 5 Fr (12.9%), with only one case of severe pancreatitis. Factors associated with higher rates PEP were younger age and pancreatic sphincterotomy. Complete follow-up was not available in 37 patients. Spontaneous migration was demonstrated in 115 of the 4 Fr (95.8%) and 134 of the 5 Fr (68.7%). The remaining 66 (five from the 4 Fr and 61 from the 5 Fr), were removed by endoscopy. The mean delay to demonstrate spontaneous migration was 34.2 days. CONCLUSIONS PPS in high-risk patients reduced the risk of post-ERCP pancreatitis and nearly eliminated severe pancreatitis. No significant difference between the 4 Fr and 5 Fr in reduction of post-ERCP pancreatitis was observed. However, spontaneous migration was more frequent with the 4-Fr stent.
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Abstract
Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.
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Abstract
Use of stents in the pancreas has been confined and limited to referral centers that specialize in the treatment of patients with severe pancreatitis and acute relapsing pancreatitis. With therapeutic development in endoscopic treatment of pancreatic diseases and a better understanding of the cause and prevention of ERCP related complications, the use of stents has been extended to transmural drainage of pancreatic fluid collection or of pancreatic ducts has well as to prophylaxis of post-ERCP pancreatitis. As a result, indication for pancreatic stenting and the kind of stents to be used as well as the followup after placement varies. This article reviews the major indication for pancreatic stent placement and focuses on the choice of stent, technique of implantation and followup.
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Moffatt DC, Coté GA, Fogel EL, Watkins JL, McHenry L, Lehman GA, Sherman S. Acute pancreatitis after removal of retained prophylactic pancreatic stents. Gastrointest Endosc 2011; 73:980-6. [PMID: 21521566 DOI: 10.1016/j.gie.2011.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 01/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Prophylactic pancreatic stents (PPSs) are used to decrease the risk of post-ERCP pancreatitis (PEP) in high-risk patients. The risk associated with PPS removal is unknown. OBJECTIVE To describe the rate of PEP in patients undergoing PPS removal without pancreatogram or other manipulation of the major or minor papilla. DESIGN Retrospective, cohort study. SETTING Tertiary care academic center. PATIENTS This study involved 230 patients undergoing removal of PPSs from 1997 to 2010. INTERVENTION PPS removal. MAIN OUTCOME MEASUREMENTS Rate of acute pancreatitis associated with removal of PPS alone. RESULTS Acute pancreatitis occurred after PPS removal in 7 of 230 (3.0%) cases. PEP was graded as mild, moderate, and severe in 2, 5, and 0 cases, respectively. Statistically significant risk factors of PEP after PPS removal include use of a 5F stent (P=.001), use of a stent with an internal flange (P<.01), and occurrence of PEP after the initial ERCP (P<.01). Longer duration of stent within the pancreatic duct before removal was of borderline significance (P=.06). Patient age; sex; indication for initial procedure; the presence of pancreas divisum, ansa loop, or chronic pancreatitis; and history of pancreatic or biliary sphincterotomy or orifice dilation were not significant risk factors for pancreatitis after PPS removal. LIMITATIONS Retrospective analysis of prospectively collected data. Small number of events. CONCLUSION Removal of retained PPSs may cause mild or moderate acute pancreatitis. This risk of acute pancreatitis may diminish the overall efficacy of PPS use by delaying the occurrence of PEP rather than eliminating it. This implies that PPSs should be used only in patients at high risk for PEP.
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Affiliation(s)
- Dana C Moffatt
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana, USA; Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Choudhary A, Bechtold ML, Arif M, Szary NM, Puli SR, Othman MO, Pais WP, Antillon MR, Roy PK. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73:275-82. [PMID: 21295641 DOI: 10.1016/j.gie.2010.10.039] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 10/25/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. OBJECTIVE We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. DESIGN MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency. SETTING Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. PATIENTS Adult patients undergoing ERCP. INTERVENTIONS Pancreatic stent placement for the prevention of post-ERCP pancreatitis. MAIN OUTCOME MEASUREMENTS Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. RESULTS Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies. LIMITATIONS Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. CONCLUSIONS Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.
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Iqbal S, Shah S, Dhar V, Stavropoulos SN, Stevens PD. Is there any difference in outcomes between long pigtail and short flanged prophylactic pancreatic duct stents? Dig Dis Sci 2011; 56:260-5. [PMID: 20464492 DOI: 10.1007/s10620-010-1262-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 04/20/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence of post-ERCP pancreatitis (PEP) especially in high-risk patients. However, there is no consensus on the best type of PD stent. The purpose of our study was to evaluate the differences in the outcomes between long (>3 cm) pigtail and short (≤3 cm) flanged 4 Fr Freeman Pancreatic Flexi-Stents in preventing PEP. METHODS We retrospectively reviewed all ERCP procedures performed between 08/01/2006 and 10/01/2007 by one of two experienced endoscopists (>5 years of experience) with the assistance of a trainee. Patient data was collected for indications, risk factors for PEP, type and reason for PD stent, complications, and any mortality. The PD stent was removed endoscopically if it was still in place on abdominal X-ray done 2 weeks post-ERCP. The data was analyzed with Student's t test, Chi-square, and ANOVA tests by using SPSS software version 15.0. RESULTS Out of a total of 753 ERCP procedures, 179 (23.8%) required either long or short prophylactic PD stents. The incidence of PEP was 3.7% versus 13.6% for long and short stent groups, respectively (p=0.019). Spontaneous stent dislodgement rate was 95.4% versus 81.8% for long and short stent groups, respectively (p=0.007). There was no difference in non-pancreatic complications between the two stent groups. There was no procedure-related mortality. CONCLUSIONS Long (>3 cm) pigtail PD stent due to their specific design showed better outcomes as compared to short (<3 cm) flanged PD stent in preventing PEP and spontaneous stent dislodgement rates. However, further prospective trials are needed.
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Affiliation(s)
- Shahzad Iqbal
- Department of Medicine, Division of Gastroenterology, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, USA.
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Hwang JC, Kim JH, Lim SG, Yoo BM, Cho SW. Endoscopic resection of ampullary adenoma after a new insulated plastic pancreatic stent placement: a pilot study. J Gastroenterol Hepatol 2010; 25:1381-5. [PMID: 20659227 DOI: 10.1111/j.1440-1746.2010.06273.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Although pancreatic stent insertion is recommended for the prevention of post-procedure pancreatitis during endoscopic papillectomy, insertion of the stent after the procedure can be technically difficult. The aim of the present study was to determine the feasibility and safety of inserting a newly developed insulated pancreatic stent before endoscopic papillectomy. METHODS We conducted a prospective pilot study involving 11 consecutive patients with adenomas of the major duodenal papilla. After a 5F polytetrafluoroethylene-insulated pancreatic stent was inserted through the tumor, the stent and tumor were simultaneously grasped with a snare. After resection of the tumor with the stent in place, the tumor was incised perpendicularly along the edge of the stent for retrieval of the specimen. RESULTS In all patients, the insulated pancreatic stents were successfully inserted before endoscopic papillectomy and were resistant to electrical current; retrieval of the specimen was technically feasible and successful without stent migration. There were no stent-related complications, but five papillectomy-related complications (including mild bleeding [n = 4] and late papillary stenosis [n = 1]) occurred without any episodes of acute pancreatitis or perforation. CONCLUSIONS Pre-resection stenting with a polytetrafluoroethylene-insulated stent in patients with adenomas of the major duodenal papilla is a feasible and useful technique to prevent pancreatitis.
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Affiliation(s)
- Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, Yongtong-gu, Suwon, Korea
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Chacko A, Dutta AK. Endoscopic resection of ampullary adenomas: novel technique to reduce post procedure pancreatitis. J Gastroenterol Hepatol 2010; 25:1338-9. [PMID: 20659220 DOI: 10.1111/j.1440-1746.2010.06386.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Prophylaxis of post-ERCP pancreatitis: a practice survey. Gastrointest Endosc 2010; 71:934-9, 939.e1-2. [PMID: 20226455 DOI: 10.1016/j.gie.2009.10.055] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 10/20/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP. OBJECTIVE To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants. DESIGN A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy. INTERVENTION Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits. MAIN OUTCOME MEASUREMENTS Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs. LIMITATIONS Survey, not an audit of practice. CONCLUSIONS Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.
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Freeman ML. Pancreatic stents for prevention of post-ERCP pancreatitis: for everyday practice or for experts only? Gastrointest Endosc 2010; 71:940-4. [PMID: 20438883 DOI: 10.1016/j.gie.2009.12.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 12/30/2009] [Indexed: 12/26/2022]
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The safety and utility of prophylactic pancreatic duct stents in the prevention of post-ERCP pancreatitis: an analysis of practice in a single UK tertiary referral center. Surg Endosc 2010; 24:1923-8. [PMID: 20112114 DOI: 10.1007/s00464-009-0875-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 12/19/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND The use of temporary prophylactic pancreatic duct (PD) stents in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients has been shown to be effective in multiple trials. However, there are limited data on the clinical implications of PD stents and their impact on practice outside of the trial setting. METHODS The utility of prophylactic pancreatic stenting was evaluated in a retrospective analysis of 1,000 consecutive ERCPs performed in a single tertiary referral pancreatobiliary center over a 24-month period, based upon a predetermined protocol to identify patients at high risk of postprocedure pancreatitis. RESULTS One thousand procedures performed in 688 patients were studied. Sixty-one patients were considered for stent placement and stents were successfully placed in 58 cases. The overall rate of post-ERCP pancreatitis in our study population was 3.6%. The rate of pancreatitis in the stented patients was considered high at 22.4%, but the majority (69%) were classified as mild and there were no reported severe episodes. This compares to pancreatitis in the nonstented group, in whom the majority (73.9%) experienced either moderate or severe episodes. CONCLUSION A strategy of prophylactic PD stents in this study has eliminated severe post-ERCP pancreatitis in high-risk patients. However, the high pancreatitis rate in stented patients may represent the cost to achieve this, while stent type and size employed are likely contributing factors. To maximize the benefits of PD stenting, there is a need to identify and treat all those considered at high risk.
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Cennamo V, Fuccio L, Zagari RM, Eusebi LH, Ceroni L, Laterza L, Fabbri C, Bazzoli F. Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis?: A meta-analysis of randomized controlled trials. Am J Gastroenterol 2009; 104:2343-50. [PMID: 19532133 DOI: 10.1038/ajg.2009.269] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The most common technique used to achieve primary deep biliary cannulation is the standard contrast-assisted method. To increase the success rate and reduce the risk of complications, a wire-guided cannulation strategy has been proposed. Prospective studies provided conflicting results as to whether the wire-guided cannulation technique increases the cannulation rate and reduces post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis risk compared with the standard method. The objective of this study was to carry out a meta-analysis of randomized controlled trials (RCTs) that compares primary biliary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. METHODS Literature searches of electronic databases and online clinical trial registers up to March 2009 were conducted to identify RCTs comparing primary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. A meta-analysis of these clinical trials was performed. RESULTS Five RCTs were included. Overall, the primary cannulation rates reported with the wire-guided cannulation technique and the standard method were 85.3 and 74.9%, respectively. The pooled analysis of all the selected studies comparing the wire-guided cannulation technique with the standard method yielded an odds ratio (OR) of 2.05 (95% confidence interval (CI): 1.27-3.31). The pooled analysis comparing the post-ERCP pancreatitis rates for the wire-guided-cannulation groups with those for the standard-method groups yielded an OR of 0.23 (95% CI: 0.13-0.41). CONCLUSIONS This meta-analysis shows that the wire-guided technique increases the primary cannulation rate and reduces the risk of post-ERCP pancreatitis compared with the standard contrast-injection method. Further large, well-performed, randomized controlled studies are needed to confirm these findings.
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Affiliation(s)
- Vincenzo Cennamo
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna 40138, Italy
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Chahal P, Tarnasky PR, Petersen BT, Topazian MD, Levy MJ, Gostout CJ, Baron TH. Short 5Fr vs long 3Fr pancreatic stents in patients at risk for post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2009; 7:834-9. [PMID: 19447196 DOI: 10.1016/j.cgh.2009.05.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 04/24/2009] [Accepted: 05/02/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Prophylactic placement of pancreatic duct (PD) stents reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in high-risk patients. Some endoscopists prefer longer length, unflanged 3Fr PD stents because they are supposedly more effective and have a higher rate of spontaneous dislodgement; we compared outcomes of patients with these 2 types of stents. METHODS Patients at high risk for PEP were randomly assigned to groups given either a straight, 5Fr, 3 cm long, unflanged PD stent (n = 116) or a 3Fr, 8 cm or longer, unflanged PD stent (n = 133). Abdominal radiographs were obtained at 24 hours, 7 days, and 14 days following stent placement to assess spontaneous stent dislodgement. PEP was defined according to consensus criteria. RESULTS After 14 days, the spontaneous stent dislodgement rates were 98% for 5Fr stents and 88% for 3Fr stents (P = .0001). PEP occurred in 12% of patients. The incidence of PEP was higher in the 3Fr group (14%) than the 5Fr group (9%), although this difference was not statistically significant (P = .3). Placement failure did not occur in any patients in the 5Fr stent group, but did occur in 11 of the 133 patients in the 3Fr stent group (P = .0003). CONCLUSIONS Among patients at high-risk for PEP, the spontaneous dislodgement rate of unflanged, short-length, 5Fr PD stents is significantly higher than for unflanged, long-length, 3Fr stents. This decreases the need for endoscopic removal. A higher rate of PD stent placement failure and PEP was observed in patients with 3Fr stents. To view this article's video abstract, go to the AGA's YouTube Channel.
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Abstract
AIM: To investigate the endoscopic ampullectomy practices of expert biliary endoscopists.
METHODS: An anonymous survey was mailed to 79 expert biliary endoscopists to assess ampullectomy practices.
RESULTS: Forty six (58%) biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years (± 8.6). Endoscopists performed an average of 1.1 (± 0.8) ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was “always” utilized by 67% of respondents vs“sometimes” in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% “always” and 37% “sometimes” performed it prior to resection. Fifty three percent reported “never” performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy (OR = 10.9; P = 0.09). Participants overwhelmingly favored “always” placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection (23%). Argon plasma coagulation was the favored adjunct modality (83%) for removal of residual adenomatous tissue. Practitioners uniformly (100%) preferred follow-up examination to be within 6 mo post-ampullectomy.
CONCLUSION: Among biliary experts, there is less variation in ampullectomy practices than is reflected in the literature.
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Madácsy L, Kurucsai G, Fejes R, Székely A, Székely I. Prophylactic pancreas stenting followed by needle-knife fistulotomy in patients with sphincter of Oddi dysfunction and difficult cannulation: new method to prevent post-ERCP pancreatitis. Dig Endosc 2009; 21:8-13. [PMID: 19691794 DOI: 10.1111/j.1443-1661.2008.00819.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. METHODS Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods. RESULTS Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. CONCLUSIONS In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.
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Affiliation(s)
- László Madácsy
- First Department of Internal Medicine, Fejér Megyei Szent György Hospital, Székesfehérvár, Hungary.
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Madácsy L, Kurucsai G, Joó I, Gódi S, Fejes R, Székely A. Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series. Surg Endosc 2008; 23:1887-93. [DOI: 10.1007/s00464-008-0199-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 10/10/2008] [Indexed: 12/14/2022]
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Abstract
PURPOSE OF REVIEW Although few controlled trials exist in the field, endoscopic papillectomy has evolved over the recent years with new data on preoperative staging and improved methods for its safe and successful completion. In 2006, a consensus guideline was published by the American Society of Gastrointestinal Endoscopy evaluating the role of endoscopy in managing ampullary adenomas. RECENT FINDINGS The recent literature of endoscopic papillectomy has focused on the preoperative management of ampullary tumors, with a paper evaluating the role of endoscopic ultrasound. Also, a randomized controlled trial has shown that the use of pancreatic duct stents is associated with less incidence of postendoscopic papillectomy pancreatitis, although the study was probably underpowered. Several methods can be used to help locate the pancreatic duct postendoscopic papillectomy (endoscopic ultrasound-guided rendezvous and methylene blue injection). The recurrence and complication rate in more recent papers continue to be acceptable, at about 30 and 20%, respectively. SUMMARY Endoscopic papillectomy is a reasonable alternative to transduodenal surgical excision, but more controlled studies with long-term data are needed to evaluate preoperative staging accuracy and recurrence rates.
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Elta GH. Temporary prophylactic pancreatic stents: which patients need them? Gastrointest Endosc 2008; 67:262-4. [PMID: 18226688 DOI: 10.1016/j.gie.2007.07.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2007] [Accepted: 07/21/2007] [Indexed: 01/04/2023]
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Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354-65. [PMID: 17981248 DOI: 10.1016/j.cgh.2007.09.007] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Placement of pancreatic stents is a relatively new and increasingly adopted approach to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Evidence for the efficacy of pancreatic stents in reducing post-ERCP pancreatitis continues to accumulate. Routine use of pancreatic stents in high-risk cases at advanced centers has changed the complexion of ERCP, reducing the incidence and severity of post-ERCP pancreatitis to a more acceptable level, and eliminating some of the fear factor surrounding previously prohibitively risky settings, such as treatment of sphincter of Oddi dysfunction (SOD). On the other hand, the adoption of prophylactic pancreatic stenting into some practices has been sporadic. Problems with pancreatic stent placement include technical difficulty with placement, need for follow-up evaluation to ensure passage or removal, and potential for inducing pancreatic ductal injury. There remain many challenges and unanswered questions which will be addressed in this review, including which patients are at risk for post-ERCP pancreatitis, how might pancreatic stents reduce risk, what is the evidence supporting efficacy of pancreatic stenting in reducing risk; and based on those data, which ERCPs are at sufficiently high risk to warrant a stent; at what point in an ERCP should a pancreatic stent be placed; how long pancreatic stents need to remain in place to be effective, the risk of inducing pancreatic duct injury by placement of a stent; the frequency and consequences of failure at attempted stent placement, and effectiveness of pancreatic stent placement in the hands of those with limited experience. Current recommendations for use of pancreatic stents and areas requiring further investigation are discussed.
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Affiliation(s)
- Martin L Freeman
- Minnesota Pancreas and Liver Center, Division of Gastroenterology, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Frank CD, Adler DG. Post-ERCP pancreatitis and its prevention. ACTA ACUST UNITED AC 2006; 3:680-8. [PMID: 17130878 DOI: 10.1038/ncpgasthep0654] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 09/01/2006] [Indexed: 12/14/2022]
Abstract
Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP), and typically develops in 5-7% of patients. Although most post-ERCP pancreatitis (PEP) is mild, severe pancreatitis and its complications (including a systemic inflammatory response or the development of pseudocysts or pancreatic necrosis) can occur, and in rare cases death can result. A means of preventing PEP in all patients who undergo the procedure remains elusive. Proper patient selection for ERCP is critical to avoid unnecessary risk. Pharmacologic attempts to prevent PEP have been largely unsuccessful; encouraging results have been difficult to validate. Prophylactic stenting of the pancreatic duct and minimally traumatic cannulation techniques offer the most promise as a means of preventing PEP. This manuscript reviews risk factors for PEP as well as pharmacologic and procedural means that can be used to reduce its incidence.
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Affiliation(s)
- Carl D Frank
- University of Texas-Houston Medical School, Houston, Texas, USA
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