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Liu KJ, Hu Y, Guo SB. Effect of rectal indomethacin on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography for choledocholithiasis: a prospective randomized clinical trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:20-208. [PMID: 37982566 DOI: 10.17235/reed.2023.9899/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND AND AIM the aim of this study was to evaluate the efficacy and safety of rectal indomethacin for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients with common bile duct (CBD) stones. METHODS a total of 167 patients undergoing ERCP between November 2019 and November 2022 for CBD stones in the First Affiliated Hospital of Dalian Medical University were prospectively analyzed. The patients were divided into an indomethacin group (n = 58) and a control group (n = 109). The primary endpoint was the percent of patients who experienced PEP. RESULTS PEP was observed in a total of 26 patients (15.57 %); four patients (6.90 %) in the indomethacin group and 22 (20.18 %) in the control group (p = 0.042). Mild, moderate and severe PEP was observed in three (5.17 %), one (1.72 %) and zero patients, respectively, in the indomethacin group, and in eleven (10.09 %), nine (8.26 %) and two (1.83 %) patients, respectively, in the control group. There was one case (0.92 %) of death due to PEP in the control group. No cases of moderate or severe bleeding were observed in either group. CONCLUSIONS rectal indomethacin is an effective and safe method to prevent PEP for patients with CBD stones undergoing ERCP.
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Affiliation(s)
- Kai-Ji Liu
- Gastroenterology, The Fifth Affiliated Hospital of Southern Medical University
| | - Yang Hu
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University
| | - Shi-Bin Guo
- Gastroenterology, The First Affiliated Hospital of Dalian Medical University, China
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Xie Y, Cheng Z, Deng C, Deng M, Zhang H. Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis based on prospective, randomized, and controlled trials. Medicine (Baltimore) 2023; 102:e35174. [PMID: 37832051 PMCID: PMC10578773 DOI: 10.1097/md.0000000000035174] [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: 06/23/2023] [Accepted: 08/21/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVES To evaluate the efficacy of nafamostat mesilate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) by conduct a systematic review and meta-analysis. METHOD We retrieved for all randomized controlled trials (RCTs) about compare nafamostat mesilate with placebo in preventing PEP published before August 23, 2022, in 5 major electronic databases. The primary outcome was PEP rate, and the secondary outcome was post-ERCP hyperamylasemia (PEHA) rate. Subgroup analyses were performed to reveal the factors that may affect the preventive effect of nafamostat. Assessment of the quality of evidence was conducted based on Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. RESULTS According to the search strategy and criteria of inclusion and exclusion, 8 articles with a number of 3210 patients were included. The PEP incidence of the nafamostat group was inferior compared with the placebo group (4.6% vs 8.5%, RR = 0.50, 95% CI: 0.38-0.66). Subgroup analyses revealed that nafamostat had a preventive effect on patients with different risk stratification (High-risk: RR = 0.61, 95% CI: 0.43-0.86, Low-risk: RR = 0.28; 95% CI: 0.17-0.47). Different doses (20 mg: RR = 0.50, 95% CI: 0.36-0.69, 50 mg: RR = 0.45, 95% CI: 0.27-0.74) and duration (<12 hour: RR = 0.55, 95% CI: 0.37-0.81, ≥12 h: RR = 0.44, 95% CI: 0.29-0.66) of administration of nafamostat are adequate for the prevention of PEP, but postoperative administration may not help (preoperative: RR = 0.52, 95% CI: 0.39-0.69, postoperative: RR = 0.54, 95% CI: 0.23-1.23). Nafamostat may not efficacious in preventing severe PEP (Mild: RR = 0.49, 95% CI, 0.35-0.68, Moderate: RR = 0.47, 95% CI: 0.25-0.86, Severe: RR = 0.91, 95% CI, 0.25-3.29) or in low-quality studies (Low-quality: RR = 0.69, 95% CI: 0.13-3.60, High-quality: RR = 0.49, 95% CI: 0.37-0.65). CONCLUSION Preoperative use of nafamostat can effectively prevent PEP in patients with various risk stratification. Nafamostat can prevent mild and moderate PEP, but may not prevent severe PEP and PEHA. There should be more high-quality RCTs in future to strengthen the evidence of nafamostat in preventing PEP.
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Affiliation(s)
- Yu Xie
- Department of Infectious Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ziyao Cheng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Cunliang Deng
- Department of Infectious Diseases, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hailong Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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3
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American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc 2023; 97:153-162. [PMID: 36517310 DOI: 10.1016/j.gie.2022.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 01/22/2023]
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Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial. J Clin Gastroenterol 2023; 57:204-210. [PMID: 34049378 DOI: 10.1097/mcg.0000000000001563] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/05/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders. GOALS Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients. STUDY In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 μg somatostatin followed by an infusion of 500 μg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11). RESULTS A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred. CONCLUSIONS In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.
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5
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Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol 2023; 16:17562848231155984. [PMID: 36895283 PMCID: PMC9989421 DOI: 10.1177/17562848231155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.
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Affiliation(s)
- Federica Borrelli de Andreis
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy.,Gastroenterology Unit, Istituti Clinici Maugeri, University of Pavia, Pavia, Italy.,Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Mascagni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, 00168, Italy.,IHU Strasbourg 1, Place de l'Hopital 67091 Strasbourg Cedex, France.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
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An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.
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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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Obeidat AE, Mahfouz R, Monti G, Kozai L, Darweesh M, Mansour MM, Alqam A, Hernandez D. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: What We Already Know. Cureus 2022; 14:e21773. [PMID: 35251843 PMCID: PMC8890589 DOI: 10.7759/cureus.21773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
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Matsumoto T, Okuwaki K, Imaizumi H, Kida M, Iwai T, Yamauchi H, Kaneko T, Hasegawa R, Masutani H, Tadehara M, Adachi K, Watanabe M, Kurosu T, Tamaki A, Kikuchi H, Ohno T, Koizumi W. Nafamostat Mesylate is Not Effective in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2021; 66:4475-4484. [PMID: 33495919 DOI: 10.1007/s10620-020-06782-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/10/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications such as post-ERCP pancreatitis (PEP). Protease inhibitors, including nafamostat mesylate (NM), have been evaluated for prophylaxis against PEP. AIM We describe the first multicenter randomized controlled trial assessing the prophylactic efficacy of NM against PEP. METHODS In this multicenter prospective study, we aimed to enroll 800 patients aged ≥ 20 years with a planned ERCP between December 2012 and March 2019. The primary outcome was the incidence and severity of PEP in patients who did not receive NM (non-NM) versus those who did (NM; 20 mg). Secondary outcomes included the incidence of PEP by NM initiation (pre- and post-ERCP), risk factors for PEP, and NM-related adverse events. RESULTS Only 441 of the planned 800 patients were enrolled (non-NM: n = 149; NM: n = 292 [pre-ERCP NM: n = 144; post-ERCP NM: n = 148]). Patient characteristics were balanced at baseline with no significant differences between groups. PEP occurred in 40/441 (9%) patients (non-NM: n = 15 [10%]; NM: n = 25 [9%]), including 17 (12%) and eight (8%) in the pre-ERCP and post-ERCP NM groups, respectively. In the NM group, the incidence of PEP was lower in the low-risk group than in the high-risk group. Pancreatic injection and double-guidewire technique were independent risk factors for PEP. NM-related adverse events of hyperkalemia occurred in two (0.7%) patients. CONCLUSIONS We found no evidence for the prophylactic effect of NM against PEP, regardless of the timing of administration; however, further studies are needed.
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Affiliation(s)
- Takaaki Matsumoto
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.,Department of Gastroenterology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toru Kaneko
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Rikiya Hasegawa
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hironori Masutani
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masayoshi Tadehara
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kai Adachi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masafumi Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takahiro Kurosu
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Akihiro Tamaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hidehiko Kikuchi
- Department of Gastroenterology, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka, Kanagawa, 254-8502, Japan
| | - Takashi Ohno
- Department of Gastroenterology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
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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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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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Chiu YJ, Chen SC, Kang YN, Hou SK, Chao CC, Chang CC. Efficacy of gabexate mesilate in preventing post endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis of randomized clinical trials. J Formos Med Assoc 2021; 120:1090-1099. [DOI: 10.1016/j.jfma.2020.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 01/26/2023] Open
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13
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Liao WC, Tu TC, Lee KC, Tseng JH, Chen MJ, Sun CK, Wang SY, Chang WK, Chang PY, Wu MS, Lin TJ, Lee HL, Chen JH, Yuan KC, Liu NJ, Wu HC, Liang PC, Wang HP, Hwang TL, Lee CL. Taiwanese consensus recommendations for acute pancreatitis. J Formos Med Assoc 2020; 119:1343-1352. [PMID: 31395463 DOI: 10.1016/j.jfma.2019.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/11/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.
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Affiliation(s)
- Wei-Chih Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tien-Chien Tu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jseng-Hwei Tseng
- Department of Imaging & Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheuk-Kay Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shang-Yu Wang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taiwan
| | - Pi-Yi Chang
- Department of Radiology, Taichung Veterans General Hospital, Taiwan
| | - Ming-Shun Wu
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Jung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
| | - Hsiang-Lin Lee
- Department of Surgery, Chung Shan Medical University Hospital, Institute of Medicine4, Chung Shan Medical University, Taichung, Taiwan
| | - Jiann-Hwa Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Kuo-Ching Yuan
- Division of Acute Care Surgery and Trauma, Department of Surgery, Taipei Medical University Hospital, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsing-Chien Wu
- Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taiwan
| | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taiwan
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taiwan
| | - Chia-Long Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan.
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14
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Seta T, Takahashi Y, Yamashita Y, Nakayama T. Status of use of protease inhibitors for the prevention and treatment of pancreatitis after endoscopic retrograde cholangiopancreatography: An epidemiologic analysis of the evidence-practice gap using a health insurance claims database. Drug Discov Ther 2020; 13:137-144. [PMID: 31327789 DOI: 10.5582/ddt.2019.01029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Existing evidence suggests that protease inhibitors (PIs) used to prevent or treat pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) are ineffective, and their use is not recommended by clinical practice guidelines. However, in Japan, PIs are administered with the aim to prevent or treat post-ERCP pancreatitis. This study aimed to clarify the gap between guideline recommendations and contents of practice. We used the health insurance claims database of Japan Medical Data Center. Among patients who had undergone ERCP, those with acute pancreatitis or post-ERCP pancreatitis recorded in claims as disease names were defined as post-ERCP pancreatitis patients. The study period was divided into three terms according to the date of publication of clinical practice guidelines for acute pancreatitis. Among 2,945 patients who had undergone ERCP, 2,847 were eligible for analysis. Of these, 1,375 (48.3%) patients had claims with pancreatitis recorded as the disease name; PIs were prescribed to 1,238 (90.0%). Rates of prescription of PIs were 72.3% in 2005-07, 70.9% in 2008-09, and 83.6% in 2010-15, showing a significant increase (p < 0.001). In conclusion, PIs are administered in clinical practice in Japan for the purpose of preventing or treating pancreatitis, with an increasing trend in prescription in recent years.
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Affiliation(s)
- Takeshi Seta
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center
| | | | - Yukitaka Yamashita
- Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health
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15
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Lyu Y, Wang B, Cheng Y, Xu Y, Du W. Comparative Efficacy of 9 Major Drugs for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: A Network Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:426-432. [DOI: 10.1097/sle.0000000000000707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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16
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Perdigoto DN, Gomes D, Almeida N, Mendes S, Alves AR, Camacho E, Tomé L. Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in the Indomethacin Era - A Prospective Study. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:176-183. [PMID: 31192286 DOI: 10.1159/000492313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/23/2018] [Indexed: 12/18/2022]
Abstract
Background and Aims Although endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure used to treat conditions affecting the biliopancreatic system, it can lead to several complications. Post-ERCP pancreatitis (PEP) is the most frequent one, with an incidence ranging from 3 to 14%. Our aim was to assess the potential risk factors associated with PEP occurrence in patients undergoing ERCP with indomethacin prophylaxis. Methods Prospective, single-center, real-world observational study (January to December 2015) with inclusion of patients submitted to ERCP, where relevant patient-related and procedure-related data had been collected. Patients had to have been admitted for a minimum of 24 h in order to establish the presence of early complications. All patients were submitted to PEP prophylaxis with 1 or 2 methods: rectal indomethacin and pancreatic duct (PD) stenting. Results A total of 188 patients who had undergone ERCP were included (52.7% women; mean age 69.2 ± 16.0 years) and PEP was diagnosed in 13 (6.9%). PEP prophylaxis consisted of indomethacin in all cases (100%) and PD stenting in 7.4%. The pancreatitis was mild in 11 patients (84.6%) and severe in the other 2. One of them died (0.5%). None of the patient-related risk factors were associated with changes in PEP probability. Of all patients, 33.0% had 2 or more procedure-related risk factors. A higher number of synchronous procedure-related risk factors showed a statistically significant correlation with PEP occurrence, p = 0.040. Conclusions The 6.9% PEP rate is considered acceptable since 33.0% patients had a medium-high risk for PEP due to challenging biliary cannulation. The total number of procedure-related risk factors seems to play a critical role in the development of PEP despite indomethacin prophylaxis.
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Affiliation(s)
- David N Perdigoto
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal.,Medical School, Coimbra University, Coimbra, Portugal
| | - Dário Gomes
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal.,Medical School, Coimbra University, Coimbra, Portugal
| | - Nuno Almeida
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal.,Medical School, Coimbra University, Coimbra, Portugal
| | - Sofia Mendes
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Ana Rita Alves
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Ernestina Camacho
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Luís Tomé
- Gastroenterology Department, Coimbra Hospital and University Center, Coimbra, Portugal.,Medical School, Coimbra University, Coimbra, Portugal
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17
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Shih HY, Hsu WH, Kuo CH. Postendoscopic retrograde cholangiopancreatography pancreatitis. Kaohsiung J Med Sci 2019; 35:195-201. [PMID: 30887733 DOI: 10.1002/kjm2.12040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.
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Affiliation(s)
- Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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18
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Wang G, Xiao G, Xu L, Qiu P, Li T, Wang X, Wen P, Wen J, Xiao X. Effect of somatostatin on prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia: A systematic review and meta-analysis. Pancreatology 2018; 18:370-378. [PMID: 29550097 DOI: 10.1016/j.pan.2018.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/22/2018] [Accepted: 03/09/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To perform a meta-analysis of all available studies on the effect of prophylactic somatostatin administration on prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and post-ERCP hyperamylasemia (PEHA). METHODS Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index were searched to retrieve relevant trials. Randomized, placebo-controlled trials in adult patients that compared somatostatin versus placebo in prevention of PEP were included. Meta-analysis was performed using a random-effects model to assess the ratios of PEP, PEHA and post-ERCP abdominal pain. RESULTS Total ratio of PEP of somatostatin group was significantly lower than that of placebo group. For the short-term injection or bolus injection there were no heterogeneity and no significance between the ratio of PEP of somatostatin group and placebo group. For the long-term injection subgroup there was heterogeneity, and the ratio of PEP of somatostatin group was significantly lower than that of placebo group. There was no significance between the ratio of PEP of somatostatin group and placebo group for the low-risk PEP subgroup, while the ratio of PEP of somatostatin group was significantly lower than that of placebo group for the high-risk PEP subgroup. The ratio of PEP of somatostatin group was significantly lower than that of placebo group for the long-term injection high-risk PEP subgroup. There was no significance between the ratio of PEHA of somatostatin group and placebo group for the short-term injection subgroup or bolus injection subgroup. The ratio of PEHA of somatostatin group was significantly lower than that of placebo group for the long-term injection subgroup. The total ratio of post-ERCP abdominal pain of somatostatin group was significantly lower than that of placebo group. The funnel plot of incidence of PEP and PEHA showed no asymmetry with a negative slope. CONCLUSION Prophylactic use of long-term injection of somatostatin can significantly reduce the incidence of PEP, PEHA and post-ERCP abdominal pain for the high-risk PEP patients, while it is not necessary to be used for the low-risk PEP patients.
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Affiliation(s)
- Guiliang Wang
- Department of Digestive Internal Medicine, Gannan Medical University Pingxiang Hospital, 128 Guangchang Road, Pingxiang, 337055, People's Republic of China; Department of International School of Nursing, Hainan Medical University, Haikou, 571199, People's Republic of China
| | - Gui Xiao
- Department of International School of Nursing, Hainan Medical University, Haikou, 571199, People's Republic of China; Laboratory of Shock, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Linfang Xu
- Department of Digestive Internal Medicine, Gannan Medical University Pingxiang Hospital, 128 Guangchang Road, Pingxiang, 337055, People's Republic of China
| | - Ping Qiu
- Department of Digestive Internal Medicine, Gannan Medical University Pingxiang Hospital, 128 Guangchang Road, Pingxiang, 337055, People's Republic of China
| | - Ting Li
- Laboratory of Shock, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Xiaoli Wang
- Department of International School of Nursing, Hainan Medical University, Haikou, 571199, People's Republic of China
| | - Ping Wen
- Department of Digestive Internal Medicine, Gannan Medical University Pingxiang Hospital, 128 Guangchang Road, Pingxiang, 337055, People's Republic of China
| | - Jianbo Wen
- Department of Digestive Internal Medicine, Gannan Medical University Pingxiang Hospital, 128 Guangchang Road, Pingxiang, 337055, People's Republic of China
| | - Xianzhong Xiao
- Laboratory of Shock, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, 410008, People's Republic of China.
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19
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Mine T, Morizane T, Kawaguchi Y, Akashi R, Hanada K, Ito T, Kanno A, Kida M, Miyagawa H, Yamaguchi T, Mayumi T, Takeyama Y, Shimosegawa T. Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol 2017; 52:1013-1022. [PMID: 28653082 DOI: 10.1007/s00535-017-1359-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/04/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed. METHODS The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline. RESULTS In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP. CONCLUSIONS We reported here the essence of the clinical practice guideline for PEP.
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Affiliation(s)
- Tetsuya Mine
- Tokai University, School of Medicine, Isehara, Japan.
| | | | | | - Ryukichi Akashi
- Kumamoto City Medical Association Health Care Center, Kumamoto, Japan
| | | | - Tetsuhide Ito
- Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University, Sendai, Japan
| | - Mitsuhiro Kida
- Kitasato University School of Medicine, Sagamihara, Japan
| | | | | | - Toshihiko Mayumi
- University of Occupational and Environmental Health, Kitakyushu, Japan
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20
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Mok SRS, Ho HC, Shah P, Patel M, Gaughan JP, Elfant AB. Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial. Gastrointest Endosc 2017; 85:1005-1013. [PMID: 27816497 DOI: 10.1016/j.gie.2016.10.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/24/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Prospective data have shown the benefit of rectal indomethacin (IND) for preventing post-ERCP pancreatitis (PEP). A recent pilot study demonstrated a lower incidence of PEP after an 8-hour lactated Ringer's solution (LR) infusion. The aim of this study was to evaluate the efficacy of IND with or without bolus LR in patients at high-risk for PEP. METHODS In this randomized, double-blinded, placebo-controlled trial we assigned patients to standard normal saline solution (NS) + placebo, NS + IND, LR + placebo, or LR + IND. Each liter of fluid infusion was completed within 30 minutes. Patients were determined high-risk based established criterion and excluded if they had pancreatitis, contraindications to IND, or signs of volume overload. Our primary outcome was PEP, defined by standardized criterion. Our secondary outcomes were severe acute pancreatitis, localized adverse events, death, length of stay, and readmission. RESULTS Our sample consisted of 192 patients (48 per group) who completed follow-up at 24 hours and at 30 days post-ERCP. All patients had at least 1 high-risk criterion for PEP, and 56% had >1. PEP occurred in 3 patients (6%) in the LR + IND versus 10 (21%) in the NS + placebo group (P = .04). Readmission rates were lower in the LR + IND group (1 [2%]) versus the NS + placebo group (6 [13%]; P = .03). No differences were found between the other study groups. There was 1 case of severe pancreatitis (NS + IND) and 1 case of pseudocyst (LR + IND). CONCLUSIONS In patients at high risk for PEP, LR + IND reduced the incidence of PEP and readmission rates compared with NS + placebo. (Clinical trial registration number: NCT02641561.).
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Affiliation(s)
- Shaffer R S Mok
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Henry C Ho
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Paurush Shah
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Milan Patel
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - John P Gaughan
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Adam B Elfant
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
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21
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Hou YC, Hu Q, Huang J, Fang JY, Xiong H. Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis. Sci Rep 2017; 7:46650. [PMID: 28440297 PMCID: PMC5404221 DOI: 10.1038/srep46650] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 03/24/2017] [Indexed: 12/16/2022] Open
Abstract
Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are not commonly used clinically for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To evaluate the efficacy and safety of NSAIDs for post-ERCP prophylaxis, we systematically reviewed sixteen randomized controlled trials (involving 6458 patients) that compared rectal NSAIDs with placebo or no treatment for post-ERCP pancreatitis prophylaxis updated to August 2016. GRADE framework was used to assess the quality of evidence. There was “high quality” evidence that rectal NSAIDs were associated with significant reduction in the risk of overall post-ERCP pancreatitis (RR, 0.55; 95% CI, 0.42–0.71). Subgroup analyses demonstrated that diclofenac (RR, 0.41; 95% CI, 0.19–0.90) was probably superior to indomethacin (RR, 0.58; 95% CI, 0.45–0.75), post-ERCP administration (RR, 0.46; 95% CI, 0.24–0.89) was probably superior to pre-ERCP (RR, 0.53; 95% CI, 0.42–0.67), and that mixed-risk population received more benefits (RR, 0.54; 95% CI, 0.33–0.88) than average-risk population (RR, 0.60; 95% CI, 0.41–0.88), but less than high-risk population (RR, 0.41; 95% CI, 0.19–0.91). Moreover, “high quality” evidence showed that rectal NSAIDs were safe when given as a standard dose (RR = 0.80; 95% CI, 0.47–1.36). In conclusion, this meta-analysis revealed that rectal NSAIDs are effective and safe in the prevention of post-ERCP pancreatitis in populations with all levels of risk.
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Affiliation(s)
- Yi-Chao Hou
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Qiang Hu
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Jiao Huang
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Jing-Yuan Fang
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Hua Xiong
- Division of Gastroenterology and Hepatology, Key Laboratory Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai 200001, China
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22
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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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23
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Hu J, Li PL, Zhang T, Chen JP, Hu YJ, Yu Z, Wang JP, Zhu D, Tong XF. Role of Somatostatin in Preventing Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis: An Update Meta-analysis. Front Pharmacol 2016; 7:489. [PMID: 28018225 PMCID: PMC5156829 DOI: 10.3389/fphar.2016.00489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022] Open
Abstract
Background: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Although, somatostatin (SOM) has been used in the prevention of post-ERCP pancreatitis (PEP), the efficacy of SOM remains inconsistent. Methods: Electronic databases, including PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), and the Science Citation Index were searched to retrieve relevant studies. Details of the study population, including patients’ characteristics, sample size, regimen of drug administration and incidence of PEP, hyperamylasemia and abdominal pain were extracted by two investigators. Data were analyzed with Review Manager 5.3 software. Results: Eleven randomized controlled trials, enrolling a total of 4192 patients, were included in the meta-analysis. After data were pooled, we observed decreased incidence of ERCP-induced outcomes, such as PEP (RR = 0.63, 95% CI: 0.40, 0.98; P = 0.04) and hyperamylasemia (RR = 0.75, 95% CI: 0.66, 0.84; P < 0.001) in patients treated with SOM than those with placebo. Subgroup analysis by ethnicity found decreased incidence of PEP and hyperamylasemia in Asia only. Subgroup analysis by treatment schedule and dosage revealed decreased incidence of PEP and hyperamylasemia when SOM were treated with a single bolus or long-term infusion, or at dose above 3000 μg. We did not observed efficacy of SOM on abdominal pain in pooled or subgroup analysis. Conclusion: This meta-analysis of patients undergoing ERCP showed reduced incidence of PEP and hyperamylasemia when SOM was administrated with single bolus, long-term infusion, or high dosage. More data are needed to confirm our findings.
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Affiliation(s)
- Jing Hu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Pei-Lin Li
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Tao Zhang
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Jin-Ping Chen
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Yao-Jun Hu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Zheng Yu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Jin-Peng Wang
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Dan Zhu
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
| | - Xiao-Fei Tong
- Department of Gastroenterology, Fu Xing Hospital, Capital Medical University Beijing, China
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24
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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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Ishiwatari H, Urata T, Yasuda I, Matsusaki S, Hisai H, Kawakami H, Ono M, Iwashita T, Doi S, Kawakubo K, Hayashi T, Sonoda T, Sakamoto N, Kato J. No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2016; 61:3292-3301. [PMID: 27447477 DOI: 10.1007/s10620-016-4251-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/09/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a serious complication. Rectal diclofenac (100 mg) has been shown to reduce the incidence of pancreatitis; however, this dosage form is unavailable in several countries. AIMS We aimed to investigate the preventive effect of oral diclofenac on pancreatitis after ERCP in a multicenter, randomized, prospective, placebo-controlled, double-blind trial. METHODS Patients undergoing a first ERCP in seven high-volume centers between July 2012 and August 2014 were considered eligible. Participants were administered oral diclofenac (50 mg) or placebo before and after ERCP. The primary endpoint was the incidence of pancreatitis. A subgroup analysis was performed for patients at high or low risk of pancreatitis. Secondary endpoints were pancreatic enzyme levels (amylase and lipase). RESULTS We initially enrolled 430 patients (216 in the diclofenac and 214 in the placebo group), and 23 were excluded after randomization. The overall incidence of pancreatitis was 9.8 % (20/205) and 9.4 % (19/202) in the diclofenac and placebo groups, respectively (p = 0.90). The incidence of pancreatitis was 20.3 % (13/64) and 21.3 % (13/61) in patients at high risk of pancreatitis (p = 0.78) and 5.0 % (7/141) and 4.3 % (6/141) in patients at low risk of pancreatitis in the diclofenac and placebo groups (p = 0.94), respectively. There were no significant differences in serum amylase and lipase levels between the two groups before and 24 h after ERCP. CONCLUSIONS Oral administration of diclofenac before and after ERCP showed no benefit in the prevention of pancreatitis. CLINICAL TRIALS REGISTRY NO UMIN000008109.
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Affiliation(s)
- Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takahiro Urata
- Department of Gastroenterology, Japanese Red Cross Kumamoto Hospital, 1-1-2, Nagamineminami, Higashiku, Kumamoto, 861-8520, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Shimpei Matsusaki
- Department of Gastroenterology, Suzuka General Hospital, 53-1275, Uyamanohana, Yasuzukacho, Suzuka, Mie, 513-8630, Japan
| | - Hiroyuki Hisai
- Department of Gastroenterology, Japanese Red Cross Date Hospital, 81, Suenagacho, Date, Hokkaido, 052-8511, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Center for Digestive Disease, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki City, Miyazaki, 889-1692, Japan
| | - Michihiro Ono
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1, Yanagito, Gifu, Gifu, 501-1194, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Junji Kato
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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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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Ang TL, Kwek ABE, Song M, Li JW, Thurairajah PH. Comparative study of strategies for preventing post-ERCP pancreatitis after early precut sphincterotomy for biliary access. J Dig Dis 2016; 17:692-696. [PMID: 27556283 DOI: 10.1111/1751-2980.12401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/14/2016] [Accepted: 08/21/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Needle knife precut sphincterotomy (PS) during endoscopic retrograde cholangiopancreatography (ERCP) has been associated with a high risk of post-ERCP pancreatitis (PEP). This study aimed to examine the effect of no prophylaxis, somatostatin, rectal diclofenac and pancreatic duct (PD) stenting in reducing rates of PEP in patients who underwent early PS. METHODS This was a retrospective comparative study and the study period was from January 2006 to December 2015. A standardized approach to early PS was used: (i) inadvertent guidewire cannulation of the PD > thrice; (ii) impacted bile duct stone; (iii) inability to achieve deep cannulation within 10 min. PEP prophylactic measures included: (i) none when there was minimal papilla trauma; (ii) somatostatin infusion; (iii) rectal diclofenac; (iv) PD stent. The difference in rates of PEP between the different strategies was analysed. RESULTS During the study period, PS was performed in 191 ERCP patients (mean age 66 years; 56.5% males). The ERCP success rate after PS was 93.2% (178/191). Overall the PEP rate was 3.1% (6/191) and the severity in all cases was mild. PEP occurred in 6.1% of patients with PD cannulation but not in those without (P = 0.016). PEP rates were 1.8%, 7.3%, 1.8% and 0% in control, somatostatin, diclofenac and PD stenting groups, respectively (P = 0.209). CONCLUSIONS There was no significant difference in PEP rates after early PS whether or not prophylactic measures were adopted if there was minimal papilla trauma. A trend towards lower PEP rates was observed in patients who had either rectal diclofenac or PD stenting, compared to somatostatin.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mingjun Song
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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A Randomized Comparative Study of 24- and 6-Hour Infusion of Nafamostat Mesilate for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Randomized Comparison Trial. Pancreas 2016; 45:1179-83. [PMID: 27253231 DOI: 10.1097/mpa.0000000000000625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although prolonged intravenous infusion (24 hours) of nafamostat mesilate is effective for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it requires hospitalization and is expensive. The aim of this study was to compare the efficacy of 24- versus 6-hour intravenous infusion of 20 mg nafamostat mesilate for the prevention of post-ERCP pancreatitis (PEP). METHODS A total of 382 patients who underwent ERCP were randomly assigned into 2 groups: 24 hours or 6 hours. In both groups, nafamostat mesilate (20 mg) infusion was initiated up to an hour before ERCP and continued for either 24 or 6 hours. RESULTS The overall incidence of pancreatitis was 2.4% (9/371). The rates of PEP following 24- and 6-hour infusion were 2.8% (5/179) and 2.1% (4/192), respectively (P = 0.744). No significant difference was observed in the severity of pancreatitis between the groups. On multivariate analysis, increasing pancreatic duct cannulations (odds ratio, 1.685; 95% confidence interval, 1.036-2.741; P = 0.036) was identified as a statistically significant risk factor of PEP. CONCLUSIONS No difference was found in the incidence of PEP regardless of the duration of nafamostat mesilate infusion. Therefore, 6-hour infusion of 20 mg nafamostat mesilate may be useful for the prevention of PEP in an outpatient setting.
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Shaygan-Nejad A, Masjedizadeh AR, Ghavidel A, Ghojazadeh M, Khoshbaten M. Aggressive hydration with Lactated Ringer's solution as the prophylactic intervention for postendoscopic retrograde cholangiopancreatography pancreatitis: A randomized controlled double-blind clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 20:838-43. [PMID: 26759569 PMCID: PMC4696367 DOI: 10.4103/1735-1995.170597] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and may cause significant morbidity and even death. There is no effective prophylactic intervention for patients with average risk yet. This study aims to investigate preventive effect of aggressive hydration for post-ERCP pancreatitis. Materials and Methods: In a double-blind controlled setting, 150 patient were randomly assigned to receive either aggressive hydration with lactated Ringer's solution (3 mL/kg/h during ERCP, followed by a 20 mL/kg bolus and 3 mL/kg/h for 8 h after the procedure, n = 75) or standard amount of hydration (1.5 mL/kg/h during and for 8 h after ERCP, n = 75). Patients were observed for volume overload as well as pancreatic pain and serum levels of amylase at baseline and 2, 8, and 24 h after ERCP. Post-ERCP pancreatitis was defined as hyperamylasemia (level of amylase >300) and pancreatic pain during the 24 h follow-up. Hyperamylasemia and pancreatic pain were the secondary end points. Results: Mean age of the patients was 50.8 ± 13.5 years. Most of the patients were female (66%). Pancreatitis developed in 21 patients, including 22.7% of patients receiving standard hydration and 5.3% patients receiving aggressive hydration (P = 0.002). Hyperamylasemia was detected in 44.0% of patients receiving standard hydration and 22.7% of patients aggressive hydration (P = 0.006). The pancreatic pain was reported by 5.3% of patients receiving aggressive hydration and 37.3% of patients receiving standard hydration (P ≤ 0.005). Conclusion: Aggressive hydration with lactated Ringer's solution may effectively prevent post-ERCP pancreatitis as well as hyperamylasemia and pancreatic pain in patients with average risk.
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Affiliation(s)
- Alireza Shaygan-Nejad
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdol Rahim Masjedizadeh
- Research Institute for Infectious Diseases of the Digestive System, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Ghavidel
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Manouchehr Khoshbaten
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Factors Affecting the Efficacy of Nonsteroidal Anti-inflammatory Drugs in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Systematic Review and Meta-analysis. Pancreas 2015; 44:859-67. [PMID: 26168316 PMCID: PMC4824288 DOI: 10.1097/mpa.0000000000000326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To identify the factors affecting the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS We systematically searched databases for relevant studies published from inception to November 2013. RESULTS A meta-analysis of 11 randomized trials (n = 2497) revealed a significant reduction in PEP in patients who received NSAIDs compared with that in patients who received placebo (relative risk [RR], 0.59; 95% confidence interval [CI], 0.41-0.85; P = 0.005). In subgroup analysis by treatment type, indomethacin had no significant effect (RR, 0.66; 95% CI, 0.38-1.15; P = 0.14), whereas other NSAIDs showed significant benefit (RR, 0.51; 95% CI, 0.29-0.91; P = 0.02). Only rectal administration significantly reduced the incidence of PEP (RR, 0.43; 95% CI, 0.32-0.58; P < 0.00001). The risk for PEP was the lowest among patients who received NSAIDs before ERCP (RR, 0.48; 95% CI, 0.29-0.78; P = 0.003). NSAIDs did not significantly reduce the risk of PEP in men (RR, 0.61; 95% CI, 0.34-1.09), patients with sphincter of Oddi dysfunction (RR, 0.98; 95% CI, 0.38-2.54), or patients with pancreatic duct injection (RR, 0.64; 95% CI, 0.35-1.18). CONCLUSIONS Rectal administration of NSAIDs (especially diclofenac), before ERCP, seemed to be the most effective strategy for preventing PEP.
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Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, Dumonceau JM, Elta GH, Fogel EL, Freeman ML, Lehman GA, Naveed M, Romagnuolo J, Scheiman JM, Sherman S, Singh VK, Elmunzer BJ. Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review. Clin Gastroenterol Hepatol 2015; 13:1231-9; quiz e70-1. [PMID: 25579870 DOI: 10.1016/j.cgh.2014.11.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. METHODS We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. RESULTS After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. CONCLUSIONS On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Megan A Adams
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marisa L Conte
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Cote
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Evan L Fogel
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Glen A Lehman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mariam Naveed
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2015; 44:415-21. [PMID: 25479585 DOI: 10.1097/mpa.0000000000000278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to investigate whether prophylactic administration of nafamostat mesilate reduces the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its efficacy, and risk factors for PEP. METHODS Potential subjects comprised 876 patients who underwent ERCP between September 2008 and February 2011. Of these, 58 patients were excluded after meeting exclusion criteria, and 818 patients were randomized. Patients in the nafamostat mesilate group were administered 20 mg of nafamostat mesilate dissolved in 500 mL of 5% glucose solution, whereas the control group received 500 mL of 5% glucose solution alone, over 2 hours from the start of ERCP. RESULTS Post-ERCP pancreatitis occurred in 5.1% (41 patients) overall, with a significantly lower frequency in the nafamostat mesilate group (3.5%) than in the control group (6.7%; P = 0.0349). Analysis of the 322 patients who had undergone ERCP for the first time (n = 158 in the nafamostat mesilate group; n = 164 in the control group) found that PEP again significantly less frequently occurred in the nafamostat mesilate group (5.7%) than in the control group (13.4%; P = 0.0172). CONCLUSIONS Our randomized controlled study suggested that short-term administration of nafamostat mesilate 20 mg may reduce the incidence of PEP.
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Yoshihara T, Horimoto M, Kitamura T, Osugi N, Ikezoe T, Kotani K, Sanada T, Higashi C, Yamaguchi D, Ota M, Mizuno T, Gotoh Y, Okuda Y, Suzuki K. 25 mg versus 50 mg dose of rectal diclofenac for prevention of post-ERCP pancreatitis in Japanese patients: a retrospective study. BMJ Open 2015; 5:e006950. [PMID: 25795692 PMCID: PMC4368931 DOI: 10.1136/bmjopen-2014-006950] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The aim of the present study was to assess the appropriate administration dose of non-steroidal anti-inflammation drugs to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Importantly, the 100 mg dose of diclofenac recommended in Western countries has not been permitted in Japan. DESIGN A retrospective study. SETTINGS A single centre in Japan. PARTICIPANTS This study enrolled patients who underwent ERCP at the Department of Gastroenterology, Osaka Saiseikai Senri Hospital, from April 2011 through June 2013, and who received either a 25 or a 50 mg dose of rectal diclofenac after ERCP. PRIMARY OUTCOME MEASURE The occurrence of post-ERCP pancreatitis (PEP). A multivariate regression model was used to assess the effect of the 50 mg dose (the 50 mg group) of rectal diclofenac and to compare it to the occurrence of PEP referring to the 25 mg group. RESULTS A total of 155 eligible patients received either 25 mg (84 patients) or 50 mg (71 patients) doses of rectal diclofenac after ERCP to prevent PEP. The proportion of PEP was significantly lower in the 50 mg group than in the 25 mg group (15.5% (11/71) vs 33.3% (28/84), p=0.018). In a multivariate analysis, the occurrence of PEP was significantly lower in the 50 mg group than in the 25 mg group even after adjusting potential confounding factors (adjusted OR=0.27, 95% CI 0.11 to 0.70). CONCLUSIONS From this observation, the occurrence of PEP was significantly lower among ERCP patients with the 50 mg dose of rectal diclofenac than among those with the 25 mg dose.
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Affiliation(s)
- Takeo Yoshihara
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Masayoshi Horimoto
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Naoto Osugi
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Tatsuro Ikezoe
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Kaori Kotani
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Toru Sanada
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Churi Higashi
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Daisuke Yamaguchi
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Makiyo Ota
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Tatsunori Mizuno
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Yasukazu Gotoh
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Yorihide Okuda
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Kunio Suzuki
- Department of Gastroenterology, Osaka Saiseikai Senri Hospital, Suita, Osaka, Japan
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography-related adverse events: general overview. Gastrointest Endosc Clin N Am 2015; 25:97-106. [PMID: 25442961 DOI: 10.1016/j.giec.2014.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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Qin X, Lei WS, Xing ZX, Shi F. Prophylactic effect of somatostatin in preventing Post-ERCP pancreatitis: an updated meta-analysis. Saudi J Gastroenterol 2015; 21:372-8. [PMID: 26655132 PMCID: PMC4707805 DOI: 10.4103/1319-3767.167187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Somatostatin is regarded as a prophylactic agent on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), but studies are still controversial. MATERIALS AND METHODS Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index, were searched to retrieve relevant trials. In addition, meeting abstracts and the reference lists of retrieved articles were reviewed for further relevant studies. RESULTS Eleven randomized controlled trials (RCTs), enrolling a total of 2869 patients, were included in the meta-analysis. After data were pooled from somatostatin trials, PEP occurred in 8.36% of controls versus 5.62% of the treated group, with a slight significance [relative risk (RR) =0.58, 95% confidence interval (CI) 0.35-0.98, P = 0.04]. The funnel plot showed no asymmetry with a negative slope (P = 0.108). The meta-analysis produced negative results for short-term infusion of somatostatin (RR = 1.40, 95% CI 0.93-2.12, P = 0.11), whereas a bolus or long-term injection of the drug proved effective (RR = 0.25, 95% CI 0.13-0.47,P < 0.0001; RR = 0.44, 95% CI 0.27-0.71,P = 0.0008). Postprocedure hyperamylasemia and pain was also observed in the meta-analysis, the pooled RR was significant for reduced risk of postprocedure hyperamylasemia (RR = 0.72, 95%CI 0.63 to 0.81,P < 0.00001), but not for the pain (RR = 0.67, 95% CI 0.42 to 1.08,P= 0.10). CONCLUSION The current meta-analysis on the prophylactic use of somatostatin in patients undergoing ERCP documents a lack of benefit when given as short-term infusion, but showed an advantage of a single bolus or long-term injection. The beneficial effect of somatostatin, in reducing the incidence of postprocedural hyperamylasemia seems of marginal clinical significance. However, more new confirmatory data are needed to settle residual doubts.
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Affiliation(s)
- Xie Qin
- Department of Human Anatomy, College of Basic and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China,Department of Geriatric Medicine and Gastroenterology, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Wen S. Lei
- Department of Human Anatomy, College of Basic and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhang X. Xing
- Department of Geriatric Medicine and Gastroenterology, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Feng Shi
- Department of Human Anatomy, College of Basic and Forensic Medicine, Sichuan University, Chengdu, Sichuan Province, China,Address for correspondence: Prof. Feng Shi, Department of Human Anatomy, College of Basic and Forensic Medicine, Sichuan University, No.17, Section 3, South Renmin Road, Chengdu, Sichuan, China 610041. E-mail:
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Lee TH, Park DH. Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16582-16595. [PMID: 25469026 PMCID: PMC4248201 DOI: 10.3748/wjg.v20.i44.16582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/11/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
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Elmunzer BJ. Pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: Present and future. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pancreatography (ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for "ERCP" and "pancreatitis" and "post-ERCP pancreatitis". in PubMed and Medline. This review looks at the diagnosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and pharmacological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnecessary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction (SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stenting of patients with SOD and rectally administered nonsteroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP is associated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49 (0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.
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Affiliation(s)
- Lin-Lee Wong
- Lin-Lee Wong, Her-Hsin Tsai, Department of Gastroenterology, Castle Hill Hospital, HEY NHS Trust and Hull York Medical School, Cottingham HU165JQ, United Kingdom
| | - Her-Hsin Tsai
- Lin-Lee Wong, Her-Hsin Tsai, Department of Gastroenterology, Castle Hill Hospital, HEY NHS Trust and Hull York Medical School, Cottingham HU165JQ, United Kingdom
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Risk Factors of Post-ERCP Pancreatitis at a Tertiary Referral Center in Japan. Surg Laparosc Endosc Percutan Tech 2014; 24:270-3. [DOI: 10.1097/sle.0b013e3182901461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park JY, Jeon TJ, Hwang MW, Sinn DH, Oh TH, Shin WC, Choi WC. Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: a prospective, randomized trial. Pancreatology 2014; 14:263-7. [PMID: 25062874 DOI: 10.1016/j.pan.2014.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 02/21/2014] [Accepted: 03/31/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications. METHODS A total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6-8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain. RESULTS The overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001). CONCLUSIONS There was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.
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Affiliation(s)
- Ji Young Park
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Tae Joo Jeon
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea.
| | - Mi Won Hwang
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Oh
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Won Chang Shin
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Won-Choong Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
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Zheng MH, Bai JL, Meng MB, Chen YP. Gabexate mesylate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis update. CURRENT THERAPEUTIC RESEARCH 2014; 69:288-304. [PMID: 24692807 DOI: 10.1016/j.curtheres.2008.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/16/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP), and the benefit of pharmacologic treatment of the condition is unclear. Although prophylactic use of gabexate mesylate (GM) for the reduction of pancreatic injury after ERCP has been evaluated, uncertainty remains regarding the effectiveness of GM treatment in post-ERCP pancreatitis (PEP). OBJECTIVE The aim of this study was to determine through systematic review and meta-analysis the effectiveness and tolerability of GM in the prophylaxis of PEP. METHODS MEDLINE (January 1966-July 2007), EMBASE (January 1966- July 2007), the Cochrane Controlled Trials Register on The Cochrane Library (Issue 2, 2007), and the China Biological Medicine Database (January 1978-July 2007) were searched. We used the method recommended by The Cochrane Collaboration to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) of GM in the prevention of PEP. RESULTS Of the 38 studies identified, 31 were excluded for the following reasons: they were reviews or editorials (9 articles); were meta-analyses (4); had differences in cointerventions (4); were nonrandomized controlled trials or had incorrect randomization (4); were repeat publications (2); lacked a placebo group (1); or other (7). Seven RCTs, totaling 2883 patients, conducted in a variety of languages were included in the meta-analysis. When the RCTs were analyzed, odds ratios for GM were 0.65 (95% CI, 0.36-1.18; P 0.16) for PER 1.90 (95% CI, 0.54-6.65; P 0.32) for severe PEP, 0.55 (95% CI, 0.17-1.77; P 0.32) for the case-fatality ratio of PEP, 0.88 (95% CI, 0.74-1.05; P 0.16) for post-ERCP hyperamylasemia, and 0.78 (95% CI, 0.49 1.25; P 0.30) for post-ERCP abdominal pain. No evidence of publication bias was found. CONCLUSIONS No beneficial effects of GM on acute pancreatitis, the PEP mortality rate, or post-ERCP abdominal pain or hyperamylasemia were found; therefore, GM cannot be recommended for the prophylaxis of PEP.
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Affiliation(s)
- Ming-Hua Zheng
- Department of Infection and Liver Diseases, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
| | - Jian-Ling Bai
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mao-Bin Meng
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yong-Ping Chen
- Department of Infection and Liver Diseases, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
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Yuhara H, Ogawa M, Kawaguchi Y, Igarashi M, Shimosegawa T, Mine T. Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis. J Gastroenterol 2014; 49:388-99. [PMID: 23720090 DOI: 10.1007/s00535-013-0834-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 05/09/2013] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is the most frequent complication of ERCP. Several meta-analyses have examined the effects of protease inhibitors (gabexate mesilate, ulinastatin, and nafamostat mesilate) and non-steroidal anti-inflammatory drugs (NSAIDs) on post-ERCP pancreatitis, but the results have been confusing. Since the previous meta-analysis, several new studies have been published on this topic. To provide an updated quantitative assessment of the effectiveness of protease inhibitors and NSAIDs in preventing post-ERCP pancreatitis, we conducted a meta-analysis of randomized trials for patients at risk of post-ERCP pancreatitis. Twenty-six articles were included in this meta-analysis. Nafamostat mesilate (summary RR = 0.41; 95 %CI 0.28-0.59; n = 4 studies) and NSAIDs (summary RR = 0.58; 95 %CI = 0.44-0.76; n = 7 studies) were associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. However, gabexate mesilate (summary RR = 0.64; 95 %CI = 0.36-1.13; n = 6 studies) and ulinastatin (summary RR = 0.65; 95 %CI = 0.33-1.30; n = 2 studies) were not associated with decreased risk of post-ERCP pancreatitis in the high-quality studies. This is the first meta-analysis to compare the effects of three protease inhibitors. Solid evidence supports the use of nafamostat mesilate and NSAIDs for preventing post-ERCP pancreatitis.
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Affiliation(s)
- Hiroki Yuhara
- Department of Gastroenterology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
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Wong LL, Tsai HH. Prevention of post-ERCP pancreatitis. World J Gastrointest Pathophysiol 2014; 5:1-10. [PMID: 24891970 PMCID: PMC4024515 DOI: 10.4291/wjgp.v5.i1.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/26/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pancreatography (ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for “ERCP” and “pancreatitis” and “post-ERCP pancreatitis”. in PubMed and Medline. This review looks at the diagnosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and pharmacological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnecessary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction (SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stenting of patients with SOD and rectally administered nonsteroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP is associated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49 (0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.
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Buxbaum J, Yan A, Yeh K, Lane C, Nguyen N, Laine L. Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2014; 12:303-7.e1. [PMID: 23920031 PMCID: PMC3879172 DOI: 10.1016/j.cgh.2013.07.026] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 07/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). We performed a pilot study to determine whether aggressive periprocedural hydration with lactated Ringer's solution reduces the incidence of pancreatitis after ERCP. METHODS Patients who underwent first-time ERCP were randomly assigned to groups (2:1) that received aggressive hydration with lactated Ringer's solution (3 mL/kg/h during the procedure, a 20-mL/kg bolus after the procedure, and 3 mL/kg/h for 8 hours after the procedure, n = 39) or standard hydration with the same solution (1.5 mL/kg/h during and for 8 hours after procedure, n = 23). Serum levels of amylase, visual analogue pain scores (scale of 0-10), and volume overload were assessed at baseline and 2, 8, and 24 hours after ERCP. The primary end point, post-ERCP pancreatitis, was defined as hyperamylasemia (level of amylase >3 times the upper limit of normal) and increased epigastric pain (≥3 points on visual analogue scale) persisting for ≥24 hours after the procedure. Secondary end points included hyperamylasemia, increased pain, and volume overload. RESULTS None of the patients who received aggressive hydration developed post-ERCP pancreatitis, compared with 17% of patients who received standard hydration (P = .016). Hyperamylasemia developed in 23% of patients who received aggressive hydration vs 39% of those who received standard hydration (P = .116, nonsignificant); increased epigastric pain developed in 8% of patients who received aggressive hydration vs 22% of those who received standard hydration (P = .146, nonsignificant). No patients had evidence of volume overload. CONCLUSIONS On the basis of a pilot study, aggressive intravenous hydration with lactated Ringer's solution appears to reduce the development of post-ERCP pancreatitis and is not associated with volume overload. ClinicalTrials.gov, Number: NCT 01758549.
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Affiliation(s)
- James Buxbaum
- Division of Gastroenterology, the University of Southern California, Los Angeles, CA
| | - Arthur Yan
- Division of Gastroenterology, the University of Southern California, Los Angeles, CA
| | - Kelvin Yeh
- Division of Gastroenterology, the University of Southern California, Los Angeles, CA
| | - Christianne Lane
- Division of Gastroenterology, the University of Southern California, Los Angeles, CA
| | - Nancy Nguyen
- Division of Gastroenterology, the University of Southern California, Los Angeles, CA
| | - Loren Laine
- Yale University School of Medicine, New Haven, Connecticut and VA Connecticut Healthcare System, West Haven, Connecticut.
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Mazaki T, Mado K, Masuda H, Shiono M. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014; 49:343-55. [PMID: 23612857 DOI: 10.1007/s00535-013-0806-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP. METHODS We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP. RESULTS Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95 % confidence interval (CI) 0.29-0.53; P < 0.001]. Subgroup analysis stratified according to the severity of PEP showed that a PS was beneficial in patients with mild to moderate PEP (RR 0.45; 95 % CI 0.32-0.62; P < 0.001) and in patients with severe PEP (RR 0.26; 95 %CI 0.09-0.76; P = 0.01). In addition, subgroup analysis performed according to patient selection demonstrated that PS placement was effective for both high-risk and mixed case groups. CONCLUSIONS This meta-analysis showed that PS placement prevented PEP after ERCP as compared with no PS placement. We therefore recommend PS placement after ERCP for the prevention of PEP.
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Affiliation(s)
- Takero Mazaki
- Department of Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan,
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Abstract
Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.
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Affiliation(s)
- Jennifer Maranki
- Temple University School of Medicine, 3401 N. Broad St., Suite 830 Parkinson Pavilion, Philadelphia, PA, 19140, USA,
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Shi H, Chen S, Swar G, Wang Y, Ying M. Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography: a review and meta-analysis. Pancreas 2013; 42:1093-100. [PMID: 23867366 DOI: 10.1097/mpa.0b013e3182909da5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The role of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP) is debated. A meta-analysis was performed to evaluate the efficacy and safety of CO2 insufflation for ERCP. METHODS Searches were conducted in multiple databases composed of Pub-Medline, EMBASE, the Cochrane Library, science citation index expanded, Google scholar, and CNKI China series full-text database. Outcome measurements are listed below: ERCP procedural data, post-ERCP abdominal discomfort, radiographic evaluation of bowel gas volume, and CO2 safety data concerning CO2 elimination. RESULTS Seven published randomized clinical trials involving 756 patients fulfilling the inclusion criteria were selected for meta-analysis, almost all of high quality. The incidence of ERCP-related complications was reduced by CO2 insufflation, so were the events of 1-hour, 3-hour, and 6-hour post-ERCP abdominal pain, based on their corresponding statistical results. Besides, CO2 insufflation was associated with less gas volume in the bowel lumen after the procedure. There were no significant differences between CO2 and air insufflation in total procedure time, the success rate of selective cannulation, post-ERCP abdominal distension, respectively. Subsequent sensitivity and subgroup analyses produced conflicting results. CONCLUSIONS Compared with air insufflation, CO2 insufflation during ERCP reduces post-ERCP abdominal pain, post-ERCP bowel remnant gas volume, and ERCP-related complications, without clinically significant systematic CO2 retention.
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Affiliation(s)
- Hong Shi
- From the *Department of Gastrointestinal Endoscopy, Fujian Provincial Tumor Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; †Institute of Minimally Invasive Medicine, Tongji University, Shanghai, China; and ‡Department of Surgery, Fujian Provincial Tumor Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, 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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50
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Response to Drs Gu and Liu. Gastrointest Endosc 2013; 77:673-4. [PMID: 23498150 DOI: 10.1016/j.gie.2012.12.003] [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: 12/05/2012] [Accepted: 12/05/2012] [Indexed: 02/08/2023]
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