Stenting the pancreas: is this the solution to post-ERCP pancreatitis?

Evaluation of recombinant platelet-activating factor acetylhydrolase for reducing the incidence and severity of post-ERCP acute pancreatitis

BACKGROUND

Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Platelet-activating factor (PAF) has been implicated in the pathophysiologic events associated with acute pancreatitis. Animal and human studies suggested that recombinant PAF acetylhydrolase (rPAF-AH) might ameliorate the severity of acute pancreatitis.

OBJECTIVE

Our purpose was to determine whether prophylactic rPAF-AH administration reduces the frequency or severity of post-ERCP pancreatitis in high-risk patients.

DESIGN

Randomized, multicenter, double-blind, placebo-controlled study.

INTERVENTIONS

Patients received rPAF-AH at a dose of either 1 or 5 mg/kg or placebo. Patients were administered a single intravenous infusion over 10 minutes of study drug or placebo <1 hour before ERCP.

MAIN OUTCOME MEASUREMENTS

Standardized criteria were used to diagnose and grade the severity of post-ERCP pancreatitis. Adverse events were prospectively recorded.

RESULTS

A total of 600 patients were enrolled. There were no statistically significant differences among the treatment groups with respect to patient demographics, ERCP indications, and patient and procedure risk factors for post-ERCP pancreatitis with the following exceptions: the rPAF-AH 5 mg/kg group had significantly fewer patients younger than 40 years old and scheduled to undergo a therapeutic ERCP involving the pancreatic sphincter or duct. Post-ERCP pancreatitis occurred in 17.5%, 15.9%, and 19.6% of patients receiving rPAF-AH (1 mg/kg), rPAF-AH (5 mg/kg), and placebo, respectively (P = .59 for rPAF-AH 1 mg/kg vs placebo and P = .337 for rPAF-AH 5 mg/kg vs placebo). There was no statistically significant difference between the groups with regard to the severity of pancreatitis, frequency of amylase/lipase elevation more than 3 times normal, or abdominal pain.

CONCLUSIONS

There was no apparent benefit of rPAF-AH treatment compared with placebo in reducing the incidence of post-ERCP pancreatitis in subjects at increased risk.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study

OBJECTIVES

Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study.

METHODS

A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria.

RESULTS

Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis.

CONCLUSION

This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Oral allopurinol does not prevent the frequency or the severity of post-ERCP pancreatitis

BACKGROUND

Pancreatitis is the most common major complication of ERCP. Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic allopurinol, an inhibitor of oxygen-derived free radical production, would reduce the frequency and severity of post-ERCP pancreatitis. Methods A total of 701 patients were randomized to receive either allopurinol or placebo 4 hours and 1 hour before ERCP. A database was prospectively collected by a defined protocol on patients who underwent ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis.

RESULTS

The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 12.55%. It occurred in 46 of 355 patients in the allopurinol group (12.96%) and in 42 of 346 patients in the control group (12.14%; p = 0.52). The pancreatitis was graded mild in 7.89%, moderate in 4.51%, and severe in 0.56% of the allopurinol group, and mild in 6.94%, moderate in 4.62%, and severe in 0.58% of the control group. There was no significant difference between the groups in the frequency or the severity of pancreatitis.

CONCLUSIONS

Prophylactic oral allopurinol did not reduce the frequency or the severity of post-ERCP pancreatitis.

Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success

BACKGROUND

Increasingly, pancreatic stents are being placed to prevent post-ERCP pancreatitis. However, guidewire and stent placement may fail if the duct is small or tortuous, potentially exacerbating the risk. This study assessed the impact of unsuccessful pancreatic stent placement on complications and the efficacy of a modified technique for stent insertion when pancreatic ductal anatomy makes stent insertion technically difficult.

METHODS

Technical variables and 30-day complications of consecutive therapeutic ERCPs, including attempted major papilla pancreatic stent insertion were prospectively studied. Success rates for pancreatic stent placement were compared for a 1-year period during which conventional deep guidewire insertion was used and another 1-year period in which a modified technique was used as needed in patients with ductal anatomy that made stent placement technically difficult. In the modified technique, a short (2-3 cm) small diameter (3F-5F) stent was placed over a 0.018-in nitinol-tipped guidewire, passed as little as 1 to 2 cm beyond the pancreatic sphincter.

RESULTS

In 225 high-risk therapeutic ERCPs, pancreatitis occurred after the procedure in two of 3 (66.7%) patients in whom pancreatic stent insertion failed vs. 32 of 222 (14.4%) patients with successful insertion (p=0.06). Severe pancreatitis occurred only after unsuccessful stent insertion. Significant multivariate risk factors for post-ERCP pancreatitis were unsuccessful pancreatic stent insertion (odds ratio 16.1: 95% CI[1.3, 200]), sphincter of Oddi dysfunction (odds ratio 3.2: 95% CI[1.4, 7.5]), and prior post-ERCP pancreatitis (odds ratio 3.2: 95% CI[1.4, 7.1]). The following were not risk factors: performance of pancreatic, biliary, or needle-knife pre-cut sphincterotomy; number of pancreatic contrast injections; and difficult cannulation. Stent placement was unsuccessful in 3 (3.2%) of 93 attempts during the 1-year period in which a conventional technique was used vs. none of 132 attempts in a subsequent year in which the modified technique was used.

CONCLUSIONS

Failed attempts at pancreatic stent placement are associated with an extremely high risk of post-ERCP pancreatitis. Success can be consistently achieved by use of a modified technique.

Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management

Adverse outcomes of endoscopic retrograde cholangiopancreatography (ERCP) include technical failures and complications. Complications cause significant morbidity to patients and anxiety to endoscopists. The key to preventing complications is to understand which patients and procedures are at highest risk so that appropriate decisions can be made as to whether ERCP should be performed at all, and if so, how. Patients who need ERCP the least are often the ones most likely to develop complications. For marginal indications, ERCP should be avoided. Success rates are higher and complication rates lower for endocopists performing large numbers by endoscopists with adequate experience.

Does prophylactic administration of corticosteroid reduce the risk and severity of post-ERCP pancreatitis: a randomized, prospective, multicenter study

BACKGROUND

Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. There have been continuing efforts to identify a pharmacologic agent capable of reducing the frequency and severity of this complication. On the basis of several case reports, experimental data, and knowledge of their mechanism of action, corticosteroids might be effective in this regard. The aim of this randomized, double-blind, controlled trial was to determine whether prophylactic, orally administered corticosteroid reduces the frequency and/or severity of post-ERCP pancreatitis.

METHODS

A total of 1115 patients were randomized to receive either prednisone (40 mg) or a placebo orally 15 hours and 3 hours before ERCP. A 160 variable database was prospectively collected according to a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis.

RESULTS

The overall frequency of pancreatitis was 15.07%. It occurred in 92 of 555 patients in the corticosteroid group (16.6%), and in 76 of 560 patients in the control group (13.6%; p = 0.19). The pancreatitis was mild in 10.04%, moderate in 4.04%, and severe in 0.99%. There was no difference between the groups with regard to the severity of pancreatitis. Moreover, the groups were similar with regard to age, gender, body mass index, frequency of prior pancreatitis, type of procedure performed (diagnostic or therapeutic), difficulty of cannulation, frequency of pre-cut sphincterotomy, pancreatic sphincterotomy, sphincter of Oddi dysfunction, sphincter of Oddi manometry, pancreatic acinarization, chronic pancreatitis, number of pancreatic duct injections, and bile duct diameter.

CONCLUSION

Prophylactic orally administered corticosteroid did not reduce the frequency or severity of post-ERCP pancreatitis.

Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography

Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Technique-related risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient's coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study

BACKGROUND

Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers.

METHODS

Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria.

RESULTS

Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic.

CONCLUSIONS

Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.

Endoscopic retrograde cholangiopancreatography and the pancreas: when and why?

Historically, endoscopic retrograde cholangeopancreatography (ERCP) has played a unique role as a diagnostic and therapeutic modality for diseases of the pancreas. Despite the advent of new imaging techniques, ERCP continues to play a central role in the evaluation and treatment of pancreatitis of various causes. Endoscopic cholangiography and stenting remain mainstays in the palliation of inoperable obstructive jaundice in patients with cancer of the pancreas.

ERCP-induced Pancreatitis

The most important consideration in preventing ERCP-induced pancreatitis is patient selection. If you want to avoid pancreatitis, avoid performing ERCP in young patients for sphincter of Oddi dysfunction. Sphincter of Oddi manometry, difficult biliary cannulations (repeated pancreatic duct cannulations/injections), and precut and pancreatic sphincterotomy are associated with increased risk of pancreatitis. Pancreatic endotherapy, precut sphincterotomy, and Sphincter of Oddi manometry should be reserved for expert endoscopists. Short-term pancreatic stenting appears to decrease the risk of pancreatitis in patients undergoing these higher-risk procedures. Chemoprevention for ERCP-induced pancreatitis appears promising, but needs further critical study with larger patient populations and agents amenable to outpatient use. Fortunately, most ERCP-induced pancreatitis is mild. More severe pancreatitis requires a team approach to management with surgery, radiology, gastroenterology, and other specialists (eg, nephrologist) as indicated participating in the patient's care.

Pancreatic duct stenting as a treatment for hereditary pancreatitis

Hereditary pancreatitis is a genetically transmitted condition usually presenting in childhood or adolescence. The natural history of the condition is that recurrent episodes of pancreatitis may be followed by the development of pancreatic exocrine and endocrine failure. Treatment options are limited, usually consisting of surgical drainage procedures whose efficacy is uncertain and whose effect on disease progression is unknown. We report a child with hereditary pancreatitis treated by means of a pancreatic duct stent placed via endoscopic retrograde cholangiopanctreatography resulting in long-term control of symptoms and speculate that earlier intervention may alter the disease course.